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COLLEGE  OF  PHYSICIANS 
AND   SURGEONS 


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Reference  Library 

Given  by 


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[;iANS, 


THE  PRINCIPLES  AND 
PRACTICE  OF  MEDICINE 


DESIGNED  FOR    THE  USE  OF  PRACTITIONERS 
AND  STUDENTS  OF  MEDICINE 


BY 

WILLIAM    OSLER,   M.D. 

FELLOW    OF    THE    ROYAL    SOCIETY  ;     FELLOW    OF    THE     ROYAL    COLLEGE    OF    PHYSICIANS, 
LONDON;    REGIUS   PROFESSOR  OF   MEDICINE,  OXFORD  UNIVERSITY;    HONORARY   PRO- 
FESSOR  OF    MEDICINE,  JOHNS    HOPKINS    UNIVERSITY,  BALTIMORE  ;    FORMERLY 
PROFESSOR    OF    THE    INSTITUTE    OF    MEDICINE,    McGILL    UNIVERSITY, 
MONTREAL,    AND    PROFESSOR    OF   CLINICAL    MEDICINE    IN   THE 
UNIVERSITY   OF    PENNSYLVANIA,    PHILADELPHIA 


SEVENTH  EDITION,  THOROUGHLY  REVISED 


NEW    YORK    AND    LONDON 

D.    APPLETON     AND     COMPANY 

1909 


COPTRIGHT,  1892,  1895,  1898,  1901,  1903,  1903.  1904,  1905,  1909, 
By  D.  APPLETON  AND  COMPANY 


FEINTED  AT  THE  APPLETON  PEESS 
NEW  YOEK,    U.    S.   A. 


TO    THE 

ittetttorg  of  ms  ®eacl)crs : 
WILLIAM   ARTHUR  JOHNSON, 

.  PEIEST   OP   THE   PARISH   OF   WESTON,    ONTARIO. 

JAMES  BOVELL, 

OF  THE  TORONTO   SCHOOL   OF   MEDICINE,    AND   OF  THE 
UNIVERSITY  OF  TRINITY   COLLEGE,    TORONTO. 

ROBERT  PALMER  HOWARD, 

DEAN  OF  THE  MEDICAL   FACULTY   AND   PROFESSOR  OF  MEDICINE, 
MCGILL  UNIVERSITY,    MONTREAL. 


Digitized  by  the  Internet  Arciiive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/principlespractiOOosle 


PREFACE  TO  THE   SEVENTH  EDITION. 


The  three  years  that  have  passed  since  the  last  edition  have  been  rich  in 
additions  to  our  knowledge  of  disease  and  its  treatment,  particularly  in  con- 
nection with  the  acute  infections.  I  have  incorporated  all  the  more  impor- 
tant advances — the  long-expected  epoch-making  discoveries  in  syphilis,  the 
work  of  the  New  York  Pneumonia  Commission,  the  triumph  of  the  British 
army  and  naval  surgeons  in  stamping  out  Malta  fever,  the  splendid  work 
of  Gorgas  and  his  colleagues  at  Panama,  the  studies  of  Strong  and  his  asso- 
ciates in  the  Philippine  Islands,  the  fresh  work  which  has  been  done  in 
trypanosomiasis  psorosomiasis,  tropical  splenomegaly,  the  experiences  of  the 
last  epidemic  of  cerebro-spinal  fever  in  New  York,  Belfast,  and  Glasgow,  with 
the  hopeful  work  of  Flexner  at  the  Eockefeller  Institute,  the  all-important 
contributions  on  "  carriers  "  in  the  acute  infections,  the  results  of  the  Wash- 
ington Congress  with  the  new  views  on  infection,  heredity,  diagnosis,  and 
treatment  of  tuberculosis,  the  remarkable  studies  upon  epidemic  anterior 
poliomyelitis,  and  the  work  upon  Eocky  Mountain  fever,  milk  sickness,  and 
the  serum  disease.  One  cannot  but  be  impressed  with  the  extraordinary  rapid- 
ity of  the  progress  of  our  knowledge  of  the  acute  infections ! 

The  section  on  parasites  has  been  carefully  revised,  and  has  received  many 
additions.  In  the  chapters  on  the  diseases  of  special  organs  much  new  matter 
has  been  incorporated — a  new  section  in  acute  dilation  of  the  stomach,  a 
complete  revision  of  the  subject  of  peptic  ulcer  in  the  light  of  recent  surgical 
work,  new  sections  on  diverticulitis,  parotitis,  pancreatic  and  adrenal  insuffi- 
ciency, oedema  of  the  lungs,  Banti's  disease,  polycythsemia,  etc.  In  the  sec- 
tion upon  Diseases  of  the  Nervous  System  the  studies  of  Marie  and  his 
pupils  upon  aphasia  and  the  new  work  on  spastic  paraplegia,  Oppenheim's 
disease,  posterior  basic  meningitis,  psychasthenia,  etc.,  have  been  incorporated. 

The  new  points  which  have  come  up  in  treatment  have  been  discussed, 
particularly  the  important  advances  in  serum  therapy  and  on  the  surgical 
treatment  of  internal  diseases,  and  I  have  added  a  note  on  the  cult  of  the  day 


vi:  PREFACE   TO   THE   SEVENTH   EDITION. 

— faith  healing.  In  addition  to  these,  scores  of  minor  alterations  have  been 
made,  too  numerous  to  mention. 

Since  the  ajjpearance  of  the  last  edition  the  work  has  appeared  in  French, 
translated  by  MM.  Salomon  and  Lazard  under  the  supervision  of  Professor 
Marie  (Steinheil  &  Cie.,  Paris) ;  and  in  German,  translated  by  Dr.  Edmund 
Hoke,  with  additions  by  Professor  von  Jaksch,  of  Prague.  Spanish  and  Clii- 
nese  translations  are  in  course  of  preparation. 

I  have  many  to  thank — my  fellow-teachers  in  the  medical  schools  of  the 
English-speaking  world  for  their  kind  reception  of  previous  editions,  many 
friends  for  suggestions  and  advice,  scores  of  practitioners  all  over  the  world 
for  interesting  memoranda  of  cases;  Dr.  Broome,  of  Messrs.  D.  Appleton  and 
Comj)any,  for  his  kind  help  in  many  ways,  and  my  nephew.  Dr.  W.  W.  Erancis, 
of  Montreal,  who  has  seen  the  proofs  of  this  edition  through  the  press. 

William  Oslek. 


CONTENTS. 


SECTION   I. 
DISEASES   DUE  TO  ANIMAL  PARASITES. 

PAGE 

A.  Diseases  due  to  Protozoa i 

I.  Psorospermiasis 1 

II.  Amoebic  Dysentery 2 

III.  Trypanosomiasis 7 

IV.  Tropical  Splenomegaly  (Tropical  Cachexia) 9 

V.  Malarial  Fever 10 

Intermittent  Fever 16 

Continued  and  Remittent  Malarial  Fevers 20 

Pernicious  Malarial  Fever 21 

Malarial  Cachexia 23 

B.  Diseases  due  to  Parasitic  Infusoria 25 

C.  Diseases  due  to  Flukes  (Distomiasis)     .        .        .        .        .        .        .        .        .        .  26 

D.  Diseases  caused  by  Cestodes 28 

I.  Intestinal  Cestodes;  Tape-worms 28 

II.  Visceral  Cestodes 31 

Cysticercus  Cellulosse 31 

Echinococcus  Disease     .        .        .       ' 32 

Multilocular  Echinococcus 37 

E.  Diseases  caused  by  Nematodes 38 

I.  Ascariasis .  38 

II.  Trichiniasis 39 

III.  Ankylostomiasis 44 

IV.  Filariasis _ 47 

V.  Dracontiasis 49 

VI.  Other  Nematodes 50 

Acanthocephala 51 

F.  Parasitic  Arachnida  and  Ticks 52 

G.  Parasitic  Insects 53 

H.    Parasitic  Flies  (Myiasis) 55 

SECTION  II. 
SPECIFIC   INFECTIOUS   DISEASES. 

I.    Typhoid  Fever 57 

II.    Typhus  Fever       . .        .  105 

III.  Relapsing  Fever 109 

IV.  Small-pox 112 

Variola  Vera 115 

Hsemorrhagic  Small-pox 117 

Varioloid 119 

V.    Vaccinia  (Cow-pox) — Vaccination 123 

VI.    Varicella  (Chicken-pox) 128 

VII.    Scarlet  Fever 130 

VIII.    Measles  (Morbilli  Rubeola) 140 

IX.    Rubella  (Rotheln,  German  Measles) .  145 

X.    Epidemic  Parotitis  (Mumps) 146 

XI-    Whooping-cough          ,,,,,, 148 

vii 


vni 


CONTENTS. 


XII. 

XIII. 

XIV. 

XV. 

XVI. 

XVII. 

XVIII. 


XIX. 

XX. 

XXI. 

XXII. 

XXIII. 

XXIV. 

XXV. 

XXVI. 

XXVII. 

XXVIII. 

XXIX. 

XXX. 

XXXI. 


XXXII. 
XXXIII. 


XXXIV. 
XXXV. 


Influenza. 

Dengue    . 

Cerebro-spinal  Fever 

Pneumonia 

Diphtheria 

Erysipelas 

Septicaemia  and  Pysemia 

Septicaemia 

Septico-Pyaemia . 

Terminal  Infections 
Rheumatic  Fever  . 
Cholera  Asiatica     . 
Yellow  Fever  . 
The  Plague 
Bacillary  Dysentery 
Malta  Fever    . 
Beri-beri 
Anthrax  . 
Hydrophobia  . 
Tetanus   . 
Glanders 
Actinomycosis 
Syphilis    . 

Acquired 

Congenital  . 

Visceral 
Gonorrhoeal  Infection 
Tuberculosis    . 

I.  General  Etiology  and  Morbid  Anatomy 
II.  Acute  Tuberculosis 

III.  Tuberculosis  of  the  Lymphatic  System 

IV.  "  of  the  Lungs  (Phthisis,  Consumption) 
V.            "  of  the  Alimentary  Canal 

VI.  "  of  the  Liver 

VII.  "  of  the  Brain  and  Spinal  Cord 

VIII.  "  of  the  Genito-urinary  System 

IX.  "  of  the  Mammary  Gland    . 

X.  "  of  the  Circulatory  System 

XI.  Diagnosis  of  Tuberculosis 
XII.  Prognosis  in  Tuberculosis 

XIII.  .Prophylaxis  in  Tuberculosis   . 

XIV.  Treatment  of  Tuberculosis 

Leprosy   

Infectious  Diseases  of  Doubtful  Nature 

1.  Febricula  (Ephemeral  Fever) 

2.  Infectious  Jaundice  (Weil's  Disease) 

3.  Milk-sickness 

4.  Glandular  Fever   .... 

5.  Mountain  Fever    .... 

6.  Miliary  Fever  (Sweating  Sickness) 

7.  Foot  and  Mouth  Disease     . 

8.  Psittacosis 

9.  Rocky  Mountain  Spotted  Fever — ^Tick  Fever 
10.  Swine  Fever 


CONTENTS. 


IX 


SECTION   III. 
THE   INTOXICATIONS  AND  SUN-STROICE. 
Alcoholism    . 

1.  Acute  Alcoholism 


II. 
III. 
IV. 

V. 


VI. 


I. 

II. 

III. 

IV. 

V. 

VI. 

VII. 

VIII. 


2.  Chronic  Alcoholism 

3.  Delirium  Tremens 
Morphia  Habit     . 
Lead  Poisoning    . 
Arsenical  Poisoning     . 
Food  Poisoning    . 

1.  Meat  Poisoning   . 

2.  Poisoning  by  Milk  Products 

3.  Poisoning  by  Shell-fish  and  Fish 

4.  Grain  and  Vegetable  Food  Poisoning 
Sun-s,troke 

SECTION  rv. 

CONSTITUTIONAL  DISEASES. 

Arthritis  Deformans 

Chronic  Rheumatism 

Muscular  Rheumatism        ..,.„.. 

Gout ..        =        .., 

Diabetes  Mellitus         .....        o        .        . 
Diabetes  Insipidus       .        .        .        . 

Rickets ,        .        . 

Obesity *    . 


PAGE 

369 
369 
369 
371 
373 
375 
379 
380 
381 
382 
383 
383 
385 


389 
394 
396 
397 
408 
424 
426 
431 


.       SECTION  V. 
DISEASES   OF  THE   DIGESTIVE  SYSTEM. 

A.  Diseases  of  the  Mouth 434 

Stomatitis _  434 

Acute  Stomatitis <>        .        .  434 

Aphthous  Stomatitis 434 

Ulcerative  Stomatitis .  435 

Parasitic  Stomatitis  (Thrush) .        .        .  436 

Gangrenous  Stomatitis 437 

Mercurial  Stomatitis 437 

Geographical  Tongue  (Eczema  of  the  Tongue)  .......  438 

Leukoplakia  buccalis 439 

Fetor  Oris 439 

Oral  Sepsis ••        =        ......  440 

Affections  of  the  Mucous  Glands 440 

B.  Diseases  of  the  Salivary  Glands 440 

Supersecretion , 440 

Xerostomia 441 

Inflammation  of  the  Salivary  Glands       .        .        «      , .        .        .       o        .        .441 

C.  Diseases  of  the  Pharynx   .............  442 

Circulatory  Disturbances 442 

Acute  Pharyngitis 442 

Chronic  Pharyngitis 443 

Ulceration  of  the  Pharynx 443 

Acute  Infectious  Phlegmon  of  the  Pharynx    .        .        ,        .        .        .        .        .  444 

Retro-pharyngeal  Abscess 444 

Angina  Ludovici .        ,        ,        .        .        .        .        .  444 


X  CONTENTS. 

PAGE 

D.  Diseases  of  the  Tonsils „        .        .        .        .  445 

I.   Acute  Tonsillitis 445 

Follicular  or  Lacunar  Tonsillitis        ........  445 

Suppurative  Tonsillitis 446 

II.  Chronic  Tonsillitis 447 

E.  Diseases  of  the  ffisophagus 451 

■   I.  Acute  (Esophagitis 451 

II.   Spasm  of  the  (Esophagus 453 

III.  Stricture  of  the  (Esophagus -  453 

IV.  Cancer  of  the  (Esophagus 454 

V.   Rupture  of  the  (Esophagus 455 

VI.   Dilatations  and  Diverticula 456 

F.  Diseases  of  the  Stomach 456 

I.   Acute  Gastritis 456 

Phlegmonous  Gastritis 458 

Toxic  Gastritis 458 

Diphtheritic  Gastritis 459 

Mycotic  or  Parasitic  Gastritis      .........  459 

II.   Chronic  Gastritis  (Chronic  Dyspepsia) 459 

III.  Dilatation  of  Stomach 467 

IV.  The  Peptic  Ulcer,  Gastric  and  Duodenal 470 

V.  Cancer  of  Stomach 479 

VI.  Hypertrophic  Stenosis  of  the  Pylorus 486 

VII.  Hgemorrhage  from  the  Stomach 487 

VIII.  Neuroses  of  the  Stomach 490 

G.  Diseases  of  the  Intestines         .        .     • 497' 

I.  Diseases  of  the  Intestines  associated  with  Diarrhoea  ....  497 

Catarrhal  Enteritis:  Diarrhoea    .        .        .• 497 

Diphtheritic  or  Croupous  Enteritis 500 

Phlegmonous  Enteritis 501 

Ulcerative  Enteritis 501 

11.  Diarrhoea!  Diseases  in  Children       .........  504 

III.  Appendicitis  (Typhlitis  and  Perityphlitis) 512 

IV.  Intestinal  Obstruction 519 

V.  Constipation  (Costiveness) 525 

VI.  Enteroptosis  (Glenard's  Disease) 528 

VII.  Miscellaneous  Affections 530 

Mucous  Colitis 530 

Dilatation  of  the  Colon .        .        .        .531 

Intestinal  Sand •  532 

Diverticulitis — Perisigmoiditis 532 

Affections  of  the  Mesentery 532 

H.  Diseases  of  the  Liver 534 

I.  Jaundice  (Icterus) 534 

II.  Icterus  Neonatorum 538 

III.  Acute  Yellow  Atrophy 538 

IV.  Affections  of  the  Blood-vessels  of  the  Liver 540 

V.  Diseases  of  the  Bile-passages  and  Gall-bladder 542 

VI.  Cholelithiasis 548 

VII.  Cirrhoses  of  the  Liver 556 

VIII.  Abscess  of  the  liiver .  563 

IX.  New  Growths  in  the  Liver 567 

X.  Fatty  Liver 570 

XI.  Amyloid  Liver 571 

XII.  Anomalies  in  Form  and  Position  of  the  Liver      ,,,,..  572 


CONTENTS. 


XI 


PAGE 

I.  Diseases  of  the  Pancreas 573 

I.  Insufficiency 573 

II.  Hsemorrhage 573 

III.  Acute  Pancreatitis 574 

IV.  Chronic  Pancreatitis 577 

V.  Pancreatic  Cysts ■ 577 

VI.  Tumors  of  the  Pancreas 579 

VII.  Pancreatic  Calcuh        .        .        . •  530 

J.  Diseases  of  the  Peritonaeum 5g0 

I.  Acute  General  Peritonitis 580 

II.  Peritonitis  in  Infants 534 

III.  Localized  Peritonitis 584 

IV.  Chronic  Peritonitis 586 

V.  New  Growths  in  the  Peritonaeum 588 

VI.  Ascites  (Hydro-peritonseum) 589 

SECTION  VI. 
DISEASES   OF  THE   RESPIRATORY  SYSTEM. 

A.  Diseases  of  the  Nose 593 

I.   Acute  Coryza 593 

II.  Autumnal  Catarrh  (Hay  Fever) 594 

III.  Epistaxis 595 

B.  Diseases  of  the  Larynx 595 

I.   Acute  Catarrhal  Laryngitis ,  596 

II.   Chronic  Laryngitis _  597 

III.  Edematous  Laryngitis 598 

IV.  Spasmodic  Laryngitis  (Laryngismus  stridulus) 598 

V.   Tuberculous  Laryngitis 6qq 

VI.  Syphilitic  Laryngitis gQj 

C.  Diseases  of  the  Bronchi    .       ' g02 

I.   Acute  Bronchitis      .        , 6Q2 

II.   Chronic  Bronchitis 594 

III.  Bronchiectasis qqq 

IV.  Bronchial  Asthma 609 

V.    Fibrinous  Bronchitis 513 ' 

D.  Diseases  of  the  Lungs gl4 

I.   Circulatory  Disturbances  in  the  Lungs 614 

II.    Broncho-pneumonia  (Capillary  Bronchitis) 620 

III.  Chronic  Interstitial  Pneumonia  (Cirrhosis  of  Lung) 628 

IV.  Pneumonokoniosis 631 

V.   Emphysema 633 

Compensatory  Emphysema .  633 

Hypertrophic  Emphysema 634 

Atrophic  Emphysema 638 

Acute  Vesicular  Emphysema      . 638 

Interstitial  Emphysema 638 

VI.   Gangrene  of  the  Lung 638 

VII.  Abscess  of  the  Lung 640 

VIII.  New  Growths  in  the  Lungs 641 

E.  Diseases  of  the  Pleura 643 

I.   Acute  Pleurisy 643 

Fibrinous  or  Plastic  Pleurisy      ...00....  643 

Sero-fibrinous  Pleurisy .        .        .  643 

Purulent  Pleurisy  (Empyema) 648 


xii  CONTENTS. 

PAGE 

Tuberculous  Pleurisy 650 

Other  Varieties  of  Pleurisy 650 

II.  Chronic  Pleurisy 655 

III.  Hydrothorax .  656 

IV.  Pneumothorax  (Hydro-pneumothorax  and  Pyo-pneumothorax)       .        .  657 
V.  Affections  of  the  Mediastinum 660 

SECTION  VII. 
DISE.\SES   OF   THE   KIDNEYS. 

I.    Malformations 664 

II.  Movable  Kidney 664 

III.  Circulatory  Disturbances 667 

IV.  AnomaHes  of  the  Urinary  Secretion 668 

1.  Anuria 668 

2.  Haematuria 669 

3.  Haemoglobinuria .        ,  670 

4.  Albuminuria 672 

5.  Pyuria  (Pus  in  the  Urine) 676 

6.  Chyluria  (Non-parasitic) 676 

7.  Lithuria        ...        ...        , 677 

8.  Oxaluria       ................  678 

9.  Cystinuria 679 

10.  Phosphaturia       .        .        .        o 679 

11.  Indicanuria          .........        ....  680 

12.  Melanuria 680 

13.  Alkaptonuria  and  Ochronosis  . 681 

14.  Pneumaturia 681 

15.  Other  Substances        ............  682 

V.    Uraemia 683 

VI.  Acute  Bright' s  Disease       ............  686 

VII.  Chronic  Bright's  Di.sea.se     ............  692 

Chronic  Parenchymatous  Nephritis      .        , ■        .  692 

Chronic  Interstitial  Nephritis        ...........  694 

VIII.    Amyloid  Disease .702 

IX.    Pyelitis 703 

X.    Hydronephrosis 707 

XL    Nephrohthiasis  (Renal  Calculus) .„        ...  709 

XII.    Tumors  of  the  Kidney »        ....  713 

XIII.  Cystic  Disease  of  the  Kidney o 715 

XIV.  Perinephric  Abscess 717 

SECTION  VIII. 
DISEASES   OF  THE   BLOOD  AND   DUCTLESS   GLANDS. 

I.    Ansemia 718 

Secondary  Ansemia 719 

Primary  or  Essential  Ansemia 721 

II.    Leuksemia 731 

III.  Hodgkin's  Disease 738 

IV.  Purpura 742 

V.    Hsemophilia 747 

VI.    Scurvy  . 750 

VII.  Status  L;\Tnphaticus  (L\Tnphatism) .        ...        ......  755 

VIII.  Diseases  of  the  Suprarenal  Bodies 756 

Addison's  Disease 756 


CONTENTS.  xiii 


PAGE 


IX.    Diseases  of  the  Spleen 760 

Movable  Spleen 760 

Rupture  of  the  Spleen 761 

Infarct  and  Abscess  of  the  Spleen 761 

Splenomegaly           762 

Chronic  Polycythsemia  with  Cyanosis  and  Enlarged  Spleen    ....  762 

X.    Diseases  of  the  Thyroid  Gland  .        .        .        o 763 

Congestion 763 

Acute  Thyroiditis .763 

Goitre 763 

Tumors  of  the  Thyroid 764 

Exophthalmic  Goitre 765 

Myxoedema 768 

XI.    Diseases  of  the  Thymus  Gland 771 

XII.    Infantilism 773 


SECTION  IX. 

DISEASES   OF  THE  CIRCULATORY  SYSTEM. 

Diseases  of  the  Pericardium 775 

I.  Pericarditis 775 

II.  Other  Affections  of  the  Pericardium 784 

Diseases  of  the  Heart 785 

I.  Endocarditis 785 

Acute  Endocarditis 785 

Chronic  Endocarditis     ....;...,,.  792 

II.  Chronic  Valvular  Disease  ......' 793 

General  Introduction 793 

Aortic  Incompetency     ..«.-<...,..  796 

Aortic  Stenosis 802 

Mitral  Incompetency 804 

Mitral  Stenosis 808 

Tricuspid  Valve  Disease .        .811 

Pulmonary  Valve  Disease     .        ,        . 813 

Combined  Valvular  Lesions  ..........  813 

III.  Affections  of  the  Myocardium  ..........  820 

Dilatation  and  Hypertrophy 820 

Lesions  due  to  Disease  of  the  Coronary  Arteries 823 

Acute  Interstitial  Myocarditis 824 

Fragmentation  and  Segmentation 825 

Parenchymatous  Degeneration 825 

Fatty  Heart     .       ■ 825 

Other  Degenerations  of  the  Myocardium   . 826 

IV.  Aneurism  of  the  Heart 830 

V.  Rupture  of  the  Heart 830 

VI.  New  Growths  and  Parasites 831 

VII.  Wounds  and  Foreign  Bodies 831 

VIII.  Functional  Affections  of  the  Heart 832 

Palpitation 832 

Arrhythmia 833 

Rapid  Heart  (Tachycardia)          .        .        o        .        .,       ,       .       .        .  835 

Slow  Heart  (Bradycardia)  Heart  Block     .        .       .       ,       „        .        .  836 

Heart  Block  (Stokes- Adams  Disease) 837 


xiv  ■  CONTENTS. 

PAGE 

IX.  Angina  Pectoris 839 

X.  Congenital  Affections  of  the  Heart 843 

C.  Diseases  of  the  Arteries 847 

I.  Degenerations 847 

II.  Arterio-sclerosis  (Arterio-capillary  Fibrosis) 847 

III.  Aneurism 853 

Aneurism  of  the  Thoracic  Aorta 855 

Aneurism  of  the  Abdominal  Aorta 863 

Aneurism  of  the  Branches  of  the  Abdominal  Aorta.        ....  865 

Arterio-venous  Aneurism 865 

Polyarteritis  Acuta  Nodosa  (Periarteritis  Nodosa)          ....  866 

SECTION  X. 
DISEASES   OF  THE   NERVOUS   SYSTEM. 

A.  General  Introduction 867 

B.  System  Diseases 885 

I.  Introduction 885 

II.  Diseases  of  the  Afferent  or  Sensory  System 886 

Locomotor  Ataxia 886 

General  Paralysis  of  the  Insane  and  Tabo-Paralysis        ....  895 

Herpes  Zoster 900 

III.  Diseases  of  the  Efferent  or  Motor  Tract 901 

A.  Of  the  whole  Tract 901 

Progressive  (Central)  Muscular  Atrophy 901 

Bulbar  Paralysis 904 

Progressive  Neural  Muscular  Atrophy        ......  905 

The  Muscular  Dystrophies    .........  906 

B.  System  Diseases  of  the  Upper  Motor  Segment 909 

Spastic  Paralysis  of  Adults 909 

Spastic  Paralysis  of  Infants 910 

Hereditary  Spastic  Paraplegia .912 

Erb's  Sj^philitic  Spinal  Paralysis 913 

Secondary  Spastic  Paralysis 913 

Hysterical  Spastic  Paraplegia       .' 914 

C.  System  Diseases  of  the  Lower  ^lotor  Segment 914 

Chronic  Anterior  Polio-myelitis .        .914 

Ophthalmoplegia .        .        .914 

Acute  Anterior  Polio-myelitis -        .        .914 

Acute  and  Subacute  Polio-myelitis  in  Adults    .....  918 

Acute  Ascending  (Landry's)  Paralysis 918 

IV.  Combined  System  Diseases               919 

Ataxic  Paraplegia 920 

Primary  Combined  Sclerosis  (Putnam) 920 

Hereditary  Ataxia  (Friedreich's  Ataxia) 921 

Progressive  Interstitial  Hj-pertrophic  Neuritis  of  Infants       .        .        .  922 

Toxic  Combined  Sclerosis 922 

C.  Diffuse  Diseases  of  the  Nervous  System 923 

I.  Affections  of  the  Meninges 923 

Diseases  of  the  Dura  Mater  (Pachymeningitis) 923 

Hsemorrhagic  Pachymeningitis    .        .        .        .        =        .        .        .        .  923 

Diseases  of  the  Pia  Mater     .....        o«..        .  925 

Simple  Meningitis  of  Infants        .0.00        =        00.  928 

TI.  Scleroses  of  the  Brain        .        .        ,        <,        »        »        »        o       «        o        .  928 


CONTENTS.  XV 

PAGE 

D.  Diffuse  and  Focal  Diseases  of  the  Spinal  Cord    ........  931 

I.  Topical  Diagnosis 931 

II.  Affections  of  the  Blood-vessels 934 

Congestion 934 

Ansemia 934 

Embolism  and  Thrombosis 935 

Endarteritis 935 

Haemorrhage  into  the  Spinal  Membranes »        .  935 

Haemorrhage  into  the  Spinal  Cord 936 

Caisson  Disease 937 

III.  Compression  of  the  Spinal  Cord 938 

Lesions  of  the  Cauda  Equina  and  Conus  MeduUaris        ....  940 

IV.  Tumors  of  the  Spinal  Cord  and  its  Membranes 941 

V.  Syringomyelia •  943 

IV.  Acute  Myelitis 944 

E.  Diffuse  and  Focal  Diseases  of  the  Brain .  947 

I.  Topical  Diagnosis       ....        o        ....-•        -  947 

II.  Aphasia 955 

III.  Affections  of  the  Blood-vessels .  961 

Cerebral  Circulation       .        .        . .961 

Hypersemia  and  Anaemia 964 

CEdema  of  the  Brain 965 

Cerebral  Haemorrhage 966 

Embolism  and  Thrombosis .  977 

Aneurism  of  the  Cerebral  Arteries -        .        •  982 

Endarteritis 983 

Thrombosis  of  the  Cerebral  Sinuses  and  Veins 983 

Hemiplegia  in  Children .  985 

IV.  Tumors,  Infectious  Granulomata,  and  Cysts  of  the  Brain  ....  988 
V.  Inflammation  of  the  Brain 992 

Acute  Encephalitis 992 

Abscess  of  the  Brain 993 

VI.  Hydrocephalus 996 

F.  Diseases  of  the  Peripheral  Nerves 998 

I.  Neuritis  (Inflammation  of  the  Bundles  of  Nerve  Fibres)     ....  998 

II.  Neuromata 1004 

III.  Diseases  of  the  Cerebral  Nerves 1005 

Olfactory  Nerves  and  Tracts 1005 

Optic  Nerve  and  Tract 1006 

Lesions  of  the  Retina 1006 

Lesions  of  the  Optic  Nerve •        •  1008 

Affections  of  the  Chiasma  and  Tract 1009 

Affections  of  the  Tract  and  Centres        .......  1010 

Motor  Nerves  of  the  Eyeball 1013 

Fifth  Nerve 1017 

Facial  Nerve 1019 

Auditory  Nerve 1023 

The  Cochlear  Nerve 1023 

The  Vestibular  Nerve 1024 

Glosso-pharyngeal  Nerve       .        .        .        .        .        o        »        .        .        ■  1026 

Pneumogastric  Nerve    .....        o...-        •  1027 

Spinal  Accessory .        .        .        .        .        •  1030 

Hypoglossal  Nerve.        .        .        .        .        «        .        .        .        •        •        •  1032 


xvi  CONTENTS. 

PAGti 

IV.  Diseases  of  the  Spinal  Nerves  ....,...,.  1033 

Cervical  Plexus       ............  1033 

Brachial  Plexus       ............  1035 

Lumbar  and  Sacral  Plexuses        .........  1038 

Sciatica 1039 

G.    General  and  Functional  Diseases 1041 

I.  Acute  Delirium  (Bell's  Mania) 1041 

II.  Paralysis  Agitans 1042 

Other  Forms  of  Tremor 1044 

III.  Acute  Chorea  (Sydenham's  Chorea;  St.  Vitus's  Dance)       ....  1045 

IV.  Other  Affections  described  as  Chorea 1053 

V.  Infantile  Convulsions  (Eclampsia) -  1056 

VI.  Epilepsy .  1058 

VII.  Migraine 1066 

VIII.  Neuralgia 1068 

IX.  Professional  Spasms;  Occupation  Neuroses    .        •        .        .        .        .        .  1072 

X.  Tetany 1074 

XI.  Hysteria 1076 

XII.  Neurasthenia 1086 

XIII.  The  Traumatic  Neuroses 1096 

XIV.  Other  Forms  of  Functional  Paralysis 1099 

Periodical  Paralysis 1099 

Astasia;  Abasia       ............  1099 

H.    Vaso-motor  and  Trophic  Disorders       ..........  1100 

I.  Raynaud's  Disease     ............  1100 

II.  Erythromelalgia          ............  1102 

III.  Angio-neurotic  (Edema      ...........  1103 

IV.  Facial  Hemiatrophy 1104 

V.  Acromegaly         .............  1105 

Osteitis  Deformans         ...........  1106 

Hypertrophic  Pulmonary  Arthropathy       .......  1107 

Leontiasis  Ossea 1107 

Osteogenesis  Imperfecta 1108 

Achondroplasia  (Chondrodystrophia  Foetalis)   ......  1108 

VI.  Scleroderma 1109 

Ainhum 1110 

SECTION  XI. 
DISEASES   OF  THE   MUSCLES. 

I.  Myositis 1111 

1112 
1113 
1113 
1114 


II.  Myotonia  (Thomsen's  Disease) 

III.  Paramyoclonus  Multiplex 

IV.  Myasthenia  Gravis 
V.  Amyotonia  congenita  (Oppenheim's  Disease) 


CHAETS  AND   ILLUSTEATIONS. 


la.  Malaria — Double  Tertian  Infection — Quotidian  Fever      .....  18 

lb.  ^stivo-autumnal  Infection — Remittent  Fever  .        .        .        .        .        .        .18 

Ic.  ^stivo-autumnal  Fever — Quotidian  Paroxysms        .        .        .        .        .        .19 

Id.  Quartan  Fever 19 

II.    Typhoid  Fever  with  Relapse ...........  73 

III.  Illustrating  the  Blood  Changes  in  Typhoid  Fever     ......  77 

IV.  Typhoid  Fever — Haemorrhage  from  the  Bowels* 81 

V.    Illustrating  Influence  of  Baths  in  Typhoid  Fever      .        .        .        .        .        .  101 

VI.    Relapsing  Fever  (after  Murchison) Ill 

VII.    Small-pox  (after  Striimpell) 116 

VIII.    Scarlet  Fever 133 

IX.    Measles 142 

X.    Temperature,  Pulse,  and  Respiration  Chart  in  Pneumonia     ....  173 

XL    Showing  Coincident  Drop  in  the  Fever  and  in  the  Leucocytes  in  Pneumonia.  178 

XII.    Chronic  Tuberculosis,  Two-hourly  Chart  for  Three  Days          ....  328 

XIII.  Case  of  Sun-stroke  treated  with  Ice-bath.  Recovery.  (Rectal  Temperatures).  387 

XIV.  Showing  LTric  Acid  and  Phosphoric  Acid  Output  in  a  Case  of  Acute  Gout     .  402 
XV.     Illustrating  Influence  of  Diet  on  Sugar  and  Amount  of  LTrine  in  Diabetes     .  422 

XVI.    Blood  Chart,  illustrating  Ansemia  in  Purpura  Haemorrhagica ....  720 

XVII.     Blood  Chart,  illustrating  Chlorosis 723 

XVIII.    Blood  Chart,  illustrating  Pernicious  Ansemia 727 

XIX.    Blood  Chart,  illustrating  Leukaemia 735 

XX.    Blood  Chart,  illustrating  Rapid  Production  of  Anaemia  in  Purpura  Haem- 
orrhagica        . 746 

XXI.     Diagrams  after  Martins,  showing  schematically  the  Power  of  the  Heart 

Muscle      . .        .        .794 

XXII.    Schematic  Division  of  the  Phases  of  the  Heart's  Action  (Martins)         .        .  796 


1 

2 
3 
4 
5 
6 
7,8, 
9 
10 


Diagram  of  Motor  Path  from  Left  Brain  (Van  Gehuchten)      ....  869 

Diagram  of  Motor  Path  (Van  Gehuchten) 870 

Diagram  of  Cerebral  Localization 874 

Diagram  of  Motor  and  Sensory  Representation  in  the  Internal  Capsule        .  875 

Diagram  of  Motor  and  Sensory  Paths  in  Crura 876 

Diagram  of  Cross-section  of  Spinal  Cord 876 

Diagrams  of  Skin  Areas  corresponding  to  the  Different  Spinal  Segments,  878,  879 

Diagram  of  Motor  Path  from  Left  Brain 972 

Diagram  of  Visual  Paths  (Vialet) 1011 


*  The  red  shows  the  two-hourly,  the  black  the  morning  and  evening  temperature. 
1  xvii 


A    TEXT-BOOK    ON 
THE    PRACTICE    OF   MEDICINE. 


SECTION   I. 

DISEASES  DUE   TO   ANIMAL  PAEASITES. 

A.    DISEASES  DUE   TO   PROTOZOA. 

I.    PSOROSPERMIASIS. 

Under  this  term  are  embraced  several  affections  produced  by  the  spo- 
rozoa — also  known  as  psorosperms  and  gregarinidae — parasites  which  are 
extraordinarily  abundant  in  the  invertebrates^,  and  are  not  uncommon  in  the 
higher  mammals.  Psorosperms  are,  as  a  rule,  parasites  of  the  cells — Cytozoa. 
The  most  suitable  form  for  study  is  Coccidium  oviforme  of  the  rabbit,  which 
produces  a  disease  of  the  liver  in  which  the  organ  is  studded  throughout  with 
whitish  nodules,  ranging  in  size  from  a  pin's  head  to  a  split  pea.  On  section 
each  nodule  is  seen  to  be  a  dilated  portion  of  a  bile-duct;  the  walls  are  lined 
with  epithelium  in  the  interior  of  which  are  multitudes  of  ovoid  bodies — coc- 
cidia.  Another  very  common  form  occurs  in  the  muscles  of  the  pig,  the 
so-called  Eainey's  tube,  which  is  an  ovoid  body  within  the  sarcolemma  contain- 
ing a  number  of  small,  sickle-shaped,  unicellular  organisms,  Sarcocystis  Mies- 
cheri.     Another  species,  S.  Jiominis,  has  been  described  in  man. 

Psorosperms  do  not  play  a  very  important  role  in  human  pathology. 

1.  Internal  Psorospermiasis. — In  a  majority  of  the  cases  of  this  group 
the  psorosperms  have  been  found  in  the  liver,  producing  a  disease  similar 
to  that  which  occurs  in  rabbits.  In  Guebler's  case  there  were  tumors  which 
could  be  felt  during  life,  and  they  were  determined  by  Leuckart  to  be  due 
to  coccidia.  A  patient  of  W.  B.  Haddon's  was  admitted  to  St.  Thomas's 
Hospital  with  slight  fever  and  drowsiness,  and  gradually  became  unconscious ; 
death  occurring  on  the  fourteenth  day  of  observation.  Whitish  neoplasms 
were  found  upon  the  peritonaeum,  omentum,  and  on  the  layers  of  the  peri- 
cardium; and  a  few  were  found  in  the  liver,  spleen,  and  kidneys.  A  some- 
what similar  case,  though  more  remarkable,  as  it  ran  a  very  acute  course,  is 
reported  by  Silcott.  A  woman,  aged  fifty-three,  admitted  to  St.  Mary's  Hos- 
pital, was  thought  to  be  suffering  from  typhoid  fever.  She  had  had  a  chill 
six  weeks  before  admission.  There  were  fever  of  an  intermittent  type,  slight 
diarrhoea,  nausea,  tenderness  over  the  liver  and  spleen,  and  a  dry  tongue; 
death  occurred  from  heart-failure.  The  liver  was  enlarged,  weighed  83 
ounces,  and  in  its  substance  there  were  caseous  foci,  around  each  of  which 
was  a  ring  of  congestion.  The  spleen  weighed  16  ounces  and  contained  sim- 
3  1 


2  DISEASES  DUE  TO  ANIMAL  PARASITES. 

ilar  bodies.  The  ileum  presented  six  papiile-like  elevations.  The  masses 
resembled  tubercles,  but  on  examination  coccidia  were  found. 

The  parasites  are  also  found  in  the  kidneys  and  ureters.  Cases  of  this 
kind  have  been  recorded  by  Bland  Sutton  and  Paul  Eve.  In  Eve's  case 
the  symptoms  were  liEematuria  and  frequent  micturition,  and  death  took 
place  on  the  seventeenth  day.  The  nodules  throughout  the  pelvis  and  ureters 
have  been  regarded  as  mucous  cysts. 

2.  Cutaneous  Psorospermiasis. — The  question  of  a  protozoic  dermatitis 
has  been  much  discussed.  The  cases  described  by  Gilchrist,  Darier,  Eixford, 
Montgomery,  Ophiils,  and  others  as  dermatitis  coccidoides  have  been  shown 
to  be  due  to  a  fungus  allied  to  oidium,  and  the  disease  is  now  known  as 
oidiomycosis.  About  50  cases  have  been  reported,  nearly  all  from  the  Pacific 
coast  of  the  United  States.  The  relation  of  the  disease  to  blastomycosis  is 
still  undetermined.  The  systemic  forms  of  both  have  much  in  common — a 
chronic  infectious  process  with  multiple  abscesses  and  nodules  involving  the 
skin,  bones,  joints,  and  internal  organs,  with  symptoms  simulating  chronic 
tuberculosis  or  pyaemia. 

II.    AMCEBIC    DYSENTERY. 

Definition. — A  colitis,  acute  or  chronic,  caused  by  the  Amcebic  dysen- 
terice.  There  is  a  special  liability  to  the  formation  of  abscess  of  the  liver. 
A  widely  prevalent  disease  in  Egypt,  in  India,  and  in  tropical  countries.  It 
is  the  common  variety  of  dysentery  throughout  the  United  States.  It  is 
endemic,  the  cases  sometimes  increasing  to  such  an  extent  as  to  form  an  epi- 
demic. Sporadic  instances  apparently  occur  in  all  temperate  regions.  The 
relative  frequency  of  this  form  of  dysentery  in  the  tropics  is  illustrated  by  the 
Manila  statistics  as  given  by  Strong — of  1,328  cases  in  the  United  States 
Army,  561  were  of  the  amoebic  variety.  The  cases  of  acute  and  chronic  dysen- 
tery in  the  Johns  Hopkins  Hospital  have  been  almost  exclusively  amoebic. 
Futcher  and  Boggs  have  analyzed  the  cases  to  1908.  Of  182,  123  came  from 
the  State  of  Maryland,  171  were  in  males;  163  in  whites  to  19  in  blacks. 

Infection  takes  place  from  drinking  contaminated  water  and  by  eating 
green  vegetables,  such  as  lettuce.  Musgrave  has  grown  amoebae  from  ice- 
cream used  at  receptions,  etc. 

Amceba  Dysenteric. — The  organism  was  first  described  by  Lambl  in 
1859,  and  subsequently  by  Losch  in  1875.  It  is  placed  by  Leuckart  in  the 
Rhizopoda  class  of  the  Protozoa.  Kartulius  found  them  in  the  stools  of  the 
endemic  dysentery  in  Egypt,  and  in  the  liver  abscesses.  In  1890  I  found  them 
in  a  case  of  dysentery  with  abscess  of  the  liver  originating  in  Panama.  Sub- 
sequently from  my  wards  a  series  of  cases  was  described  by  Councilman  and 
Lafleur.  Since  then  numbers  of  observations  have  been  made  by  Dock  in  the 
United  States,  by  Quincke  and  Roos  in  Germany,  and  by  many  others.  The 
little  flakes  of  mucus  or  pus  in  the  stools  should  be  selected  for  examination 
or  the  mucus  obtained  by  passing  a  soft-rubber  catheter.  Musgrave,  on  the 
other  hand,  holds  that  the  best  results  are  obtained  by  giving  the  patient  a 
saline  cathartic  and  examining  the  fluid  portion  of  the  stool.  Students  must 
learn  to  distinguish  from  amoebae  the  swollen,  altered  epithelial  cells,  which 
are  round,  with  granular  protoplasm. 


DISEASES  DUE  TO  PROTOZOA.  3 

Amoeba  or  Entamoeba  dysenterice  is  from  fifteen  to  twenty  ix  in  diameter, 
and  consists  of  a  clear  outer  zone  (ectosarc),  and  a  granular  inner  zone  (endo- 
sarc),  and  contains  a  nucleus  and  one  or  two  vacuoles.  The  movements  are 
very  similar  to  those  of  the  ordinary  amoeba,  consisting  of  slight  protrusions 
of  the  protoplasm.  They  vary  a  good  deal,  and  usually  may  be  intensified  by 
having  the  slide  heated.  Not  infrequently  the  amoebae  contain  red  blood- 
corpuscles  which  they  have  included.  In  the  tissues  they  are  very  readily 
recognized  by  suitable  stains.  They  may  be  in  enormous  numbers,  and  some- 
times the  field  of  the  microscope  is  completely  occupied  by  them.  In  the 
pus  of  a  liver  abscess  they  may  be  very  abundant,  though  in  large,  long-stand- 
ing abscesses  they  may  not  be  found  until  after  a  few  days,  when  the  pus  begins 
to  discharge  from  the  wall  of  the  abscess  cavity.  In  the  sputum  in  the  cases  of 
pulmono-hepatic  abscess  they  are  readily  recognized. 

Amoebae  are  frequently  found  in  the  stools  of  healthy  persons,  as  Cunning- 
ham and  Lewis  pointed  out.  Schaudinn  found  them  in  from  20  to  60  per 
cent  in  Germany,  but  they  vary  greatly  in  different  localities.  Among  300 
persons  in  Manila,  Musgrave  found  101  infected  with  amoebae,  61  of  these 
had  dysentery,  the  remaining  40  had  no  diarrhoea.  In  the  next  two  months 
8  of  the  40  cases  died  and  showed  amoebic  infection  of  the  bowel.  Within 
the  next  three  months  the  remaining  32  had  dysentery.  Musgrave  believes 
that  at  any  time  the  amoeba  may  become  pathogenic.  Schaudinn  described 
two  distinct  forms — a  nonpathogenic  Entamwbi  coli,  and  a  pathogenic  larger 
form,  the  Entamoeba  histolytica,  the  same  as  the  Amoeba  dysenterice,  with  a 
strongly  refractile  hyaline  ectoplasm.  The  amoebae  have  been  cultivated  by 
Miller,  Musgrave,  Clegg,  and  others,  but  with  difficulty,  and  it  is  doubtful 
if  they  grow  apart  from  certain  bacteria.  Eesistant  forms,  somewhat  anal- 
ogous to  the  gamete  forms  of  the  malarial  parasite,  have  been  described  by 
Cunningham,  Grassi  and  Calandruccio,  and  by  Quincke.  These  "encysted 
amoebae  ■ '  are  believed  to  be  necessary,  under  certain  conditions,  for  the  trans- 
mission of  the  disease  from  one  person  to  another,  and  are  regarded  by  Mus- 
grave and  Clegg  as  the  most  dangerous  forms  of  the  organism.  Cultures  of 
amoebse  have  been  shown  to  withstand  drying  for  from  eleven  to  fifteen  months. 

Morbid  Anatomy. — The  lesions  are  found  in  the  large  intestine,  some- 
times in  the  lower  portion  of  the  ileum.  Abscess  of  the  liver  is  very  common, 
and  occurred  in  37  of  182  cases  at  the  Johns  Hopkins  Hospital. 

Intestines. — The  lesions  consist  of  ulceration,  produced  by  preceding 
infiltration,  general  or  local,  of  the  submucosa,  due  to  an  oedematous  condition 
and  to  multiplication  of  the  fixed  cells  of  the  tissue.  In  the  earliest  stage 
these  local  infiltrations  appear  as  hemispherical  elevations  above  the  general 
level  of  the  mucosa.  The  mucous  membrane  over  these  soon  becomes  necrotic 
and  is  cast  off,  exposing  the  infiltrated  submucous  tissue  as  a  grayish-yellow 
gelatinous  mass,  which  at  first  forms  the  floor  of  the  ulcer,  but  is  subsequently 
cast  off  as  a  slough. 

The  individual  ulcers  are  round,  oval,  or  irregular,  with  infiltrated, 
undermined  edges.  The  visible  aperture  is  often  small  compared  to  the  loss 
of  tissue  beneath  it,  the  ulcers  undermining  the  mucosa,  coalescing,  and  form- 
ing sinuous  tracts  bridged  over  by  apparently  normal  mucous  membrane. 
According  to  the  stage  at  which  the  lesions  are  observed,  the  floor  of  the  ulcer 
may  be  formed  by  the  submucous,  the  muscular,  or  the  serous  coat  of  the 


4  DISEASES  DUE  TO  ANIMAL  PARASITES. 

intestine.  Tlie  ulceration  may  affect  tlie  whole  or  some  portion  only  of  the 
large  intestine,  particularly  the  cgecum,  the  hepatic  and  sigmoid  flexures,  and 
the  rectum.  In  severe  cases  the  whole  of  the  intestine  is  much  thickened  and 
riddled  with  ulcers,  with  only  here  and  there  islands  of  intact  mucous  mem- 
brane. In  100  autopsies  on  this  disease  in  Manila  the  appendix  was  involved 
in  7 ;  perforation  of  the  colon  took  place  in  19. 

The  disease  advances  by  progressive  infiltration  of  the  connective-tissue 
laj^ers  of  the  intestine,  which  produces  necrosis  of  the  overlying  structures. 
Thus,  in  severe  cases  there  may  be  in  different  parts  of  the  bowel  sloughing 
en  masse  of  the  mucosa  or  of  the  muscularis,  and  the  same  process  is  observed, 
but  not  so  conspicuously,  in  the  less  severe  forms. 

In  some  cases  a  secondary  diphtheritic  inflammation  complicates  the  origi- 
nal lesions. 

Healing  takes  place  by  the  gradual  formation  of  fibrous  tissue  in  the  floor 
and  at  the  edges  of  the  ulcers,  which  may  ultimately  result  in  partial  and 
irregular  strictures  of  the  bowel. 

Microscoj)ical  examination  shows  a  notable  absence  of  the  products  of  puru- 
lent inflammation.  In  the  infiltrated  tissues  polynuclear  leucocytes  are  sel- 
dom found,  and  never  constitute  purulent  collections.  On  the  other  hand, 
there  is  proliferation  of  the  fixed  connective-tissue  cells.  Amoebee  are  found 
more  or  less  abundantly  in  the  tissues  at  the  base  of  and  around  the  ulcers,  in 
the  lymphatic  spaces,  and  occasionally  in  the  blood-vessels.  The  portal 
capillaries  occasionally  contain  them,  and  this  fact  seems  to  afford  the  best 
explanation  for  the  mode  of  infection  of  the  liver. 

The  lesions  in  the  livei'  are  of  two  kinds:  first,  local  necroses  of  the 
parenchj^ma,  scattered  throughout  the  organ,  and  possibly  due  to  the  action 
of  chemical  products  of  the  amoebas;  and,  secondly,  abscesses.  These  may 
be  single  or  multiple.  There  were  27  cases  of  hepatic  abscess  among  the  119 
cases  of  amoebic  dysentery  in  my  wards.  Of  these,  18  came  to  autopsy.  In 
10  the  abscess  was  single  and  in  8  multiple.  When  single  they  are  generally 
in  the  right  lobe,  either  toward  the  convex  surface  near  its  diaphragmatic 
attachment,  or  on  the  concave  surface  in  proximity  to  the  bowel.  Multiple 
abscesses  are  small  and  generally  superficial.  There  may  be  innumerable 
miliary  abscesses  containing  amoebse  scattered  throughout  the  entire  liver. 
Although  the  hepatic  abscess  usualh"  occurs  within  the  first  two  months  from 
the  onset  of  the  dysenterj'-,  in  one  of  my  cases  the  latter  had  lasted  one  and 
in  another  six  years.  In  5  cases  the  intestinal  symptoms  had  been  so  slight 
that  dysentery  had  never  been  complained  of.  In  2  fatal  cases  there  were  only 
scars  of  old  ulcers  and  in  2  others  the  mucosa  appeared  normal.  In  an  early 
stage  the  abscesses  are  gra}ash-yellow,  with  sharpily  defined  contours,  and  con- 
tain a  spongy  necrotic  material,  with  more  or  less  fluid  in  its  interstices.  The 
larger  abscesses  have  ragged  necrotic  walls,  and  contain  a  more  or  less  viscid, 
greenish-3-ellow  or  reddish-yellow  purulent  material  mixed  with  blood  and 
shreds  of  liver-tissue.  The  older  abscesses  have  fibrous  walls  of  a  dense, 
almost  cartilaginous  toughness.  A  section  of  the  abscess  wall  shows  an  inner 
necrotic  zone,  a  middle  zone  in  which  there  is  great  proliferation  of  the  con- 
nective-tissue cells  and  compression  and  atrophy  of  the  liver-cells,  and  an  outer 
zone  of  intense  hypera^mia.  There  is  the  same  absence  of  purulent  inflam- 
mation as  in  the  intestine,  except  in  those  cases  in  which  a  secondary  infec- 


DISEASES  DUE  TO  PROTOZOA.  5 

tion  with  p3'0genic  organisms  has  taken  place.  Lesions  in  the  kings  are  seen 
when  an  abscess  of  the  liver — as  so  frequently  happens — points  toward  the 
diaphragm  and  extends  by  continuity  through  it  into  the  lower  lobe  of  the 
right  lung.  This  is  the  commonest  situation  for  rupture  to  occur.  Nine  of 
my  cases  ruptured  into  the  lung.  In  3  cases  rupture  into  the  right  pleura 
occurred,  causing  an  empyema.  In  one  of  these  the  lung  abscess  ruptured 
into  the  pleura,  producing  a  pyo-pneumothorax.  Depending  upon  the  situa-.. 
tion  of  the  abscess,  perforation  may  occur  into  other  adjacent  structures.  In 
3  of  the  cases  perforation  took  place  into  the  inferior  vena  cava  and  in  another 
the  upper  pole  of  the  right  kidney  had  been  invaded.  The  abscess  may  rupture 
into  the  pericardium,  peritonseimi,  stomach,  intestine,  portal  and  hepatic  veins, 
or  externally.* 

Symptoms. — Differing  remarkably  in  their  symptoms,  three  groups  of  cases 
may  be  recognized : 

Mild  Form. — Infection  may  be  present  for  a  month  or  two  before  the 
individual  is  aware  of  it.  There  may  be  vague  spnptoms — headache,  lassitude, 
weakness,  slight  abdominal  pains  and  occasional  diarrhoea,  features  common 
enough  in  the  tropics.  Strong  gives  the  case  of  one  of  his  laboratory  chemists 
who  had  slight  diarrhoea  for  one  day  and  asked  to  have  the  stools  examined; 
an  unusually  rich  infection  with  amoeba  was  found.  The  next  day  he  felt  well. 
From  August  to  December  10th  amcebge  were  present  in  the  stools,  though  he 
had  no  s3anptoms.     Liver  abscess  may  occur  in  these  cases. 

Acute  x4mcebic  Dysentery. — Many  cases  have  an  acute  onset.  Pain  and 
tenesmus  are  severe.  The  stools  are  bloody,  or  mucus  and  blood  occur  to- 
gether. In  very  severe  cases  there  may  be  constant  tenesmus,  with  pain  of 
the  greatest  intensity,  and  the  passage  every  few  minutes  of  a  little  blood  and 
mucus.  In  some  cases  large  sloughs  are  passed.  The  temperature  as  a  rule 
is  not  high.  The  patient  may  become  rapidly  emaciated;  the  heart's  action 
becomes  feeble,  and  death  may  occur  within  a  week  of  the  onset.  Among 
the  other  symptoms  to  be  mentioned  are  haemorrhage  from  the  bowels,  which 
occurred  in  three  cases ;  perforation  of  an  ulcer,  which  occurred  in  three  cases, 
with  general  peritonitis.  While  in  a  majority  of  the  instances  the  patient 
recovers,  in  others  the  disease  drags  on  and  becomes  chronic.  In  a  few  cases, 
after  the  separation  of  the  sloughs,  there  is  extensive  ulceration  remaining, 
with  thickening  and  induration  of  the  colon,  and  the  patient  has  constant 
diarrhoea,  loses  weight,  and  ultimately  dies  exhausted,  usually  within  three 
months  of  the  onset.  With  the  exception  of  cancer  of  the  oesophagus  and 
anorexia  nervosa,  no  such  extreme  grade  of  emaciation  is  seen  as  in  these 
cases.     Extensive  ulceration  of  the  cornea  may  occur. 

Chroxic  Amcebic  Dysentery. — The  disease  may  be  subacute  from  the 
onset,  and  gradually  passes  into  a  chronic  stage,  the  special  characteristic  of 
which  is  alternating  periods  of  constipation  and  of  diarrhoea.  These 'may 
occur  over  a  period  of  from  six  months  to  a  year  or  more.  Some  of  our 
patients  have  been  admitted  to  the  hospital  five  or  six  times  within  a  period 
of  two  years.  During  the  exacerbations  there  are  pain,  frequent  passages  of 
mucus  and  blood,  and  a  slight  rise  of  temperature.  Many  of  these  patients  do 
not  feel  very  ill,  and  retain  their  nutrition  in  a  remarkable  way;  indeed,  in 
the  United  States  it  is  rare  to  see  the  extreme  emaciation  so  common  in  the 
*  For  a  full  account  of  Hepatic  Abscess  see  Rolleston's  work  on  Diseases  of  the  Liver. 


6  DISEASES  DUE  TO  ANIMAL  PARASITES. 

chronic  cases  from  the  tropics.  Alternating  periods  of  improvement  with 
attacks  of  diarrhoea  are  the  rule.  The  appetite  is  capricious,  the  digestion 
disordered,  and  slight  errors  in  diet  are  apt  to  be  followed  at  once  by  an 
increase  in  the  number  of  stools.  The  tongue  is  often  red,  glazed,  and  beefy. 
In  protracted  cases  the  emaciation  may  be  extreme. 

Complications  and  Sequelae. — Hepatic  and  hepato-pulmonary  abscesses, 
the  most  frequent  and  serious  complications,  have  already  been  dealt  with. 
Perforation  of  the  intestine  and  peritonitis  occurred  in  three  of  my  cases. 
Intestinal  haemorrhage  occurred  three  times.  The  infrequency  of  this  com- 
plication is  probably  due  to  the  thrombosis  of  the  vessels  about  the  areas  of 
infiltration.  Occasionally  an  arthritis,  probably  toxic  in  origin,  may  occur. 
There  was  one  case  in  my  series.  Five  cases  were  complicated  by  malaria; 
1  by  typhoid  fever;  1  by  pulmonary  tuberculosis;  and  1  by  a  strongyloides 
intestinalis  infection. 

Diagnosis. — From  the  other  forms  of  dysenter}-  the  disease  is  recog- 
nized by  the  finding  of  amcebse  in  the  stools.  Unless  one  sees  undoubted 
amoeboid  movement  a  suspected  body  should  not  be  considered  an  amoeba. 
A  non-motile  body  containing  one  or  more  red  cells  is  most  probably  an 
amoeba,  but  should  only  lead  to  further  search  for  motile  organisms.  Swollen 
epithelial  cells  are  confusing,  but  the  hyaline  periphery  is  not  amoeboid 
in  its  action  as  is  the  ectosarc  of  the  amoeba.  The  trichomonads  and  cerco- 
monads  so  frequently  associated  with  amoebge  are  not  likely  to  give  trouble. 
The  upper  level  of  liver  dulness  should  be  watched  throughout  the  course 
of  a  case.  Any  increase  upward  or  downward  should  lead  to  the  suspicion 
of  a  liver  abscess.  Hepatic  abscess  is  usually  accompanied  by  fever,  sweats,  or 
chills  and  local  pain.  It  may  be  entirely  latent.  A  varying  leucocytosis 
occurs  in  the  abscess  cases.  The  highest  count  in  my  series  was  53,000,  the 
average  being  18,350.  The  average  leucocyte  count  in  the  uncomplicated 
dysentery  cases  was  10,600.  Hepato-pulmonary  abscess  is  attended  by  local 
lung  signs  and  the  expectoration  of  "  anchovy  sauce  "  sputum  in  which  amoebse 
are  almost  invariably  found. 

Prognosis. — In  many  cases  the  disease  yields  to  rest  and  intestinal  medi- 
cation. Tendency  to  a  relapse  of  the  dysenteric  symptoms  is  one  of  the  strik- 
ing characteristics  of  the  disease.  One  of  my  cases  was  admitted  to  the 
hospital  five  times  in  nine  months.  Of  the  119  cases,  28,  or  23.5  per  cent, 
terminated  fatally.  That  hepatic  abscess  is  a  serious  complication  is  shown 
by  the  fact  that  of  the  27  cases  with  this  complication  19  died.  Seventeen 
cases  were  operated  on  with  5  recoveries. 

Treatment. — The  disease  is  probably  contracted  in  identically  the  same 
way  as  typhoid  fever.  Accordingly,  the  same  prophylactic  measures  should 
be  used.  Eest  in  bed  is  very  important  and  materially  hastens  recovery. 
The  diet  should  be  governed  by  the  severity  of  the  intestinal  manifestations. 
In  the  very  acute  cases  the  patient  should  be  given  a  liquid  diet,  consisting  of 
milk,  whey,  and  broths.  Medicines  administered  internally  yield,  on  the 
whole,  very  unsatisfactory  results.  Considering  the  fact  that  other  bacteria 
are  necessary  for  the  growth  of  the  amoeb£e  in  the  intestine,  Musgrave  thinks 
that  an  effort  should  be  made  to  limit  the  growth  of  the  former  by  the  admin- 
istration of  intestinal  antiseptics.  None  of  these  have  proved  very  satisfac- 
tory, however,  although  Strong  obtained  good  results  with  the  use  of  aceto- 


DISEASES  DUE   TO  PROTOZOA.  7 

zone  administered  by  mouth  and  by  enema.  Bismuth  probably  does  more 
harm  than  good  owing  to  the  fact  that  it  coats  the  surface  of  the  ulcers  so 
that  the  solutions  used  in  the  injections  can  not  reach  the  amoebae  in  the  ulcer 
walls.  Large  injections  of  quinine  solution  in  the  strength  of  1  to  5,000, 
gradually  increasing  to  1  to  2,500,  and  later  to  1  to  1,000,  have  given  most 
satisfactory  results  of  all  the  remedies  yet  tried.  The  success  of  the  treatment 
depends  largely  on  the  care  with  which  the  injections  are  given.  The  failures 
are  undoubtedly,  in  many  instances,  due  to  the  fact  that  sufficient  care  is  not 
used  to  insure  the  solution  reaching  the  caecum  and  ascending  colon  where  the 
ulceration  is  often  most  severe.  From  a  litre  to  two  litres  should  be  allowed 
to  flow  into  the  colon.  The  amoebae  are  rapidly  destroyed  by  the  drug.  The 
patient's  hips  should  be  elevated  and  he  should  change  his  position  so  as  to 
allow  the  fluid  to  flow  into  all  parts  of  the  colon.  The  solution  should  be 
retained,  if  possible,  for  fifteen  minutes.  These  large  injections,  which  Mus- 
grave  also  strongly  advocates,  are  said  not  to  be  without  a  certain  degree  of 
danger.  I  have,  however,  never  seen  any  ill  effects,  even  with  the  very  large 
amoiints.  Two  injections  daily  may  be  given.  When  there  is  much  tenesmus 
a  small  injection  of  thin  starch  and  half  a  drachm  to  a  drachm  of  laudanum 
gives  great  relief;  but  for  the  tormina  and  tenesmus,  the  two  most  distressing 
symptoms,  a  hypodermic  of  morphia  is  the  only  satisfactory  remedy.  Local 
application  to  the  abdomen,  in  the  form  of  light  poultices,  or  turpentine  stupes 
are  very  grateful.  Tuttle  has  recently  reported  good  results  in  the  treatment 
of  amoebic  dysentery  by  the  use  of  simple  ice-water  enemas,  given  frequently. 
When  medical  treatment  fails,  colostomy  may  be  tried  or  irrigations  given 
through  the  appendix. 


III.    TRYPANOSOMIASIS. 

Definition. — A  chronic  disorder  characterized  by  fever,  lassitude,  weak- 
ness, wasting,  and  often  a  protracted  lethargy — sleeping  sickness.  Trypano- 
soma gamhiense  is  the  active  agent  in  the  disease. 

History. — In  1843  Gruby  found  a  blood  parasite  in  the  frog  which  he 
called  Trypanosoma  sanguinis.  Subsequently  it  was  found  to  be  a  very  com- 
mon blood  parasite  in  fishes  and  birds.  In  1878  Lewis  found  it  in  the  rat — 
T.  lewisii — in  which  it  apparently  does  no  harm.  The  pathological  signifi- 
cance of  the  protozoa  was  first  suggested  in  1880  by  Griffith  Evans,  who  discov- 
ered trypanosomes — T.  evansii — in  the  disease  of  horses  and  cattle  in  India 
known  as  snrra.  Unfortunately,  as  my  good  friend  Evans  often  complained 
to  me,  but  little  attention  was  paid  to  this  really  radical  discovery — not  even 
the  subsequent  studies  of  Laveran  on  malaria  and  of  Theobald  Smith  on 
Texas  fever  stirred  workers  to  a  recognition  of  the  place  of  the  protozoa  as 
pathogenic  agents.  In  1895  Bruce  made  the  important  announcement  that 
the  tsetze  fly  disease  or  nagana  of  South  Africa,  which  made  whole  districts 
impassable  for  cattle  and  horses,  was  really  due  to  a  trypanosome — T.  hrucei. 
Normally  present  in  the  blood  of  the  big-game  animals  of  the  districts,  and 
doing  them  no  harm,  it  was  conveyed  by  the  tsetze  fly  to  the  non-immune  horses 
and  cattle  imported  into  what  were  called  the  fly-belts.  Other  trypanosomes 
are  the  Philippine  surra,  studied  by  Musgrave,  the  mal  de  caderas — T.  equi- 


8  DISEASES  DUE  TO  ANIMAL  PARASITES. 

num — of  South  America  and  a  harmless  infection  in  cattle  in  the  Transvaal 
caused  by  Trypanosoma  theileri. 

Human  Trypanosomiasis. — In  1901  Button  found  a  trypanosome  in  the 
blood  of  a  West  Indian.  In  1903  Castellani  found  trypanosomes  in  the  cere- 
bro-spinal  fluid  and  in  the  blood  of  five  cases  of  the  African  sleeping  sickness. 
The  Eoyal  Society  Commission  (Bruce  and  Nabarro)  demonstrated  the  great 
frequency  of  the  parasites  in  the  cerebro-spinal  fluid  and  in  the  blood  in  sleep- 
ing sickness,  and  suggested  that  it  was  a  sort  of  human  tsetze  fly  infection. 

Distribution". — For  many  years  it  had  been  kno-wTi  that  the  West  African 
natives  were  subject  to  a  remarkable  malady  known  as  the  lethargy  or  sleeping 
sickness.  It  was  also  met  with  among  the  slaves  imported  into  America.  The 
demonstration  of  the  association  of  the  trypanosomes  with  the  terrible  sleeping 
sickness  has  been  the  most  important  recent  "  find  "  in  tropical  medicine.  The 
disease  prevails  in  Gambia,  Sierra  Leone,  and  Liberia,  and  is  spreading  rapidly 
in  the  Congo  basin,  Uganda,  and  Ehodesia.  The  recent  opening  up  of  equa- 
torial Africa  has  led  to  intercommunication  between  the  different  districts 
which  were  formerly  isolated,  and  the  seriousness  of  the  disease  may  be  appre- 
ciated from  the  fact  that  within  three  years  after  its  introduction  100,000 
negroes  died  of  it  in  Uganda.  The  parasites  may  be  present  in  the  blood  for 
a  long  time,  at  least  without  causing  any  symptoms.  Bruce  found  them  in 
23  out  of  80  apparently  healthy  natives,  and  Button,  Todd,  and  Christy  in 
103  out  of  1,172  persons  examined. 

The  disease  is  not  confuied  to  negroes,  and  several  Europeans  have  been 
attacked.  Persons  particularly  prone  are  those  who  live  on  the  wooded  shores 
of  the  lakes  and  rivers,  such  as  fishermen  and  canoe  men. 

The  parasite  is  introduced  by  the  bite  of  a  fly,  the  Glossina  palpalis,  and 
where  this  insect  exists  the  disease  is  liable  to  prevail.  The  fly  lives  on  the 
bushes  on  the  lake  shores  or  river  banks,  and  feeds  on  the  blood  of  crocodiles, 
antelopes,  etc.  It  is  possible  that  the  trypanosomes  undergo  a  development 
in  the  body  of  the  fly.  Koch  states  that  the  disease  may  be  conveyed  to  women 
in  coition. 

Symptoms. — There  is  stated  to  be  a  long  latent  period.  The  Uganda  Com- 
missioners divide  the  course  of  the  disease  into  three  stages:  first,  of  fever 
with  rapid  pulse,  dulling  of  the  mind,  and  loss  of  weight;  secondly,  the  stage 
of  tremors  in  which  the  gait  becomes  shuffling,  the  speech  slow,  and  there  are 
tremors  of  the  tongue  and  of  the  hands  and  feet;  lastly,  a  stage  in  which  the 
patient  becomes  lethargic  with  low  temperature  and  presents  the  typical  picture 
of  the  dreaded  sleeping  sickness.  The  parasites  are  found  in  the  cerebro-spinal 
fluid,  less  constantly  in  the  blood.  In  the  early  stages  the  glands  of  the  neck 
are  involved,  and  Todd  and  Button  recommend  puncture  of  these  glands  for 
the  purpose,  of  diagnosis.  Beath  is  usually  caused  by  some  intercurrent  infec- 
tion, as  purulent  meningitis  or  suppuration  of  the  lymph  glands.  The  dura- 
tion is  seldom  longer  than  eighteen  months.  Europeans  are  not  often  attacked. 
To  stay  the  ravages  and  prevent  the  spread  of  the  disease  will  tax  the  energies 
of  the  nations  interested  in  the  settlement  of  tropical  Africa.  The  hope 
appears  to  be  in  the  extermination  of  the  animals  upon  which  the  Glossina 
palpalis  feeds  (among  which  Koch  holds  the  crocodile  to  be  the  most  impor- 
tant), just  as  the  killing  off  of  the  big  game  in  other  parts  of  iVfrica  has 
saved  the  cattle  from  the  ravages  of  the  tsetze  fly. 


DISEASES  DUE  TO  PROTOZOA.  9 

Wolferstan  Thomas  and  Breinl  introduced  the  atoxyl  treatment,  and 
Boyce  recommends  the  subsequent  use  of  bichloride  of  mercury.  Koch's  re- 
port on  the  atoxyl  treatment  is  most  encouraging;  0.5  gramme  is  injected 
on  two  successive  days,  and  repeated  at  intervals  of  ten  days.  A  few  cases 
have  been  cured.  As  prophylactic  measures,  segregation  and  prohibition  of 
immigration  from  infected  areas  should  be  carried  out.  The  work  of  Laveran 
and  Mesnil,  recently  translated  and  edited  by  Nabarro,  is  the  standard  author- 
ity on  the  disease. 

IV.     TROPICAL    SPLENOMEGALY— Tropical    Cachexia. 

(Piroplasmosis — Dum-Dum  Fever — Kala-Azar.) 

Definition. — A  chronic  disease  of  tropical  and  sub-tropical  countries, 
characterized  by  enlarged  spleen,  anaemia,  irregularly  remittent  fever,  asso- 
ciated with  the  presence  of  a  protozoon  parasite  of  the  piroplasma  type. 

In  1900  Leishman  discovered  the  parasites  in  the  spleen.  Cunningham 
had  described  similar  bodies  in  the  Delhi  boil.  In  1903  Donovan's  inde- 
pendent observations  stimulated  active  work  on  the  subject,  and  the  careful 
studies  of  Eogers,  Christophers,  Philips,  and  Bentley  have  established  the 
clinical  and  anatomical  identity  of  one  form  of  tropical  cachexial  fever. 
Musgrave  and  Woolley  have  shown  that  in  the  Philippines  there  is  a  form 
of  tropical  splenomegaly  not  associated  with  the  Leishman-Donovan  body. 

Distribution. — The  disease  is  widely  prevalent  and  almost  uniformly  fatal 
in  India,  Assam,  Ceylon,  China,  and  Egypt.     Europeans  are  rarely  attacked. 

The  Parasite. — Most  abundant  in  the  spleen,  it  has  been  found  also  in 
the  bone-marrow,  the  mesenteric  glands,  the  liver,  in  the  intestinal  ulcers,  but 
not  in  the  circulating  blood.  Seen  in  smears  of  the  spleen  juice  stained  by 
Eomanowsky's  method,  there  are  oat-shaped,  oval  and  circular  bodies,  with  a 
spherical  nucleus  close  against  the  capsule,  and  a  short,  rod-like  body  on  the 
opposite  side.  Two  of  these  bodies  may  be  closely  applied  to  each  other,  and 
groups  of  them,  from  ten  to  fifty,  may  be  arranged  in  a  rosette.  Eogers  has 
cultivated  a  trypanosoma-like  body  from  these  forms,  and  Patton  has  traced 
its  extra-corporeal  development  in  the  bed-bug. 

Symptoms. — The  following  succinct  description  is  given  by  Leishman: 

"  Splenic  and  hepatic  enlargement — the  former  being  apparently  constant, 
while  the  latter  is  common  but  not  invariable.  A  peculiar  earthy  pallor  of 
the  skin,  and,  in  the  advanced  stages,  an  intense  degree  of  emaciation  and 
muscular  atrophy.  A  long-continued,  irregularly  remittent  fever,  of  no  defi- 
nite type,  lasting  frequently  for  many  months,  with  or  without  remissions. 
Hsemorrhages,  such  as  epistaxis,  bleeding  from  the  gums,  subcutaneous  haem- 
orrhages or  purpuric  eruptions.  Transitory  cedemas  of  various  regions  or  of 
the  limbs."  The  anaemia  is  not  excessive,  rarely  below  2,000,000  per  c.mm., 
with  a  marked  leucopenia  and  a  relative  increase  in  the  lymphocytes  and  large 
mononuclears.  The  diagnosis  rests  upon  the  detection  of  the  parasites  in  the 
blood  obtained  by  puncture  from  the  spleen  or  liver,  preferably  the  latter. 

In  a  few  cases  the  disease  runs  an  acute  course — from  four  to  five  months, 
and  toward  the  end  the  parasites  are  found  in  the  peripheral  blood.     The 
disease  is  very  fully  considered  in  Eogers'  work  "  On  Tropical  Diseases." 
3 


10  DISEASES  DUE  TO  ANIMAL  PARASITES. 

Prophylaxis. — Leonard  Eogers  and  Price  have  shown  that  Jcala-azar  can 
be  eradicated  from  infected  Coolie  lines  in  Assam  by  segregation,  and  this 
points  to  the  measures  which  are  likely  to  be  successful  in  India  and  Africa. 

Treatment. — While  quinine  is  not  a  specific,  as  in  malaria,  it  seems  to 
reduce  the  fever.  Iron,  arsenic,  and  tonics  are  helpful  in  the  anemia.  The 
atoxyl  treatment  may  be  tried. 

V.    MALARIAL    FEVER. 

Definition. — An  infectious  disease  characterized  by:  (a)  paroxysms  of 
intermittent  fever  of  quotidian,  tertian,  or  quartan  type;  (&)  a  continued 
fever  with  marked  remissions;  (c)  certain  pernicious,  rapidly  fatal  forms; 
and  (d)  a  chronic  cachexia,  with  anaemia  and  an  enlarged  spleen. 

With  the  disease  are  invariably  associated  the  hamocytozoa  described  by 
Laveran,  which  are  transmitted  to  man  by  the  bite  of  the  mosquito. 

Etiology. — (1)  Geographical  Distribution. — In  Europe,  southern  Eus- 
sia  and  certain  parts  of  Italy  are  now  the  chief  seats  of  the  disease.  It  is  rare 
in  Germany,  France,  and  England,  and  the  foci  of  epidemics  are  becoming 
yearly  more  restricted.  In  the  United  States  malaria  has  progressively  dimin- 
ished in  extent  and  severity  during  the  past  fifty  years.  Erom  New  England, 
where  it  once  prevailed  extensively,  it  has  gradually  disappeared,  but  there 
has  of  late  years  been  a  slight  return  in  some  places.  In  the  city  of  New  York 
the  milder  forms  of  the  disease  are  not  uncommon.  In  Philadelphia  and  along 
the  valleys  of  the  Delaware  and  Schuylkill  Elvers,  formerly  hot-beds  of 
malaria,  the  disease  has  become  much  restricted.  In  Baltimore  a  few  cases 
occur  in  the  autumn,  but  a  majority  of  the  patients  seeking  relief  are  from 
the  outlying  districts  and  one  or  two  of  the  inlets  of  Chesapeake  Bay. 
Throughout  the  Southern  States  there  are  many  regions  in  which  malaria 
prevails ;  but  here,  too,  the  disease  has  diminished  in  prevalence  and  intensity. 
In  the  Northwestern  States  malaria  is  almost  unknown.  It  is  rare  on  the 
Pacific  coast.  In  the  region  of  the  Great  Lakes  malaria  prevails  only  in  the 
Lake  Erie  and  Lake  St.  Clair  regions.  The  St.  Lawrence  basin  remains  free 
from  the  disease. 

In  India  malaria  is  very  prevalent,  particularly  in  the  great  river  basins. 
In  Burma  and  Assam  severe  types  are  met  with.  In  Africa  the  malarial  fevers 
form  the  great  obstacle  to  European  settlements  on  the  coast  and  along  the 
river  basins.  The  hlack-water  or  West  African  fever  of  the  Gold  Coast  is  a 
very  fatal  type  of  malarial  ha^moglobinuria.  In  the  Canal  Zone,  Panama,  in 
1907  the  incidence  of  the  disease  was  reduced  one-half  compared  with  1906. 

(2)  Season. — In  the  tropics  there  are  minimal  and  maximal  periods,  the 
former  corresponding  to  the  summer  and  winter,  the  latter  to  the  spring  and 
autumn  months.  In  temperate  regions,  like  the  central  Atlantic  States,  there 
are  only  a  few  cases  in  the  spring,  usually  in  the  month  of  May,  and  a  large 
number  of  cases  in  September  and  October,  and  sometimes  in  November. 

(3)  The  Parasite. — Parasites  of  the  red  blood-corpuscles — hsemocytozoa 
— are  very  widespread  throughout  the  animal  series.  They  are  met  with  in 
the  blood  of  frogs,  fish,  birds,  and  among  mammals  in  monkeys,  bats,  cattle, 
and  man.  In  birds  and  in  frogs  the  parasites  appear  to  do  no  harm  except 
when  present  in  very  large  numbers. 


DISEASES  DUE  TO  PROTOZOA.  11 

In  1880  Laveran,  a  French  army  surgeon  stationed  at  Algiers,  noted  in 
the  blood  of  patients  with  malarial  fever  pigmented  bodies,  which  he  regarded 
as  parasites,  and  as  the  cause  of  the  disease,  Richard,  another  French  army 
surgeon,  confirmed  these  observations.  In  1885  Marchiafava  and  Celli 
described  the  parasites  with  great  accuracy,  and  in  the  same  year  Golgi  made 
the  all-important  observation  that  the  paroxysm  of  fever  invariably  coincided 
with  the  sporulation  or  segmentation  of  a  group  of  the  parasites.  In  the  fol- 
lowing year  (1886)  Laveran's  observations  were  brought  before  the  profession 
of  the  United  States  by  Sternberg.  Councilman  and  Abbott  had  already,  in 
the  previous  year,  described  the  remarkable  pigmented  bodies  in  the  red  blood- 
corpuscles  in  the  blood-vessels  of  the  brain  in  a  fatal  case,  and  in  1886  Coun- 
cilman confirmed  the  observations  of  Laveran  in  clinical  cases.  Stimulated 
by  his  work,  I  began  studying  the  malarial  cases  in  the  Philadelphia  Hospital, 
and  soon  became  convinced  of  the  truth  of  Laveran's  discovery,  and  was  able 
to  confirm  Golgi's  statement  as  to  the  coincidence  of  the  sporulation  with  the 
paroxysm.  The  work  was  taken  up  actively  in  the  United  States  by  Walter 
James,  Dock,  Koplik,  Thayer,  Hewetson,  and  others,  and  in  a  number  of  sub- 
sequent communications  I  tried  to  emphasize  the  extraordinary  clinical 
importance  of  Laveran's  discovery.* 

Among  British  observers,  Vandyke  Carter  alone,  in  India,  seems  to  have 
appreciated  at  an  early  date  the  profound  significance  of  Laveran's  work. 

The  next  important  observation  was  the  discovery  by  Golgi  that  the  para- 
site of  quartan  malarial  fever  was  different  from  the  tertian.  From  this 
time  on  the  Italian  observers  took  up  the  work  with  great  energy,  and  in  1889 
Marchiafava  and  Celli  determined  that  the  organism  of  the  severer  forms  of 
malarial  fever  differed  from  the  parasite  of  the  tertian  and  quartan  varieties. 
During  the  past  ten  years  the  work  of  observers  in  many  lands  has  confirmed 
these  essential  features,  and  has  added  greatly  to  our  knowledge  of  the  struc- 
ture and  modes  of  development  of  the  parasites. 

The  next  important  step  related  to  the  question  of  the  mode  of  infec- 
tion. It  had  been  suggested  by  King,  of  Washington,  and  others,  that  the 
disease  was  transmitted  by  the  mosquitoes.  The  important  role  played  by 
insects  as  an  intermediate  host  had  been  shown  in  the  case  of  the  Texas 
cattle  fever,  in  which  Theobald  Smith  demonstrated  that  the  hgematozoa 
developed  in,  and  the  disease  was  transmitted  by,  ticks;  but  it  remained 
for  Manson  to  formulate  in  a  clear  and  scientific  way  the  theory  of  infec- 
tion in  malaria  by  the  mosquito.  Impressed  with  the  truth  of  this,  Ross 
studied  the  problem  in  India,  and  showed  that  the  parasites  developed  in 
the  bodies  of  the  mosquitoes,  demonstrating  conclusively  that  the  infection  in 
birds  was  transmitted  by  the  mosquito.     W.  G,  MacCallum  suggested  that 

*  The  following  references  to  work  on  malaria  which  has  been  done  in  connection  with 
my  clinic,  chiefly  under  the  supervision  of  my  colleague,  Professor  Thayer,  may  be  of  in- 
terest :  Philadelphia  Medical  Times,  1886 ;  British  Medical  Journal,  March,  1887 ;  Medical 
News,  1889,  vol,  i ;  Johns  Hopkins  Hospital  Bulletin,  1889 ;  the  first  edition  of  my  Text- 
Book  of  Medicine,  1892;  Thayer  and  Hewetson,  Johns  Hopkins  Hospital  Reports,  1895; 
Thayer  Lectures  on  Malarial  Fever,  1897;  W,  G.  MacCallum,  Hsematozoa  of  Birds,  Jour,  of 
Exp.  Med.,  1898 ;  Opie,  on  the  HaBmatozoa  of  Birds,  1898 ;  Barker,  on  Fatal  Cases  of  Malaria, 
Johns  Hopkins  Hospital  Reports,  1899:  MacCallum,  on  the  Significance  of  the  Flagella, 
Lancet,  1897;  Thayer,  Transactions  American  Medical  Congress,  vol.  iv,  1900;  Lazear, 
Structure  of  the  Malarial  Parasites,  Johns  Hopkins  Hospital  Reports,  1902. 


12  DISEASES  DUE  TO  ANIMAL  PARASITES. 

the  flagella  were  sexual  elements,  and  observed  the  process  of  fertilization 
by  them.  Studies  by  Grassi,  Bastianelli  and  Bignami,  and  man}  others,  con- 
firmed the  observations  of  Eoss  and  demonstrated  the  fact  that  the  malarial 
parasites  of  human  beings  develop  only  in  mosquitoes  of  the  genus  anopheles. 

Then  came  the  practical  demonstration  by  Italian  observers,  and  by  the 
interesting  experiments  on  Manson,  Jr.,  of  the  direct  transmission  of  the 
disease  to  man  by  the  bite  of  infected  mosquitoes.  And  lastly,  as  a  practical 
conclusion  of  the  whole  matter,  the  results  of  the  antimalarial  campaign  in 
Italy  and  of  the  remarkable  experiments  of  Koch  and  his  assistants  have 
shown  that  by  protecting  the  individual  from  the  bites  of  mosquitoes,  by 
exterminating  the  insect,  or  by  carefully  treating  all  patients  so  that  no 
opportunity  may  be  offered  for  the  parasite  to  enter  the  mosquito,  malaria 
may  be  eradicated  from  any  locality. 

General  Morphology  of  the  Parasite. — Belonging  to  the  sporozoa,  it  has 
received  a,  large  number  of  names.  The  term  Plasmodium,  inapt  though  it 
may  be,  must,  according  to  the  rules  of  zoological  nomenclature,  be  applied 
to  the  human  parasite.  There  are  three  well-marked  varieties  of  the  para- 
site, which  exist  in  two  separate  phases  or  stages:  (a)  the  parasite  in  man 
who  acts  as  the  intermediate  host,  and  in  whom,  in  the  cycle  of  its  develop- 
ment, it  causes  symptoms  of  malaria;  and  (&)  an  extracorporeal  cycle,  in 
which  it  lives  and  develops  in  the  body  of  the  mosquito,  which  is  its  definitive 
host. 

I.  The  Parasite  in  Man. — (a)  The  Parasite  of  Tertian  Fever  (Plas- 
modium vivax). — The  earliest  form  seen  in  the  red  blood-corpuscle  is  round 
or  irregular  in  shape,  about  2  ft  in  diameter  and  unpigmented.  It  corresponds 
very  much  in  appearance  with  the  segments  of  the  rosettes  formed  during  the 
chill.  A  few  hours  later  the  body  has  increased  in  size,  is  still  ring-shaped, 
and  there  is  pigment  in  the  form  of  fine  grains.  It  has  a  relatively  large 
nuclear  body,  consisting  of  a  well-defined,  clear  area,  in  part  almost  transpar- 
ent, in  part  consisting  of  a  milk-white  substance,  in  which  there  lies  a  small, 
deeply  staining  chromatin  mass,  as  shown  by  Eomanowsk}'''s  method  of  stain- 
ing. At  this  period  it  usually  shows  active  amoeboid  movements,  with  tongue- 
like protrusions.  The  pigment  increases  in  amount  and  the  corpuscle  becomes 
larger  and  paler,  owing  to  a  progressive  diminution  of  its  hsemoglobin.  There 
is  a  gradual  growth  of  the  parasite,  which,  toward  the  end  of  forty-eight 
hours,  occupies  almost  all  of  the  swollen  red  corpuscle.  It  is  now  much 
pigmented,  and  is  in  the  stage  of  what  is  often  called  the  full-grown  parasite. 
Between  the  fortieth  and  forty-eighth  hours  many  of  the  parasites  are  seen 
to  have  undergone  the  remarkable  change  known  as  segmentation,  in  which 
the  pigment  becomes  collected  into  a  single  mass  or  block,  and  the  proto- 
plasm divides  into  a  series  of  from  fifteen  to  twenty  spores,  often  showing  a 
radial  arrangement.  Certain  full-grown  tertian  parasites,  however,  do  not 
undergo  segmentation.  These  forms,  which  are  larger  than  the  sporulating 
bodies,  and  contain  very  actively  dancing  pigment  granules,  represent  the 
sexually  differentiated  form  of  the  parasite — gametocytes. 

(&)  The  Parasite  of  Quartan  Fever  {Plasmodium  malarice). — The  earliest 
form  is  very  like  the  tertian  in  appearance,  but  as  it  increases  in  size  the 
earlier  granules  are  coarser  and  darker  and  the  movement  is  not  nearly  so 
marked.     By  the  second  day  the  parasite  is  still  larger,  rounded  in  shape^ 


DISEASES  DUE  TO  PROTOZOA.  13 

scarcely  at  all  amoeboid,  and  the  pigment  is  more  often  arranged  at  the  periph- 
ery of  the  parasite.  The  rim  of  protoplasm  about  it  is  often  of  a  deep  yel- 
lowish-green color  or  of  a  dark  brassy  tint.  On  the  third  day  the  segment- 
ing bodies  become  abundant,  the  pigment  flowing  in  toward  the  centre  of  the 
parasite  in  radial  lines  so  as  to  give  a  star-shaped  appearance.  The  parasites 
finally  break  up  into  from  six  to  twelve  segments.  Here  also,  as  in  the  case 
of  the  tertian  parasite,  some  full-grown  bodies  persist  without  sporulating, 
representing  the  gametocytes. 

(c)  The  Parasite  of  the  /Estivo- Autumnal  Fever  {Plasmodium,  prcecox)  is 
considerably  smaller  than  the  other  varieties ;  at  full  development  it  is  often 
less  than  one  half  the  size  of  a  red  blood-corpuscle.  The  pigment  is  much 
scantier,  often  consisting  of  a  few  minute  granules.  At  first  only  the  earlier 
stages  of  development,  small,  hyaline  bodies,  sometimes  with  one  or  two  pig- 
ment granules,  are  to  be  found  in  the  peripheral  circulation;  the  later  stages 
are  ordinarily  to  be  seen  only  in  the  blood  of  certain  internal  organs,  the  spleen 
and  bone  marrow  particularly.  The  corpuscles  containing  the  parasites 
become  not  infrequently  shrunken,  crenated,  and  brassy-colored.  After  the 
process  has  existed  for  about  a  week,  larger,  refractive,  crescentic,  ovoid,  and 
round  bodies,  with  central  clumps  of  coarse  pigment  granules,  begin  to  appear. 
These  bodies  are  characteristic  of  aestivo-autumnal  fever.  The  crescentic  and 
ovoid  forms  are  incapable  of  sporulation;  they  are  analogous  to  the  large, 
full-grown,  non-sporulating  bodies  of  the  tertian  and  quartan  parasites  which 
have  been  mentioned  above,  and  represent  sexually  differentiated  forms — 
gametocytes.  Within  the  human  host  they  are  incapable  of  further  develop- 
ment, but  upon  the  slide,  or  within  the  stomach  of  the  normal  intermediate 
host,  the  mosquito,  the  male  elements  (micro-gametocytes)  give  rise  to  a  num- 
ber of  long,  actively  motile  flagella  (micro-gametes)  which  break  loose,  pene- 
trating and  fecundating  the  female  forms — macro-gametes  (W.  G-.  Mac- 
Callum).  The  fecundated  female  form  enters  into  the  stomach  wall  of  the 
intermediate  host,  the  mosquito,  where  it  undergoes  a  definite  cycle  of 
existence. 

II.  The  Parasite  within  the  Body  of  the  Mosquito. — The  brilliant  re- 
searches of  Eoss,  followed  by  the  work  of  Grassi,  Bastianelli,  Bignami, 
Stephens,  Christophers,  and  Daniels,  have  proved  that  a  certain  genus  of 
mosquito — anopheles — is  not  only  the  intermediate  host  of  the  malarial  para- 
site, but  also  the  sole  source  of  infection.  In  the  present  state  of  our  knowl- 
edge it  would  appear  that  all  species  of  the  genus  anopheles  may  act  as  hosts 
of  the  parasite.  The  more  common  genera  of  mosquito  in  temperate  cli- 
mates are  culex  and  anopheles.  The  different  species  of  culex  form  the  great 
majority  of  our  ordinary  house  mosquitoes,  and  are  apparently  incapable  of 
acting  as  hosts  of  the  malarial  parasite.  All  malarial  regions,  however, 
which  have  been  investigated  contain  anopheles.  Although  this  is  appar- 
ently a  positive  rule,  anopheles  may,  however,  be  present  without  the  exist- 
ence of  malaria  under  two  circumstances:  first,  when  the  climate  is  too' cold 
for  the  development  of  the  malarial  parasite ;  and  secondly,  in  a  region  which 
has  not  yet  been  infected.  So  far  as  is  known,  the  parasite  exists  only  in  the 
mosquito  and  in  man.  It  is  apparently  fair  to  state  that  regions  in  which 
mosquitoes  of  the  genus  anopheles  are  present  may  become  malarious  during 
the  warm  season. 


14  DISEASES  DUE  TO  ANIMAL  PARASITES. 

A  large  number  of  species  of  anopheles  have  been  described.  In  Xorth 
America,  however,  only  four  have  been  positively  recognized:  A.  'punctlpeiinis 
(Say),  A.  maculipennis  (Wied),  A.  crucians  (Wied),  A.  argyritarsis  (Desv.). 
The  commonest  variety,  and  that  which  in  all  probability  is  most  concerned  in 
the  spread  of  the  disease,  is  A.  maculipennis,  which  is,  also,  the  most  impor- 
tant agent  in  the  spread  of  the  disease  on  the  Continent. 

The  palpi  in  the  mature  culex  are  extremely  short,  only  to  be  seen  on 
careful  observation  at  the  base  of  the  proboscis,  while  in  the  anopheles  they 
are  nearly  of  equal  length  with  the  proboscis,  so  that  on  superficial  observa- 
tion the  insect  would  appear  to  have  three  proboscides.  The  wings  of  the 
common  species  of  culex  show  no  markings  beyond  the  ordinary  veins.  The 
wings  of  all  the  x4.merican  species  of  anopheles  show  distinct  mottling.  The 
culex,  when  sitting  upon  the  wall  or  ceiling,  holds  its  posterior  pair  of  legs 
turned  up  above  its  back,  while  the  body  lies  nearly  parallel  to  the  wall.  In 
some  instances,  when  it  is  full  of  blood,  and  sitting  upon  the  ceiling,  the  body 
may  sag  downward  considerably.  The  anopheles,  when  sitting  upon  the  wall 
or  ceiling,  holds  its  posterior  pair  of  legs  commonly  either  against  the  wall 
or  hanging  downward,  though  in  some  instances  they  may  be  lifted  above  the 
back.  The  body,  however,  instead  of  lying  parallel  to  the  wall  or  ceiling, 
protrudes  at  an  angle  of  45°  or  more.  These  simple  points  are  sufficient  to 
permit  the  ready  distinction  of  species  by  almost  any  individual. 

The  culex  lays  its  eggs  in  sinks,  tanks,  cisterns,  and  any  collection  of 
water  about  or  in  houses,  while  anopheles  lays  its  eggs  in  small,  shallow  pud- 
dles or  slowly  running  streams,  especially  those  in  which  certain  forms  of 
algae  exist.  The  culex  is  essentially  a  city  mosquito,  the  anopheles  a 
country  insect. 

Evolution  in  the  Body  of  the  Mosquito. — When  a  mosquito  of  the  genus 
anopheles  bites  an  individual  whose  blood  contains  sex-ripe  forms  (gameto- 
cytes)  of  the  malarial  parasite,  flagellation  and  fecundation  of  the  female 
element  occurs  within  the  stomach  of  the  insect.  The  fecundated  element 
then  penetrates  the  wall  of  the  mosquito's  stomach  and  begins  a  definite  cycle 
of  development  in  the  muscular  coat.  Two  days  after  biting  there  begin  to 
appear  small,  round,  refractive,  granular  bodies  in  the  stomach  wall  of  the 
mosquito,  which  contain  pigment  granules  clearly  identical  with  those  pre- 
viously contained  in  the  malarial  parasite.  These  develop  until  at  the  end 
of  seven  days  they  have  reached  a  diameter  of  from  60  to  70  fi.  At  this 
period  they  may  be  observed  to  show  a  delicate  radial  striation  due  to  the 
presence  of  great  numbers  of  small  sporoblasts.  The  mother  oocyst  (z5'gote) 
then  bursts,  setting  free  into  the  body  cavity  of  the  mosquito  an  enormous 
number  of  delicate  spindle-shaped  sporozoids.  These  accumulate  in  the  cells 
of  the  veneno-salivary  glands  of  the  mosquito,  and,  escaping  into  the  ducts, 
are  inoculated  with  subsequent  bites  of  the  insect.  These  little  spindle-shaped 
sporozoids  develop,  after  inoculation  into  the  warm-blooded  host,  into  fresh 
young  parasites.  The  sporozoid  which  has  developed  in  the  oocyst  in  the 
stomach  wall  of  the  mosquito  is  then  the  equivalent  of  the  spore  resulting 
from  the  asexual  segmentation  of  the  full-grown  parasite  in  the  circulation. 
Either  one,  on  entering  a  red  blood-corpuscle,  may  give  rise  to  the  asexual 
or  sexual  cycle.  As  a  rule  the  first  several  generations  of  parasites  in  the 
human  body  pursue  the  asexual  cycle,  the  sexual  forms  developing  later. 


DISEASES  DUE  TO  PROTOZOA.  15 

These  sexual  forms,  sterile  while  in  the  human  host,  serve  as  the  means  of 
preserving  the  life  of  the  parasite  and  spreading  infection  when  the  individual 
is  subjected  to  bites  of  anopheles. 

Mr.  Howard,  of  the  Entomological  Department  at  Washington,  has  issued 
a  very  useful  pamphlet  on  the  varieties  and  the  methods  of  identification  of 
the  mosquito.  In  Africa  the  distribution  of  the  forms  has  been  studied  by 
Stephens,  Christophers,  and  Daniels.  To  those  interested  in  the  subject, 
Christophers'  careful  study  of  the  Anatomy  and  Histology  of  the  Adult 
Female  Mosquito  (Report  of  Malaria  Committee,  Royal  Society,  No.  IV) 
will  prove  of  great  help.  The  Royal  Society  Reports  (Malaria  Committee) 
and  the  Studies  of  the  Liverpool  School  may  be  consulted  for  technical  details 
and  for  valuable  information  relating  to  tropical  malaria. 

Morbid  Anatomy. — The  changes  result  from  the  disintegration  of  the 
red  blood-corpuscles,  accumulation  of  the  pigment  thereby  formed,  and 
possibly  the  influence  of  toxic  materials  produced  by  the  parasite.  Cases 
of  simple  malarial  infection,  the  ague,  are  rarely  fatal,  and  our  knowledge 
of  the  morbid  anatomy  of  the  disease  is  drawn  from  the  pernicious  malaria 
or  the  chronic  cachexia.  Rupture  of  the  enlarged  spleen  may  occur  spon- 
taneously, but  more  commonly  from  trauma.  A  case  of  the  kind  was 
admitted  under  my  colleague,  Halsted,  in  June,  1889,  and  Dock  has  reported 
two  cases.  I  have  known  fatal  haemorrhage  to  follow  the  exploratory  punc- 
ture of  an  enlarged  malarial  spleen. 

(1)  Pernicious  Malaeia. — The  blood  is  hydremic  and  the  serum  may 
even  be  tinged  with  haemoglobin.  The  red  blood-corpuscles  present  the 
endoglobular  forms  of  the  parasite  and  are  in  all  stages  of  destruction. 
The  spleen  is  enlarged,  often  only  moderately;  thus,  of  two  fatal  cases 
in  my  wards  the  spleens  measured  13  X  8  cm.  and  14  X  8  cm.  respec- 
tively. In  a  fresh  infection,  the  spleen  is  usually  very  soft,  and  the  pulp 
lake-colored  and  turbid.     The  liver  is  swollen  and  turbid. 

In  some  acute  pernicious  cases  with  choleraic  symptoms,  the  capillaries 
of  the  gastro-intestinal  mucosa  may  be  packed  with  parasites. 

(2)  Malarial  Cachexia. — In  fatal  cases  of  chronic  paludism  death 
occurs  usually  from  anaemia  or  the  haemorrhage  associated  with  it. 

The  anaemia  is  profound,  particularly  if  the  patient  has  died  of  fever. 
The  spleen  is  greatly  enlarged,  and  may  weigh  from  seven  to  ten  pounds. 

The  liver  may  be  greatly  enlarged,  and  presents  to  the  naked  eye  a 
grayish-brown  or  slate  color,  due  to  the  large  amount  of  pigment.  In  the 
portal  canals  and  beneath  the  capsule  the  connective  tissue  is  impregnated 
with  melanin.  The  pigment  is  seen  in  the  Kupffer's  cells  and  the  perivascu- 
lar tissue. 

The  kidneys  may  be  enlarged  and  present  a  grayish-red  color,  or  areas  of 
pigmentation  may  be  seen.  The  peritonaeum  is  usually  of  a  deep  slate  color. 
The  mucous  membrane  of  the  stomach  and  intestines  may  have  the  same  hue, 
due  to  the  pigment  in  and  about  the  blood-vessels.  In  some  cases  this  is  con- 
fined to  the  lymph  nodules  of  Peyer's  patches,  causing  the  shaven-beard 
appearance. 

(3)  The  Accidental  and  Late  Lesions  of  Malarial  Fever. — (a)  The 
Liver. — Paludal  hepatitis  plays  a  very  important  role  in  the  history  of 
malaria,  as  described  by  French  writers.     Only  those  cases  in  which  the  his- 


16  DISEASES  DUE   TO  ANIMAL  PARASITES. 

tory  of  chronic  malaria  is  definite,  and  in  which  the  melanosis  of  both  liver 
and  spleen  coexist,  should  be  regarded  as  of  paludal  origin. 

(h)  Pneumonia  is  believed  by  many  authors  to  be  common  in  malaria, 
and  even  to  depend  directly  upon  the  malarial  poison,  occurring  either  in 
the  acute  or  in  the  chronic  forms  of  the  disease.  I  have  no  personal  knowledge 
of  such  a  special  pneumonia. 

(c)  Nephritis. — Moderate  albuminuria  is  a  frequent  occurrence,  having 
occurred  in  46.4  per  cent  of  the  cases  in  my  wards.  Acute  nephritis  is  rela- 
tively frequent  in  aestivo-autumnal  infections,  having  occurred  in  over  4.5 
per  cent  of  my  cases.  Chronic  nephritis  occasionally  follows  long-continued 
or  frequently  repeated  infections. 

Clinical  Forms  of  Malarial  Fever. — (1)  The  Regularly  Inteemittent 
Fevees. —  (a)  Tertian  fever;  (6)  quartan  fever.  These  forms  are  charac- 
terized by  recurring  paroxysms  of  what  are  knoAVQ  as  ague,  in  which,  as  a 
rule,  chill,  fever,  and  sweat  follow  each  other  in  orderly*  sequence.  The 
stage  of  iiicubation  is  not  definitely  known;  it  probably  varies  much  accord- 
ing to  the  amount  of  the  infectious  material  absorbed.  Experimentally  the 
period  of  incubation  varies  from  thirty-six  hours  to  fifteen  days,  being  a  trifle 
longer  in  quartan  than  in  tertian  infections.  Attacks  have  been  reported 
within  a  very  short  time  after  the  apparent  exposure.  On  the  other  hand, 
the  ague  may  be,  as  is  said,  "  in  the  system,"  and  the  patient  may  have  a 
paroxysm  months  after  he  has  removed  from  a  malarial  region,  though  of 
course  this  can  not  be  the  case  unless  he  has  had  the  disease  when  living  there. 

Description  of  the  Paroxysm. — The  patient  generally  knows  he  is  going 
to  have  a  chill  a  few  hours  before  its  advent  by  unpleasant  feelings  and  uneasy 
sensations,  sometimes  by  headache.  The  paroxysm  is  divided  into  three  stages 
— cold,  hot,  and  sweating. 

Cold  Stage. — The  onset  is  indicated  by  a  feeling  of  lassitude  and  a  desire 
to  yawn  and  stretch,  by  headache,  uneasy  sensations  in  the  epigastrium,  some- 
times by  nausea  and  vomiting.  Even  before  the  chill  begins  the  thermometer 
indicates  some  rise  in  temperature.  Gradually  the  patient  begins  to  shiver, 
the  face  looks  cold,  and  in  the  fully  developed  rigor  the  whole  body  shakes,  the 
teeth  chatter,  and  the  movements  may  often  be  violent  enough  to  shake  the 
bed.  I^ot  only  does  the  patient  look  cold  and  blue,  but  a  surface  ther- 
mometer will  indicate  a  reduction  of  the  skin  temperature.  On  the  other 
hand,  the  axillary  or  rectal  temperature  may,  during  the  chill,  be  greatly 
increased,  and,  as  shown  in  the  chart,  the  fever  may  rise  meanwhile  even  to 
105°  or  106°.  Of  symptoms  associated  with  the  chill,  nausea  and  vomiting 
are  common.  There  may  be  intense  headache.  The  pulse  is  quick,  small, 
and  hard.  The  urine  is  increased  in  quantity.  The  chill  lasts  for  a  variable 
time,  from  ten  or  twelve  minutes  to  an  hour,  or  even  longer. 

The  hot  stage  is  ushered  in  by  transient  flushes  of  heat;  gradually  the 
coldness  of  the  surface  disappears  and  the  skin  becomes  intensely  hot.  The 
contrast  in  the  patient's  appearance  is  striking:  the  face  is  flushed,  the 
hands  are  congested,  the  skin  is  reddened,  the  pulse  is  full  and  bounding,  the 
heart's  action  is  forcible,  and  the  patient  may  complain  of  a  throbbing  head- 
ache. There  may  be  active  delirium.  One  of  my  patients  in  this  stage 
jumped  through  a  ward  window  and  sustained  fatal  injuries.  The  rectal 
temperature  may  not  increase  much  during  this  stage;  in  fact,  by  the  termi" 


DISEASES  DUE  TO  PROTOZOA.  17 

nation  of  the  chill  the  fever  may  have  reached  its  maximum.  The  duration 
of  the  hot  stage  varies  from  half  an  hour  to  three  or  four  hours.  The  patient 
is  intensely  thirsty  and  drinks  eagerly  of  cold  water. 

Sweating  Stage. — Beads  of  perspiration  appear  upon  the  face  and  grad- 
ually the  entire  body  is  bathed  in  a  copious  sweat.  The  uncomfortable  feel- 
ing associated  with  the  fever  disappears,  the  headache  is  relieved,  and  within 
an  hour  or  two  the  paroxysm  is  over  and  the  patient  usually  sinks  into  a 
refreshing  sleep.  The  sweating  varies  much.  It  may  be  drenching  in  char- 
acter or  it  may  be  slight. 

Chart  la  is  from  a  case  of  double  tertian  infection  with  resulting  quotidian 
paroxysms.  Charts  I&  and  Ic  give  temperature  curves  in  aestivo-autumnal 
forms.     Chart  Id  shows  a  quartan  ague. 

The  total  duration  of  the  paroxysm  averages  from  ten  to  twelve  hours,  but 
may  be  shorter.  Variations  in  the  paroxysm  are  common.  Thus  the  patient 
may,  instead  of  a  chill,  experience  only  a  slight  feeling  of  coldness.  The  most 
common  variation  is  the  occurrence  of  a  hot  stage  alone,  or  with  very  slight 
sweating.  During  the  paroxysm  the  spleen  is  enlarged  and  the  edge  can  usu- 
ally be  felt  below  the  costal  margin.  In  the  interval  or  intermission  of  the 
paroxysm  the  patient  feels  very  well,  and,  unless  the  disease  is  unusually 
severe,  he  is  able  to  be  up.  Bronchitis  is  a  common  symptom.  Herpes,  usu- 
ally labial,  is  almost  as  frequent  in  ague  as  in  pneumonia. 

Types  of  the  Regularly  Intermittent  Fevers. — As  has  been  stated  in  the 
description  of  the  parasites,  two  distinct  types  of  the  regularly  intermit- 
tent fevers  have  been  separated.  These  are  (a)  tertian  fever  and  (&) 
quartan  fever. 

(a)  Tertian  Fever. — This  type  of  fever  depends  upon  the  presence  in  the 
blood  of  the  tertian  parasite,  an  organism  which,  as  stated  above,  is  usually 
pi-esent  in  sharply  defined  groups,  whose  cycle  of  development  lasts  approx- 
imately forty-eight  hours,  segmentation  occurring  every  third  day.  In 
infections  with  one  group  of  the  tertian  parasite  the  paroxysms  occur  syn- 
chronously with  segmentation  at  remarkably  regular  intervals  of  about  forty- 
eight  hours,  every  third  day — hence  the  name  tertian.  Very  commonly, 
however,  there  may  be  two  groups  of  parasites  which  reach  maturity  on  alter- 
nate days,  resulting  thus  in  daily  (quotidian)  paroxysms — douMe  tertian 
infection.  Quotidian  fever,  depending  upon  double  tertian  infection,  is  the 
most  frequent  type  in  the  acute  intermittent  fevers  in  this  latitude. 

(&)  Quartan  Fever. — This  type  of  fever  depends  upon  infection  with  the 
quartan  parasite,  an  organism  which  occurs  in  well-defined  groups,  whose 
cycle  of  existence  lasts  about  seventy-two  hours.  In  infection  with  one  group 
of  parasites  the  paroxysm  occurs  every  fourth  day;  hence  the  term  qu/irtan. 
At  times,  however,  two  groups  of  the  parasites  may  be  present;  under  these 
circumstances  paroxysms  occur  on  two  successive  days,  with  a  day  of  inter- 
mission following.  In  infection  with  three  groups  of  parasites  there  are 
daily  paroxysms. 

Thus  a  quotidian  intermittent  fever  may  be  due  to  infection  with  either 
the  tertian  or  quartan  parasites. 

Course  of  the  Disease. — After  a  few  paroxysms,  or  after  the  disease  has 
persisted  for  ten  days  or  two  "weeks,  the  patient  may  get  well  without  any 
special  medication,     I  have  repeatedly  known  the  chills  to  stop  spontane- 


18 


DISEASES  DUE  TO  ANIMAL  PARASITES. 


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AL  Infection. — Remittent  Fever. 
a  week  as  one  of  typhoid  fever. 


DISEASES  DUE  TO  PROTOZOA. 


19 


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July  19                    20                            21                            22                             23                            21               | 

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Chart  Id. — Quartan  Fever. 


20  DISEASES  DUE  TO  ANIMAL  PARASITES. 

ously.  Eelapses  are  common.  The  infection  may  persist  for  years,  and  an 
attack  may  follow  an  accident^,  an  acute  fever,  or  a  surgical  operation.  A  rest- 
ing stage  of  the  parasite  has  been  suggested  in  explanation  of  these  long  inter- 
vals. Persistence  of  the  fever  leads  to  aneemia  and  haematogenous  jaundice, 
owing  to  the  destruction  of  the  blood-disks.  Ultimately  the  condition  may 
become  chronic — malarial  cachexia. 

(2)  The  more  Irregular,  Eemittent,  or  Continued  Fevers. — 2Estivo- 
autumnal  Fever. — This  type  of  fever  occurs  in  temperate  climates,  chiefly 
in  the  later  summer  and  autumn ;  hence  the  term  given  to  it  by  Marchiaf ava 
and  Celli,  cestivo-autumnal  fever.  The  severer  forms  of  it  prevail  in  the 
Southern  States  and  in  tropical  countries. 

This  type  of  fever  is  associated  with  the  presence  in  the  blood  of  the 
Eestivo-autumnal  parasite,  an  organism  the  length  of  whose  cycle  of  develop- 
ment, ordinarily  about  forty-eight  hours,  is  probably  subject  to  considerable 
variations,  while  the  existence  of  multiple  groups  of  the  parasite,  or  the 
absence  of  arrangement  into  definite  groups,  is  not  infrequent. 

The  symptoms  are  therefore,  as  might  be  expected,  often  irregular.  In 
some  instances  there  may  be  regular  intermittent  fever  occurring  at  uncer- 
tain intervals  of  from  twenty-four  to  forty-eight  hours,  or  even  more.  In 
the  cases  with  longer  remissions  the  paroxysms  are  longer.  Some  of  the 
quotidian  intermittent  cases  may  closely  resemble  the  quotidian  fever  depend- 
ing upon  double  tertian  or  triple  quartan  infection.  Commonly,  however, 
the  paroxysms  show  material  differences;  their  length  averages  over  twenty 
hours,  instead  of  from  ten  or  twelve;  the  onset  occurs  often  without  chills 
and  even  without  chilly  sensations.  The  rise  in  temperature  is  frequently 
gradual  and  slow,  instead  of  sudden,  while  the  fall  may  occur  by  lysis  instead 
of  by  crisis.  There  may  be  a  marked  tendency  toward  anticipation  in  the 
paroxysms,  while  frequently,  from  the  anticipation  of  one  paroxysm  or  the 
retardation  of  another,  more  or  less  continuous  fever  may  result.  Some- 
times there  is  continuous  fever  without  sharp  paroxysms.  In  these  cases  of 
continuous  and  remittent  fever  the  patient,  seen  fairly  early  in  the  disease, 
has  a  flushed  face  and  looks  ill.  The  tongue  is  furred,  the  pulse  is  full 
and  bounding,  but  rarely  dicrotic.  The  temperature  may  range  from  103° 
to  103°,  or  is  in  some  instances  higher.  The  general  appearance  of  the 
patient  is  strongly  suggestive  of  typhoid  fever — a  suggestion  still  further 
borne  out  by  the  existence  of  acute  splenic  enlargement  of  moderate  grade. 
As  in  intermittent  fever,  an  initial  bronchitis  may  be  present.  The  course 
of  these  cases  is  variable.  The  fever  may  be  continuous,  with  remissions 
more  or  less  marked;  definite  paroxysms  with  or  without  chills  may  occur, 
in  which  the  temperature  rises  to  105°  or  106°.  Intestinal  symptoms  are 
usually  absent.  A  slight  hsematogenous  jaundice  may  arise  early.  Delirium 
of  a  mild  type  may  occur.  The  cases  vary  very  greatly  in  severity.  In 
some  the  fever  subsides  at  the  end  of  the  week,  and  the  practitioner  is  in 
doubt  whether  he  has  had  to  do  with  a  mild  typhoid  or  a  simple  febricula. 
In  other  instances  the  fever  persists  for  from  ten  days  to  two  weeks;  there 
are  marked  remissions,  perhaps  chills,  with  a  furred  tongue  and  low  delir- 
ium. Jaundice  is  not  infrequent.  These  are  the  cases  to  which  the  terms 
hilious  remittent  and  typho-malarial  fevers  are  applied.  In  other  instances 
the  symptoms  become  grave  and  assume  the  character  of  the  pernicious  type. 


DISEASES  DUE  TO  PROTOZOA.  21 

It  is  in  this  form  of  malarial  fever  that  so  much  confusion  still  exists.  The 
similarity  of  the  cases  to  typhoid  fever  is  most  striking,  more  particularly  the 
appearance  of  the  facies;  the  patient  looks  very  ill.  The  cases  occur,  too, 
in  the  autumn,  at  the  very  time  when  typhoid  fever  occurs.  The  fever  yields, 
as  a  rule,  promptly  to  quinine,  though  here  and  there  cases  are  met  with — 
rarely  indeed  in  my  experience — which  are  refractory.  It  is  just  in  this  group 
that  the  observations  of  Laveran  will  be  found  of  the  greatest  value.  Several 
of  the  charts  in  Thayer  and  Hewetson's  report  show  how  closely,  in  some 
instances,  the  disease  may  simulate  typhoid  fever. 

The  diagnosis  of  malarial  remittent  fever  may  be  definitely  made  by 
the  examination  of  the  blood.  The  small,  actively  motile,  hyaline  forms 
of  the  sestivo-autumnal  parasite  are  to  be  found,  while,  if  the  case  has  lasted 
over  a  week,  the  larger  crescentic  and  ovoid  bodies  are  often  seen.  In  many 
cases  here  we  are  at  first  unable  to  distinguish  between  typhoid  and  contin- 
ued malarial  fever  without  a  blood  examination.  A  more  widespread  use  of 
this  means  of  diagnosis  will  enable  us  to  bring  some  order  out  of  the  confu- 
sion which  exists  in  the  classification  of  the  fevers  of  the  Southern  States.  At 
present  the  following  febrile  affections  are  recognized  by  various  physicians  as 
occurring  in  the  subtropical  regions  of  America:  (a)  Typhoid  fever;  (h) 
typho-malarial  fever — a  typhoid  modified  by  malarial  infection,  or  the  result 
of  a  combined  infection;  (c)  the  malarial  remittent  fever;  and  (d)  continued 
thermic  fever  (Guiteras).  In  these  various  forms,  all  of  which  may  be 
characterized  by  a  continued  pyrexia  with  remissions  or  with  chills  and  sweats 
(for  we  must  remember  that  chills  and  sweats  in  typhoid  fever  are  by  no 
means  rare),  the  blood  examination  will  enable  us  to  discover  those  which 
depend  upon  the  malarial  poison.  In  many  of  these  cases  of  continued  or 
remittent  fever  careful  inquiry  will  show  that  at  the  beginning  the  patient 
had  several  intermittent  paroxysms.  In  Baltimore  not  many  of  the  pro- 
tracted and  severe  cases  have  occurred,  and  I  am  inclined  to  think  that  future 
observations  will  show  that,  apart  from  the  thermic  fever,  there  are  only  two 
forms  of  these  continued  fevers  in  the  South — the  one  due  to  the  typhoid  and 
the  other  to  the  malarial  infection.  The  typhoid  fever  of  Philadelphia  and 
Baltimore  presents  no  essential  difference  from  the  disease  as  it  occurs  in 
Montreal,  a  city  practically  free  from  malaria.  Dock  has  shown  conclusively 
that  cases  diagnosed  in  Texas  as  continued  malarial  fever  were  really  true 
typhoid.     The  Widal  reaction  is  now  an  important  aid  in  diagnosis. 

Pernicious  Malarial  Fever. — This  is  fortunately  rare  in  temperate  cli- 
mates, and  the  number  of  cases  which  now  occur,  for  example,  in  Philadelphia 
and  Baltimore,  is  very  much  less  than  it  was  thirty  or  forty  years  ago.  Per- 
nicious fever  is  always  associated  with  the  sestivo-autumnal  parasite.  The 
following  are  the-  most  important  types : 

(a)  The  comatose  form,  in  which  a  patient  is  struck  down  with  symp- 
toms of  the  most  intense  cerebral  disturbance,  either  acute  delirium  or, 
more  frequently,  a  rapidly  developing  coma.  A  chill  may  or  may  not  pre- 
cede the  attack.  The  fever  is  usually  high,  and  the  skin  hot  and  dry.  The 
unconsciousness  may  persist  for  from  twelve  to  twenty-four  hours,  or  the 
patient  may  sink  and  die.  After  regaining  consciousness  a  second  attack 
may  come  on  and  prove  fatal.  In  these  instances,  as  has  been  stated,  the 
special  localization  of  the  infection  is  in  the  brain,  where  actual  thrombi 


22  DISEASES  DUE  TO  ANIMAL  PARASITES. 

of  parasites  with  marked  secondary  changes  in  the  surrounding  tissues  have 
been  found. 

(b)  Algid  Form. — In  this,  the  attack  sets  in  usually  with  gastric  symp- 
toms; there  are  vomiting,  intense  prostration,  and  feebleness  out  of  all 
proportion  to  the  local  disturbance.  The  patient  complains  of  feeling  cold, 
although  there  may  be  no  actual  chill.  The  temperature  may  be  normal, 
or  even  subnormal;  consciousness  may  be  retained.  The  pulse  is  feeble  and 
small,  and  the  respirations  are  increased.  There  may  be  most  severe  diar- 
rhoea, the  attack  assuming  a  choleriform  nature.  The  urine  is  often  dimin- 
ished, or  even  suppressed.  This  condition  may  persist  with  slight  exacerba- 
tions of  fever  for  several  days  and  the  patient  may  die  in  a  condition  of 
profound  asthenia.  This  is  essentially  the  same  as  described  as  the  asthenic 
or  adynamic  form  of  the  disease.  In  the  cases  with  vomiting  and  diarrhoea, 
Marchiafava  has  shown  that  the  gastro-intestinal  mucosa  is  often  the  seat  of 
a  special  invasion  by  the  parasites,  actual  thrombosis  of  the  small  vessels  with 
superficial  ulceration  and  necrosis  occurring.  Similar  lesions  were  found  by 
Barker  in  the  gastro-intestinal  tract  of  a  case  from  my  wards. 

(c)  Hcemorrliagic  Forms — Black-water  Fever — Hsemoglobinuric  Fever — 
Malarial  Hemoglobinuria. — In  temperate  regions  these  forms  are  rare;  in 
the  tropics  they  are  common.  In  the  Southern  States  there  are  many  dis- 
tricts in  which  there  is  endemic  hgemoglobinuria,  believed  to  be  of  malarial 
origin,  while  in  parts  of  Africa  there  is  the  much-disputed  malady  known  as 
black-water  fever.  There  seems  to  be  no  essential  difference  between  the 
malarial  hasmoglobinuria  of  the  Southern  States  and  the  African  black-water 
fever.  As  described  by  Stephens  and  Christophers  (Eeport  of  Malaria  Com- 
mittee, Fifth  Series),  for  two  or  three  days  the  patient  has  a  rise  of  tem- 
perature, and  if  the  blood  is  examined  before  the  black-water  the  parasites  are 
almost  invariably  present.  If  examined  after  the  administration  of  quinine 
parasites  are  absent  from  the  blood.  These  authors  believe  that  there  is  a 
causal  connection  between  the  quinine  and  the  black-water.  It  is  impossible 
to  say  why  quinine  at  one  time  can  produce  black-water,  and  at  another,  even 
a  few  hours  or  days  later,  it  can  not.  Stephens'  study  (Thompson-Yates  and 
Johnston  Laboratory  Eeports,  1903)  gives  the  distribution  of  black-water 
fever  in  the  Southern  States,  in  Central  America,  in  Italy,  and  in  Africa. 
He  gives  a  careful  analysis  of  95  cases.  Malarial  parasites  were  present  in 
95.6  per  cent  of  the  cases  before  the  onset,  and  on  the  day  of  the  appearance 
of  the  black-water  in  61.9  per  cent.  There  is  no  question  as  to  the  malarial 
nature  of  the  disease,  but  whether  there  is  a  special  malarial  parasite  is  not 
yet  settled.  There  is  little  evidence  to  show  that  the  malarial  hgemoglobinuria 
of  the  Southern  States  is  due  to  quinine  (Thayer).  In  most  instances  where 
the  disease  has  been  carefully  studied,  the  paroxysms  have  occurred  in  indi- 
viduals who  have  been  subject  to  frequently  repeated  attacks  of  malaria  and 
have  been  reduced  to  a  more  or  less  cachectic  condition.  Only  8  cases  occurred 
among  the  Isthmian  Canal  employees  in  1907.  Brem,  Herrick,  and  the  other 
workers  on  the  Isthmus  have  not  settled  the  relationship  to  the  malarial 
attacks.  They  rather  favour  the  view  of  some  special  character  of  the  organ- 
ism. They  do  not  think  that  quinine  is  an  important  factor;  on  the  other 
hand,  they  find  that  intra-muscular  injections  of  quinine  are  almost  a  specific, 
10  grains  every  four  hours  for  the  first  48  hours. 


DISEASES  DUE  TO  PROTOZOA.  23 

Malarial  Cachexia. — The  general  symptoms  are  those  of  secondary  anaemia 
— breathlessness  on  exertion,  oedema  of  the  ankles,  haemorrhages,  particularly 
into  the  retina.  Occasionally  the  bleeding  is  severe,  and  I  have  twice  known 
fatal  haematemesis  to  occur  in  association  with  the  enlarged  spleen.  The  fever 
is  variable.  The  temperature  may  be  low  for  days,  not  going  above  99.5°. 
In  other  instances  there  may  be  irregular  fever,  and  the  temperature  rises 
gradually  to  102.5°  or  103°. 

With  careful  treatment  the  outlook  is  good,  and  a  majority  of  cases  Re- 
cover. The  spleen  is  gradually  reduced  in  size,  but  it  may  take  several  months, 
or,  indeed,  in  some  instances  several  years,  before  the  ague-cake  entirely 
disappears. 

Earer  Complications. — Paraplegia  may  be  due  to  a  peripheral  neuritis 
or  to  changes  in  the  cord,  and  hemiplegia  may  occur  in  the  pernicious  comatose 
form,  or  occasionally  at  the  very  height  of  a  paroxysm.  Acute  ataxia  has 
been  described,  and  there  are  remarkable  cases  with  the  symptoms  of  dissem- 
inated sclerosis  (Spiller).  Multiple  gangrene  may  occur,  as  in  an  instance 
reported  by  me,  in  which  a  patient  with  sestivo-autumnal  infection  presented 
many  areas  on  the  skin.  Orchitis  has  been  described  by  Charvot  in  Algiers 
and  Fedeli  in  Eome. 

Prophylaxis. — In  the  discovery  of  Laveran  there  lay  the  promise  of  bene- 
fits more  potent  than  any  gift  science  had  ever  ofEered  to  mankind — viz.,  the 
possibility  of  the  extermination  of  malaria.  By  the  persistent  missionary 
efforts  of  Boss  this  promise  has  reached  the  stage  of  practical  fulfilment,  and 
one  of  the  greatest  scourges  of  the  race  is  now  at  our  command.  The  story 
of  the  Canal  Zone,  Panama,  under  Colonel  Gorgas  is  a  triumph  of  the  appli- 
cation of  scientific  methods.  Between  1881  and  1904  among  the  employees 
of  the  French  Canal  Company  (a  maximum  in  1887  of  17,885,  of  whom 
15,726  were  negroes)  the  monthly  mortality  ranged  from  60  to  80,  and  on 
seven  occasions  was  above  100,  once  reaching  the  enormous  figure  of  176.97 
per  1,000.  With  the  measures  given  below  the  mortality  has  fallen  to  that 
of  temperate  regions.  For  1907  the  death  rate  among  white  employees 
(10,709)  was  16.71  per  1,000,  among  the  negroes  (28,634)  33.28  per  1,000. 
In  May,  1908,  the  mortality  among  44,816  employees  had  fallen  to  the  remark- 
ably low  figure  of  10.44  per  1,000  ! 

The  measures  of  prophylaxis  are  in  the  main  three :  ( 1 )  The  rigid  protec- 
tion of  houses  against  mosquitoes  by  screens  and  the  use  of  mosquito  nets.  The 
reports  of  the  Italian  Society  for  the  Study  of  Malaria  upon  their  efforts  to 
protect  the  workers  on  the  railways,  as  well  as  the  work  of  Eoss  at  Ismailia, 
show  how  extraordinary  are  the  results  of  these  simple  measures.  The  protec- 
tion of  the  sleeper  at  night  is  one  of  the  most  essential  measures.  (2)  An 
earnest  warfare  against  the  mosquito  on  the  part  of  sanitary  authorities.  In- 
struction should  be  furnished  to  the  people  upon  the  habits  and  life  history  of 
the  insect,  and  of  its  relation  to  the  disease.  Pools,  ponds,  and  marshy  districts 
should  be  drained,  and  in  the  malaria  season  petroleum  should  be  used  freely, 
as  it  prevents  the  development  of  the  larvae.  Every  case  of  malaria  should  be 
regarded  as  a  centre  of  infection,  and  in  a  systematic  warfare  against  the 
disease  should  be  reported  to  the  health  authorities.  In  the  tropics,  segre- 
gation of  Europeans  may  do  much  to  lessen  the  chances  of  infection.  (3) 
Lastly,  every  case  should  receive  thorough  and  prolonged  treatment  with 


24  DISEASES  DUE  TO  ANIMAL  PARASITES. 

quinine.  There  is  far  too  much  carelessness  on  this  point  in  the  profes- 
sion. Malarial  infection  is  a  difficult  one  to  eradicate.  Quinine  is  the  only 
known  drug  which  is  an  effective  parasiticide.  Patients  should  be  told  to 
resume  the  treatment  in  the  spring  and  autumn  for  several  years  after  the 
primary  infection.  In  very  malarial  districts,  as  many  persons  harbor  the 
parasites,  who  do  not  show  any  (or  at  the  most  very  few)  signs,  a  systematic 
treatment  with  quinine  should  be  instituted,  particularly  of  the  young  children. 

Diagnosis. — The  endemic  index  of  a  country  may  be  determined  by  the 
"  parasite  rate  "  or  by  the  "  spleen  rate."  It  is  best  sought  for  in  children 
in  whom,  as  is  well  known,  the  infection  may  occur  without  much  disturb- 
ance of  the  health.  To  determine  the  index  by  examining  the  blood  for  the 
parasites  is  a  laborious  and  almost  impossible  task;  on  the  other  hand,  as 
the  work  of  Eoss  in  Greece  and  Mauritius  has  shown,  the  index  may  be  readily 
gauged  by  an  examination  of  the  spleen.  Thus,  in  the  last-named  island,  of 
31,022  children,  34.1  per  cent  had  enlarged  spleen. 

The  individual  forms  of  malarial  infection  are  readily  recognized,  but  it 
requires  a  long  and  careful  training  to  become  an  expert  in  blood  examination. 
Great  progress  has  been  made  in  the  past  twenty  years,  and  a  diagnosis  of 
malaria  is  no  longer  a  refuge  for  our  ignorance.  One  lesson  it  is  hard  for 
the  practitioner  to  learn — namely,  that  an  intermittent  fever  which  resists 
quinine  is  not  malarial. 

The  malarial  poison  is  supposed  to  influence  many  affections  in  a  remark- 
able way,  giving  to  them  a  paroxysmal  character.  A  whole  series  of  minor 
ailments  and  some  more  severe  ones,  such  as  neuralgia,  are  attributed  to 
certain  occult  effects  of  paludism.  The  more  closely  such  cases  are  investi- 
gated the  less  definite  appears  the  connection  with  malaria. 

Treatment. — As  a  rule,  anopheles  are  more  likely  to  bite  after  sun- 
down, so  that  in  regions  in  which  the  disease  prevails  extensively  mosquito 
netting  should  be  used.  Persons  going  to  a  malarial  region  should  take  about 
10  grains  of  quinine  daily,  though  Sezary  found  that  2  grains  three  times  a 
day  was  a  sufficient  protection  against  the  disease.  During  the  paroxysm  the 
patient  should,  in  the  cold  stage,  be  wrapped  in  blankets  and  given  hot  drinks. 
The  reactionary  fever  is  rarely  dangerous  even  if  it  reaches  a  high  grade.  The 
body  may,  however,  be  sponged.  In  quinine  we  possess  a  specific  remedy 
against  malarial  infection.  Experiment  has  shown  that  the  parasites  are  most 
easily  destroyed  by  quinine  at  the  stage  when  they  are  free  in  the  circulation 
— ^that  is,  during  and  just  after  segmentation.  While  in  most  instances  the 
parasites  of  the  regularly  intermittent  fevers  may  be  destroyed,  even  in  the 
intra-corpuscular  stage,  in  aestivo-autumnal  fever  this  is  much  more  difficult. 
It  should,  then,  be  our  object,  if  we  wish  to  most  effectually  eradicate  the 
infection,  to  have  as  much  quinine  in  circulation  at  the  time  of  the  paroxysm 
and  shortly  before  as  is  possible,  for  this  is  the  period  at  which  segmentation 
occurs.  In  the  regularly  intermittent  fevers  from  10  to  30  grains  in  divided 
doses  throughout  the  day  will  in  many  instances  prevent  any  fresh  paroxysms. 
If  the  patient  comes  under  observation  shortly  before  an  expected  paroxysm, 
the  administration  of  a  good  dose  of  quinine  just  before  its  onset  may  be 
advisable  to  obtain  a  maximum  effect  upon  that  group  of  parasites.  The 
quinine  will  not  prevent  the  paroxysm,  but  will  destroy  the  greater  part  of 
the  group  of  organisms  and  prevent  its  further  recurrence.    It  is  safer  to  give 


DISEASES  DUE  TO  PARASITIC  INFUSORIA.  25 

at  least  20  to  30  grains  daily  for  the  first  three  days,  and  then  to  continue 
the  remedy  in  smaller  doses  for  the  next  two  or  three  weeks.  In  gestivo- 
autumnal  fever  larger  doses  may  be  necessary,  though  in  relatively  few  in- 
stances is  it  necessary  to  give  more  than  30  to  40  grains  in  the  twenty-four 
hours. 

The  quinine  should  be  ordered  in  solution  or  in  capsules.  The  pijls 
and  compressed  tablets  are  more  uncertain,  as  they  may  not  be  dissolved. 

A  question  of  interest  is  the  efficient  dose  of  quinine  necessary  to  cure 
the  disease.  I  have  a  number  of  charts  showing  that  grain  doses  three  times 
a  day  will  in  many  cases  prevent  the  paroxysm,  but  not  always  with  the  cer- 
tainty of  the  larger  doses.  In  cases  of  aestivo-autumnal  fever  with  pernicious 
symptoms  it  is  necessary  to  get  the  system  under  the  influence  of  quinine  as 
rapidly  as  possible.  In  these  instances  the  drug  should  be  administered  hypo- 
dermically  as  the  dihydrochlorate  in  15  to  20  grain  doses,  every  two  or  three 
hours.  The  muriate  of  quinine  and  urea  is  also  a  good  form  in  which  to 
administer  the  drug  hypodermically ;  10,  15,  or  20  grain  doses  may  be  neces- 
sary. In  the  most  severe  instances  some  observers  advise  the  intravenous 
administration  of  quinine,  for  which  the  very  soluble  bimuriate  is  well 
adapted.  Fifteen  grains  with  a  grain  of  sodium  chloride  may  be  injected  in 
about  2  drachms  of  distilled  water.  For  extreme  restlessness  in  these  cases 
opium  is  indicated,  and  cardiac  stimulants,  such  as  alcohol  and  strychnine, 
are  necessary.  If  in  the  comatose  form  the  internal  temperature  is  raised, 
the  patient  should  be  put  in  a  bath  and  doused  with  cold  water.  For  malarial 
anaemia,  iron  and  arsenic  are  indicated. 

An  interesting  question  is  much  discussed,  whether  quinine  does  not  cause 
or  at  any  rate  aggravate  the  hasmoglobinuria.  We  have  not  yet  seen  a  case  in 
which  this  condition  has  occurred  as  a  result  of  the  use  of  the  drug,  and  Bas- 
tianelli  states  that  it  is  not  seen  in  the  Eoman  malarial  fevers.  He  recom- 
mends that  in  any  case  of  hsemoglobinuria  if  the  blood  shows  parasites 
quinine  should  be  administered  freely.  In  the  post-malarial  forms  quinine 
aggravates  the  attack.  In  an  active  malarial  infection  the  patient  runs  less 
risk  with  the  quinine. 


B.    DISEASES  DUE  TO  PARASITIC  INFUSORIA. 

Several  flagellates  are  parasitic  in  man.  The  Trichomonas  vaginalis, 
which  measures  15  /a  to  25  /x  in  length,  and  has  four  flagella,  which  are  as 
long  as  or  longer  than  the  body,  is  by  no  means  uncommon  in  the  acid  vaginal 
mucus. 

The  Trichomonas  or  C ercomonas  hominis  lives  in  the  intestines,  and  is 
met  with  in  the  stools  under  all  sorts  of  conditions.  Freund  from  Dock's 
clinic  has  reported  a  series  of  cases  which  show  that  the  parasite  may  cause 
acute  and  chronic  diarrhoea  with  severe  abdominal  pain,  and  anatomically  an 
acute  enteritis.  In  one  of  Dock's  cases  the  parasites  were  associated  with  a 
ha3mojrhagic  cystitis  without  bacteria. 

The  Lamhlia  intestinalis  is  another  intestinal  monad,  larger  than  the 
common  trichomonas.     Flagellates  have  also  been  found  in  the  expectoration 


26  DISEASES  DUE  TO  ANIMAL  PARASITES. 

in  cases  of  gangrene  of  the  lung  and  of  bronchiectasis,  and  in  the  exudate 
of  pleurisy. 

The  Balantidium  coli,  oval  in  form,  70  [x  to  100  fi  long  and  50  /x  to  70  /* 
broad,  may  be  pathogenic.  It  is  common  in  pigs,  and  has  been  known  to 
produce  an  epidemic  dysentery  in  apes  (Harlow  Brooks).  The  pathological 
significance  of  this  parasite  has  been  much  discussed  of  late,  particularly  by 
Strong  and  Musgrave,  Klimenko  and  Arkanazy.  It  has  not  only  been  found 
in  the  stools  and  on  the  mucous  membrane  of  the  intestine,  but  the  parasites 
have  occurred  in  the  mucosa  itself  and  in  the  submucosa.  Apparently  they 
do  not  extend  beyond  the  wall  of  the  bowel. 


C.    DISEASES  DUE   TO   FLUKES.-DISTOMIASIS. 

The  following  are  important  clinical  forms : 

1.  Pulmonary  Distomiasis ;  Parasitic  Haemoptysis. — Paragonimus  (Dis- 
toma)  Westermanii,  the  Asiatic  lung  or  bronchial  fluke,  is  from  8  to  16  mm. 
in  length  by  4  to  8  mm.  broad,  and  of  a  pinkish  or  reddish-brown  color. 

It  is  found  extensively  in  China  and  Japan  and  Formosa,  and  cases  are 
occasionally  imported  into  Europe  and  America.  Stiles  states  that  an  im- 
ported case  has  been  found  in  Portland,  Oregon.  It  has  been  found  in  the 
United  States  in  the  cat,  in  the  dog,  and  in  the  hog.  One  instance  of  pulmo- 
nary distomiasis  has  been  reported  caused  by  the  giant  liver  fluke. 

Clinically  the  disease,  as  described  by  Manson  and  Einger,  is  characterized 
by  a  chronic  cough,  with  rusty-brown  sputum,  and  occasional  attacks  of 
haemoptysis,  usually  trifling,  but  sometimes  very  severe.  The  ova,  which  are 
abundant  in  the  sputum,  are  oval,  smooth,  and  measure  from  80  /x  to  100  /*  in 
length  by  40  /a  to  60  /a  in  breadth.  The  parasites  may  affect  other  organs — 
the  liver  and  the  brain. 

2.  Hepatic  Distomiasis. — Five  species  of  liver  flukes  of  the  family 
Fasciolidse  are  known  to  occur  in  man.  More  specifically  these  are :  ( 1 )  The 
common  liver  fluke — Fasciola  hepatica — which  is  a  very  common  parasite  in 
the  ruminants;  (2)  The  lancet  fluke — dicrocoelium  (Distoma)  lanceatum; 
(3)  Opisthorchis  (Distoma)  felineus,  which  is  found  in  Prussia  and  Siberia, 
and  by  Ward  in  cats  in  Nebraska ;  (4)  Opisthorchis  noverca — Distomum  con- 
junctum — the  Indian  liver  fluke  described  in  man  by  McConnell;  (5)  Opis- 
thorchis {Distoma)  sinensis,  which  is  by  far  the  most  important  of  the  liver 
flukes  and  occurs  extensively  in  Japan,  China,  and  India.  It  is  10  to  20  mm. 
long  by  2  to  5  mm.  broad.  The  eggs  are  oval,  27  fi  to  SO  fi  by  15  ju.  to  17  fi, 
dark  brown,  with  sharply  defined  operculum.  A  number  of  imported  cases 
have  been  found  in  Canada  and  the  United  States.  White  found  18  cases  in 
San  Francisco. 

The  symptoms  of  hepatic  distomiasis  are  best  described  in  connection  with 
this  latter  form.  The  following  account  is  abstracted  from  Wallace  Taylor. 
Young  children  are  the  chief  sufferers.  Many  members  of  a  family  are  usu- 
ally affected.  In  some  villages  a  large  proportion  of  the  inhabitants  are 
attacked.  Among  important  symptoms  are  an  irregular,  intermittent  diar- 
rhoea; at  first  there  may  or  may  not  be  blood.     The  liver  gradually  enlarges. 


DISEASES  DUE  TO  FLUKES— DISTOMIASIS.  27 

There  may  be  pain  and  an  intermittent  jaundice.  There  is  not  much  fever. 
After  lasting  for  two  or  three  years  dropsy  comes  on,  anasarca  and  ascites. 
The  patient  is  greatly  reduced  by  the  diarrhoea  and  becomes  very  anaemic. 
Even  then  transient  recovery  may  take  place,  but  as  a  rule  there  is  a  recur- 
rence, and  the  patient  dies  after  many  years  of  illness.  The  ova  of  the  para- 
site are  readily  found  in  the  stools. 

3.  Intestinal  Distomiasis. — In  India  the  Fasciolopsis  (Distoma)  BusMi 
has  been  found  in  a  number  of  cases  in  the  small  intestines.  The  Mesogoni- 
mus  heterophyes  has  been  found  in  Egypt  and  Japan. 

The  Asiatic  Amphistome — Gastrodiscus  (Ampliistoma)  liominis — a  not 
uncommon  parasite  in  India — is  easily  recognized  by  its  large  posterior  sucker. 

4.  Haemic  Distomiasis;  Bilharziosis. — One  of  the  most  important  of  para- 
sitic diseases,  caused  by  the  blood  fluke,  Scliistosom.um  hcematobium  or  Bil- 
harzia  licematohia.  Endemic  hgematuria  has  been  known  for  many  years, 
particularly  in  Egypt,  where  in  1851  Bilharz  discovered  the  parasite  of  the 
disease.  It  prevails  in  South  and  North  Africa,  particularly  the  latter,  in 
Arabia,  Persia,  and  the  west  coast  of  India.  Imported  cases  are  not  very 
uncommon  in  Europe,  and  an  occasional  instance  is  met  with  in  the  United 
States.  In  Lower  Egypt  it  is  met  with  in  one  third  of  all  the  autopsies. 
An  Asiatic  blood  fluke,  Schistosomum  japonicum,  has  recently  been  discov- 
ered which  differs  in  small  details  from  the  African  variety. 

The  parasite  is  singular  among  flukes  as  having  the  sexes  separate,  and 
the  male  usually  carries  the  female  in  a  gynsecophorous  canal.  The  mode  of 
entrance  into  the  body  is  unknown,  whether  by  the  mouth,  the  urethra,  or 
through  the  skin.  The  eggs  are  very  characteristic,  oval  in  shape,  0.16  mm.  by 
0.06  mm.,  and  one  end  has  a  terminal  spine.  The  eggs  hatch  in  water,  but  the 
further  development  of  the  free-swimming  embryos  has  not  been  followed. 
Taken  into  the  body,  possibly  with  water  or  on  cresses,  it  reaches  the  portal 
veins,  in  which  the  worms  are  most  commonly  found,  usually  young  speci- 
mens and  uncoupled.  The  males  bearing  the  females  creep  to  various  parts, 
particularly  the  bladder  and  rectum.  The  eggs  are  laid  in  the  tissues,  but 
wander,  like  other  sharp  foreign  bodies,  and  escape  with  the  urine  and  faeces. 
A  majority  of  them  remain  in  the  tissues  and  cause  irritation,  fibroid  changes, 
and  papillomata  in  the  bladder  and  rectum.  Collecting  in  the  bladder  as 
foreign  bodies  they  form  the  nuclei  of  calculi. 

Symptoms. — As  is  so  often  the  ease  with  animal  parasites,  they  may 
cause  no  inconvenience.  Irritability  of  the  bladder,  dull  pain  in  the  peri- 
nseum,  and  haematuria  are  the  most  frequent  symptoms.  A  chronic  cystitis 
follows  when  the  walls  of  the  bladder  are  much  thickened  by  the  irritation 
caused  by  the  ova.  The  angemia  caused  by  the  haemorrhage  is  slight  in  com- 
parison with  that  of  ankylostomiasis.  When  the  rectum  is  involved  there  are 
straining  and  tenesmus,  with  the  passage  of  mucus  and  blood ;  in  severe  cases 
large  papillomata  and  a  chronic  ulcerative  proctitis.  There  may  be  a  chronic 
vaginitis. 

Of  the  complications,  calculi  in  kidney  and  bladder  are  the  most  impor- 
tant. Milton,  Madden,  and  others  of  the  Cairo  School  of  Medicine  have  stud- 
ied carefully  the  surgical  aspects  of  the  disease.  Periurethral  abscess  and 
perineal  fistulse  are  very  common  in  the  chronic  cases. 

Few  symptoms  are  caused  by  the  presence  of  the  parasites  in  the  portal 


28  DISEASES  DUE   TO  ANIMAL  PARASITES. 

veins,  but  there  may  be  an  advanced  cirrhosis  of  a  Glissonian  type  due  to  ail 
enormous  thickening  of  the  periportal  tissues  (Symmers).  This  author 
has  also  reported  an  instance  of  the  Bilharzia  in  the  pulmonary  blood  in  a  case 
of  Bilharzial  colitis,  and  the  worms  were  found  living  in  the  pulmonary 
circulation. 

The  diagnosis  is  readily  made  by  finding  the  characteristic  ova  in  the 
bloody  urine  or  in  the  blood  and  mucus  from  the  rectum.  The  Bilharzia  may 
be  present  in  the  body  for  years  without  producing  serious  damage,  and  in 
slight  infections  the  symptoms  may  disappear  (Sand with),  particularly  in 
children. 

Schistosoma  Japonicum  vel  Cattoi. — In  China  and  Japan  and  in  the  Phil- 
ippines there  is  a  disease  characterized  by  cirrhosis  of  the  liver,  splenomegaly, 
ascites,  dysentery,  progressive  anaemia,  and  sometimes  by  localized  epilepsy. 
It  occurs  extensively  in  one  district  of  Japan,  and  is  known  as  the  "  Kata- 
yama "  disease.  Woolley  has  met  with  it  in  the  Philippines,  and  Catto  in 
China.  The  parasite  lives  in  the  vessels  of  the  alimentary  canal;  the  ova  are 
smaller  than  those  of  S.  licematobium,  and  have  not  the  characteristic  spinous 
ends. 

Treatment. — ^We  know  of  nothing  which  can  kill  the  parasites  in  the 
blood.  Extract  of  male  fern  is  recommended  for  the  hsematuria.  The 
chronic  cystitis  and  proctitis  demand  the  usual  measures  for  these  disorders. 


D.    DISEASES   CAUSED  BY  CESTODES. 

{Tceniasis;  Hydatid  Disease.) 

Man  harbors  the  adult  parasites  in  the  small  intestine,  the  larval  forms 
in  the  muscles  and  solid  organs. 

I.    INTESTINAL    CESTODES;    TAPE- WORMS. 

Taenia  solium,  or  pork  tape-worm.  This  is  not  a  common  form  in 
North  America.  It  is  much  more  frequent  in  parts  of  Europe  and  Asia. 
When  mature  it  is  from  6  to  12  feet  in  length.  The  head  is  small,  round, 
not  so  large  as  the  head  of  a  pin,  and  provided  with  four  sucking  disks  and 
a  double  row  of  hooklets;  hence  it  is  called,  in  contradistinction  to  the 
other  form  in  man,  the  armed  tape-worm.  To  the  head  succeeds  a  narrow, 
thread-like  neck,  then  the  segments,  or  proglottides,  as  they  are  called.  The 
segments  possess  both  male  and  female  generative  organs,  and  at  about  the 
four-hundred-and-fiftieth  they  become  mature  and  contain  ripe  ova.  The 
worm  attains  its  full  growth  in  from  three  to  three  and  a  half  months,  after 
which  time  the  segments  are  continuously  shed  and  appear  in  the  stools.  The 
segments  are  about  1  cm.  in  length  and  from  7  to  8  mm.  in  breadth.  Pressed 
between  glass  plates  the  uterus  is  seen  as  a  median  stem  with  about  eight 
to  fourteen  lateral  branches.  There  are  many  thousands  of  ova  in  each  ripe 
segment,  and  each  ovum  consists  of  a  firm  shell,  inside  of  which  is  a  little 
embryo,  provided  with  six  hooklets.  The  segments  are  continuously  passed, 
and  if  the  ova  are  to  attain  further  development  they  must  be  taken  into  the 
stomach,  either  of  a  pig,  or  of  man  himself.    The  egg-shells  are  digested,  the 


DISEASES  CAUSED  BY  CESTODES.  29 

six-hooked  embryos  become  free,  and  passing  from  the  stomach  reach  various 
parts  of  the  body  (the  liver,  muscles,  brain,  or  eye),  where  they  develop  into 
the  larvae  or  cysticerci.  A  hog  under  these  circumstances  is  said  to  be 
measled,  and  the  cysticerci  are  spoken  of  as  measles  or  bladder  worms. 

Tmnia  solium  received  its  name  because  it  was  thought  to  exist  as  a  soli- 
tary parasite  in  the  bowel,  but  two  or  three  or  even  more  worms  may  occijr. 

Taenia  saginata  or  mediocanellata — unarmed,  fat,  or  beef  tape-worm. 
This  is  a  longer  and  larger  parasite  than  Tcenia  solium.  It  is  certainly  the 
common  tape-worm  of  j^orth  America.  Of  scores  of  specimens  which  I 
have  examined  almost  all  were  of  this  variety.  According  to  Berenger-Feraud 
it  has  spread  rapidly  in  western  Europe,  owing  probably  to  the  importation 
of  beef  and  live-stock  from  the  Mediterranean  basin.  It  may  attain  a  length 
of  15  or  20  feet,  or  more.  The  head  is  large  in  comparison  with  that  of 
TcBnia  solium,  and  measures  over  2  mm.  in  breadth.  It  is  square-shaped 
and  provided  with  four  large  sucking  disks,  but  there  are  no  hooklets.  The 
ripe  segments  are  from  17  to  18  mm.  in  length  and  from  8  to  10  mm.  in 
breadth.  The  uterus  consists  of  a  median  stem  with  from  fifteen  to  thirty- 
five  lateral  branches,  which  are  given  ofE  more  dichotomously  than  in  Tcenia 
solium.  The  ova  are  somewhat  larger,  and  the  shell  is  thicker,  but  the  two 
forms  can  scarcely  be  distinguished  by  their  ova.  The  ripe  segments  are 
passed  as  in  Tcenia  solium,  and  are  ingested  by  cattle,  in  the  flesh  or  organs 
of  which  the  eggs  develop  into  the  bladder  worms  or  cysticerci. 

Of  other  forms  of  tape-worm  may  be  mentioned: 

Dipylidium  caninum  (Taenia  elliptica,  Taenia  cucumerina) . — A  small 
parasite  very  common  in  the  dog  and  occasionally  found  in  man;  the  larvaj 
develop  in  the  lice  and  fleas  of  the  dog. 

Hymenolepsis  diminuta  (Taenia  flavo-punctata) . — This  small  cestode  was 
found  in  the  intestine  of  a  child  in  Boston,  and  has  since  been  met  with  in 
twelve  cases  (Eausom).  It  is  common  in  rats.  The  larvae  develop  in  Lepi- 
doptera  and  in  beetles. 

Hymenolepsis  nana  (Taenia  nana)  occurs  not  infrequently  in  Italy. 
It  is  not  very  uncommon  in  the  United  States  (Stiles).  The  Davainea  mada- 
gascariensis  (Tcenia  madagascariensis)  is  a  rare  form. 

Taenia  confusa,  a  new  species  described  by  Ward. 

Bothriocephalus  latus. — A  cestode  worm  found  only  in  certain  districts 
bordering  on  the  Baltic  Sea,  in  parts  of  Switzerland,  and  in  Japan.  ISTicker- 
son  has  shown  that  it  is  common  among  the  Finns  in  the  Northwestern  States. 
The  parasite  is  large  and  long,  measuring  from  25  to  30  feet  or  more.  Its 
head  is  different  from  that  of  the  taenia,  as  it  possesses  two  lateral  grooves 
or  pits  and  has  no  hooklets.  The  larvae  develop  in  the  peritonaeum  and  mus- 
cles of  the  pike  and  other  fish,  and  it  has  been  shown  experimentally  that  they 
grow  into  the  adult  worm  when  eaten  by  man. 

Symptoms. — These  parasites  are  found  at  all  ages.  They  are  not  uncom- 
mon in  children  and  are  occasionally  found  in  sucklings.  W.  T.  Plant  refers 
to  a  number  of  cases  in  children  under  two  years,  and  there  is  one  in  the  liter- 
ature in  which  it  is  stated  that  the  tape-worm  was  found  in  an  infant  five 
days  old ! 

The  parasites  may  cause  no  disturbance  and  are  rarely  dangerous.  A 
knowledge  of  the  existence  of  the  worm  is  generally  a  source  of  worry  and 


30  DISEASES  DUE   TO  ANIMAL  PARASITES. 

anxiety;  the  patient  may  have  considerable  distress  and  complain  of  ab- 
dominal pains,  nausea,  diarrhoea,  and  sometimes  anemia.  Occasionally  the 
appetite  is  ravenous.  In  women  and  in  nervous  patients  the  constitutional 
disturbance  may  be  considerable,  and  we  not  infrequently  see  great  mental 
depression  and  even  hypochondria.  Various  nervous  phenomena,  such  as 
chorea,  convulsions,  or  epilepsy,  are  believed  to  be  caused  by  the  parasites. 
Such  effects,  however,  are  very  rare.  The  Bothriocephalus  may  cause  a 
severe  and  even  fatal  form  of  anaemia,  which  has  been  described  fully  in 
the  monograph  of  Schaumann,  of  Helsingfors.  It  has  been  suggested  that 
the  metabolic  products  of  the  worm  may  have  in  some  cases  a  hsemolytic 
action. 

The  diagnosis  is  never  doubtful.  The  presence  of  the  segments  is  dis- 
tinctive. The  ova,  too,  may  be  recognized  in  the  stools.  It  makes  but  little 
difference  as  to  the  form  of  tape-worm,  but  the  ripe  segments  of  Tcenia  sagi- 
nata  are  larger  and  broader,  and  show  differences  in  the  generative  system  as 
already*  mentioned. 

The  prophylaxis  is  most  important.  Careful  attention  should  be  given  to 
three  points.  First,  all  tape- worm  segments  should  be  burned;  they  should 
never  be  thrown  into  the  water-closet  or  outside ;  secondly,  careful  inspection 
of  meat  at  the  abattoirs;  and  thirdly,  cooking  the  meat  sufficiently  to  kill  the 
parasites. 

In  the  case  of  the  beef  measles,  the  distribution  of  the  parasites,  as 
given  by  Ostertag,  shows  that  the  muscles  of  the  jaw  are  much  more  fre- 
quently affected  than  other  parts — 360  times,  while  other  organs  were  infected 
but  55  times.  Sometimes  there  are  instances  of  general  infection.  Stiles 
states  that  no  exact  statistics  have  been  published  for  this  country.  In  Ber- 
lin the  proportion  of  cattle  infected  in  1892-'93  was  about  1  to  672.  Cold 
storage  kills  the  cysticercus  usually  within  three  weeks.  The  measles  are 
more  readily  overlooked  in  beef  than  in  pork,  as  they  do  not  present  such  an 
opaque  white  color. 

In  the  examination  of  hogs  for  cysticerci  "  particular  stress  should  be 
laid  upon  the  tongue,  the  muscles  of  mastication,  and  the  muscles  of  the 
shoulder,  neck,  and  diaphragm"  (Stiles).  They  may  be  seen  very  easily 
on  the  under  surface  of  the  tongue.  American  hogs  are  comparatively 
free.  In  Prussia  one  hog  is  infected  in  about  every  637.  Specimens  have 
been  found  alive  twenty-nine  daj^s  after  slaughtering.  In  the  examination 
of  1,000  hogs  in  Montreal,  Clement  and  I  found  76  instances  of  cysticerci. 
For  full  details  with  reference  to  the  inspection  of  meat  for  animal  parasites, 
the  practitioner  is  referred  to  the  work  of  Dr.  Stiles,  in  Bulletin  No.  19, 
United  States  Department  of  Agriculture,  1898. 

Treatment. — For  two  days  prior  to  the  administration  of  the  reme- 
dies the  patient  should  take  a  very  light  diet  and  have  the  bowels  moved 
occasionally  by  a  saline  cathartic.  The  practitioner  has  the  choice  of  a  large 
number  of  drugs.  As  a  rule,  the  male  fern  acts  promptly  and  well.  The 
ethereal  extract,  in  2-drachm  doses,  may  be  given  fasting,  and  followed  in  the 
course  of  a  couple  of  hours  by  a  brisk  purgative.  This  usually  succeeds  in 
bringing  away  a  large  portion,  but  not  always  the  entire  worm. 

A  combination  of  the  remedies  is  sometimes  very  effective.  An  infusion 
is  made  of  pomegranate  root,  half  an  ounce;  pumpkin  seeds,  1  ounce;  pow- 


DISEASES  CAUSED  BY  CESTODES.  31 

dered.  ergot,  a  drachm ;  and  boiling  water,  10  ounces.  To  an  emulsion  of  the 
male  fern  (a  drachm  of  ethereal  extract),  made  with  acacia  powder,  2  minims 
of  croton  oil  are  added.  The  patient  should  have  had  a  low  diet  the  previous 
day  and  have  taken  a  dose  of  salts  in  the  evening.  The  emulsion  and  infusion 
are  mixed  and  taken  fasting  at  nine  in  the  morning. 

The  pomegranate  root  is  a  very  efficient  remedy,  and  may  be  given  as 
an  infusion  of  the  bark,  3  ounces  of  which  may  be  macerated  in  10  ounces 
of  water  and  then  reduced  to  one  half  by  evaporation.  The  entire  quan- 
tity is  then  taken  in  divided  doses.  It  occasionally  produces  colic,  but  is 
a  very  effective  remedy.  The  active  principle  of  the  root,  pelletierine,  is 
now  much  employed.  It  is  given  in  doses  of  6  to  8  or  even  10  grains,  with 
a  little  tannin  (grs.  v)  in  sweetened  water,  and  is  followed  in  an  hour  by  a 
purge. 

Pumpkin  seeds  are  sometimes  very  efficient.  Three  or  4  ounces  should 
be  carefully  bruised  and  then  macerated  for  twelve  or  fourteen  hours,  and 
the  entire  quantity  taken  and  followed  in  an  hour  by  a  purge.  Of  other 
remedies,  koosso,  turpentine  in  ounce  doses  in  honey,  and  kamala  may  be 
mentioned. 

Unless  the  head  is  brought  away,  the  parasite  continues  to  grow,  and 
within  a  few  months  the  segments  again  appear.  Some  instances  are 
extraordinarily  obstinate.  Doubtless  almost  everything  depends  upon  the 
exposure  of  the  worm.  The  head  and  neck  may  be  thoroughly  protected 
beneath  the  valvulse  conniventes,  in  which  case  the  remedies  may  not  act. 
Owing  to  its  armature  Tcenia  solium  is  more  difficult  to  expel.  It  is  probable 
that  no  degree  of  peristalsis  could  dislodge  the  head,  and  unless  the  worm  is 
killed  it  does  not  let  go  its  extraordinarily  firm  hold  on  the  mucous  mem- 
brane. If  hot  water  be  put  in  the  commode  the  worm  is  less  likely  to  con- 
tract and  be  broken,  a  practice  recommended  by  Celsus. 


II.    SOMATIC  T-ffiNIASIS. 

Whereas  adult  taenia  may  give  rise  to  little  or  no  disturbance,  and  rarely, 
if  ever,  prove  directly  fatal,  the  affections  caused  by  the  larvae  or  immature 
forms  in  the  solid  organs  are  serious  and  important.  There  are  two  chief 
cestode  larvas  known  to  frequent  man :  (a)  the  Cysticercus  cellulosce,  the  larva 
of  Tcenia  solium,  and  (&)  the  Ecliinococcus,  the  larva  of  Tcenia  echinococcus. 
The  Cysticercus  tcenice  saginatce  has  been  found  only  two  or  three  times 
in  man. 

Cysticercus  Cellulosae. — When  man  accidentally  takes  into  his  stomach 
the  ripe  ova  of  Tania  solium  he  is  liable  to  become  the  intermediate  host, 
a  part  usually  played  for  this  tape-worm  by  the  pig.  This  accident  may 
occur  in  an  individual  the  subject  of  Tcenia  solium,  in  which  case  the  mature 
proglottides  either  themselves  wander  into  the  stomach  or,  what  is  more  likely, 
are  forced  into  the  organ  in  attacks  of  prolonged  vomiting.  Of  course  the 
accidental  ingestion  from  the  outside  of  a  few  ova  is  quite  possible,  and  the 
liability  of  infection  should  always  be  borne  in  mind  in  handling  the  seg- 
ments of  the  worm. 

The  symptoms  depend  entirely  upon  the  number  of  ova  ingested  and 


S2  DISEASES  DUE  TO  ANIMAL  PARASITES. 

the  localities  reached.  In  the  hog  the  cysticerci  produce  very  little  dis- 
turbance. The  muscles,  the  connective  tissue,  and  the  brain  may  be  swarm- 
ing with  the  measles,  as  they  are  called,  and  yet  the  nutrition  is  maintained 
and  the  animal  does  not  appear  to  be  seriously  incommoded.  In  the  in- 
vasion period,  if  large  numbers  of  the  parasites  are  taken,  there  is,  in  all 
probability,  constitutional  disturbance ;  certainly  this  is  seen  in  the  calf,  when 
fed  with  the  ripe  segments  of  Tcenia  saginata. 

In  man  a  few  cysticerci  lodged  beneath  the  skin  or  in  the  muscles  give 
no  trouble,  and  in  time  the  larvae  die  and  become  calcified.  They  are  occa- 
sionally found  in  dissection  subjects  or  in  post  mortems  as  ovoid  white  bodies 
in  the  muscles  or  subcutaneous  tissue.  In  America  they  are  very  rare.  I 
saw  but  one  instance  in  my  post-mortem  experience.  Depending  on  the  num- 
ber and  the  locality  specially  affected,  the  symptoms  may  be  grouped  into  gen- 
eral, cerebro-spinal,  and  ocular.  In  155  cases  compiled  by  Stiles,  the  para- 
site in  117  was  found  in  the  brain,  in  3.2  in  the  muscles,  in  9  in  the  heart, 
in  3  in  the  lungs,  subcutaneously  in  5,  in  the  liver  in  2. 

1.  General. — As  a  rule  the  invasion  of  the  larvae  in  man,  unless  in  very 
large  numbers,  does  not  cause  very  definite  symptoms.  It  occasionally  hap- 
pens, however,  that  a  striking  picture  is  produced.  A  patient  was  admitted 
to  my  wards  very  stiff  and  helpless,  so  much  so  that  he  had  to  be  assisted 
upstairs  and  into  bed.  He  complained  of  numbness  and  tingling  in  the 
extremities  and  general  weakness,  so  that  at  first  he  was  thought  to  have  a 
peripheral  neuritis.  At  the  examination,  however,  a  number  of  painful  subcu- 
taneous nodules  were  discovered,  which  proved  on  excision  to  be  the  cysticerci. 
Altogether  75  could  be  felt  subcutaneously,  and  from  the  soreness  and  stiff- 
ness they  probably  existed  in  large  numbers  in  the  muscles.  There  were  none 
in  his  eyes,  and  he  had  no  brain  symptoms. 

2.  Cerebro-spinal. — Remarkable  symptoms  may  result  from  the  presence 
of  the  cysticerci  in  the  brain  and  cord.  In  the  silent  region  they  may  be 
abundant  without  producing  any  symptoms.  I  have  in  my  possession  the 
brain  of  a  pig  containing  scores  of  "  measles,"  yet  the  animal  in  the  few 
moments  in  which  I  saw  it  just  prior  to  death  did  not  present  any  symptoms 
to  attract  attention.  In  the  ventricles  of  the  brain  the  cysticerci  may  attain 
a  considerable  size,  owing  to  the  fact  that  in  regions  in  which  they  are  unre- 
strained in  their  growth,  as  in  the  peritonseum,  the  bladder-like  body  grows 
freely.  When  in  the  fourth  ventricle,  remarkable  irritative  symptoms  may  be 
produced.  In  1884  I  saw  with  Friedlander  in  Berlin  a  case  from  Riess's 
wards  in  which  during  life  there  had  been  symptoms  of  diabetes  and  anom- 
alous nervous  symptoms.  Post  mortem,  the  cysticercus  was  found  beneath 
the  valve  of  Vieussens,  pressing  upon  the  floor  of  the  fourth  ventricle. 

3.  Ocular. — Since  von  Graefe  demonstrated  the  presence  of  the  cysticer- 
cus in  the  vitreous  humor  many  cases  have  been  placed  on  record,  as  it  is  a 
condition  easily  recognized. 

Except  in  the  eye,  the  diagnosis  can  rarely  be  made;  when  the  cysticerci 
are  subcutaneous,  one  may  be  excised.  It  is  possible  that  when  numerous 
throughout  the  muscles  they  may  be  seen  under  the  tongue,  in  which  situa- 
tion they  may  exist  in  the  pig  in  numbers. 

Echinococcus  Disease. — The  hydatid  worms  or  echinococci  are  the  larvae 
of  Tcenia  echinococcus  of  the  dog.     This  is  a  tiny  cestode  not  more  than  4 


DISEASES  CAUSED  BY  CESTODES.  33 

or  5  mm.  in  length,  consisting  of  only  three  or  four  segments^  of  which 
the  terminal  one  alone  is  mature,  and  has  a  length  of  about  3  mm.  and  a 
breadth  of  0.6  mm.  The  head  is  small  and  provided  with  four  sucking 
disks  and  a  rostellum  with  a  double  row  of  booklets.  This  is  an  exceedingly- 
rare  parasite  in  the  dog.  Cobbold  states  that  he  has  never  met  with  a  natural 
specimen  in  England.  Leidy  had  not  one  in  his  large  collection.  I  have  not 
met  with  an  instance  in  America;  Curtice,  of  Washington,  found  it  once  in 
an  American  dog.  The  worms  are  so  small  that  they  may  be  readily  over- 
looked, since  they  form  small  white,  thread-like  bodies  closely  adherent  among 
the  villi  of  the  small  intestines.  The  ripe  segment  contains  about  5,000  eggs, 
which  attain  their  development  in  the  solid  organs  of  various  animals,  particu- 
larly the  hog  and  ox,  more  rarely  the  horse  and  the  sheep.  In  some  countries 
man  is  a  common  intermediate  host,  owing  to  the  accidental  ingestion  of 
the  ova. 

Development. — The  little  six-hooked  embryo,  freed  from  the  egg-shell  by 
digestion,  burrows  through  the  intestinal  wall  and  reaches  the  peritoneal  cav- 
ity or  the  muscles ;  it  may  enter  the  portal  vessels  and  be  carried  to  the  liver. 
It  maj''  enter  the  systemic  vessels,  and,  passing  the  pulmonary  capillaries,  as  it 
is  protoplasmic  and  elastic,  may  reach  the  brain  or  other  parts.  Once  having 
reached  its  destination,  it  undergoes  the  following  changes :  The  hooklets 
disappear  and  the  little  embryo  is  gradually  converted  into  a  small  cyst  which 
presents  two  distinct  layers — an  external,  laminated,  cuticular  membrane  or 
capsule,  and  an  internal,  granular,  parenchymatous  layer,  the  endocyst.  The 
little  cyst  or  vesicle  contains  a  clear  fluid.  There  is  more  or  less  reaction  in 
the  neighboring  tissues,  and  the  cyst  in  time  has  a  fibrous  investment.  When 
this  primary  cyst  or  vesicle  has  attained  a  certain  size,  buds  develop  from 
the  parenchymatous  layer,  which  are  gradually  converted  into  cysts,  present- 
ing a  structure  identical  with  that  of  the  original  cyst,  namely,  an  elastic 
chitinous  membrane  lined  with  a  granular  parenchymatous  layer.  These  sec- 
ondary or  daughter  cysts  are  at  first  connected  with  the  lining  membrane  of 
the  primary  cyst,  but  are  soon  set  free.  In  this  way  the  parent  cyst  as  it 
grows  may  contain  a  dozen  or  more  daughter  cysts.  Inside  these  daughter 
cysts  a  similar  process  may  occur,  and  from  buds  in  the  walls  granddaughter 
cysts  are  developed.  From  the  granular  layer  of  the  parent  and  daughter 
cysts  buds  arise  which  develop  into  brood  capsules.  From  the  lining  mem- 
brane the  little  outgrowths  arise  and  gradually  develop  into  bodies  known  as 
scolices,  which  represent  in  reality  the  head  of  the  Tcenia  echinococcus  and 
present  four  sucking  disks  and  a  circle  of  hooklets.  Each  scolex  is  capable 
when  transferred  to  the  intestines  of  a  dog  of  developing  into  an  adult  tape- 
worm. The  difference  between  the  ovum  of  an  ordinary  tape-worm,  such 
as  Tcenia  solium^  and  Tcenia  echinococcus  is  in  this  way  very  striking.  In 
the  former  case  the  ovum  develops  into  a  single  larva — Cysticercus  cellulosce 
— whereas  the  egg  of  Tcenia  echinococcus  develops  into  a  cyst  which  is  capa- 
ble of  multiplying  enormously  and  from  the  lining  membrane  of  which 
millions  of  larval  tape-worms  develop.  Ordinarily  in  man  the  development  of 
the  echinococcus  takes  place  as  above  mentioned  and  by  an  endogenous  form 
in  which  the  secondary  and  tertiary  cysts  are  contained  within  the  primary; 
but  in  animals  the  formation  may  be  different,  as  the  buds  from  the  primary 
cyst  penetrate  between  the  layers  and  develop  externally,  forming  the  exoge- 
4 


34  DISEASES  DUE  TO  ANIMAL  PARASITES. 

nous  variety.  A  third  form  is  the  multilocular  echinococciis,  in  which  form 
the  primary  cj^st  huds  develop  which  are  cut  off  completely  and  are  sur- 
rounded by  thick  capsules  of  a  connective  tissue,  which  join  together  and 
ultimately  form  a  hard  mass  represented  hy  strands  of  connective  tissue 
enclosing  alveolar  spaces  about  the  size  of  peas  or  a  little  larger.  In  these 
spaces  are  found  the  remnants  of  the  eehinococcus  cyst,  occasionally  the 
scolices  or  booklets,  but  they  are  often  sterile. 

The  fluid  is  limpid,  non-albuminous;  specific  gravity  1.005  to  1.009,  occa- 
sionally higher.  It  ma}'  contain  sugar  and  succinic  acid,  and  after  repeated 
tapping  of  the  cyst,  albumin.  When  not  degenerated,  the  hydatid  heads  or 
the  characteristic  booklets  are  found  in  the  contents  of  the  cyst. 

Chaxgbs  IX  THE  Cyst. — It  is  not  known  definitely  how  long  the  eehino- 
coccus remains  alive,  probably  many  years,  possibly  as  long  as  twent}'  years. 
The  most  common  change  is  death  and  the  gradual  inspissation  of  the  contents 
and  conversion  of  the  cyst  into  a  mass  containing  putty-like  or  granular  mate- 
rial which  may  be  partially  calcified.  Eemnants  of  the  chitinous  cyst  wall  or 
booklets  may  be  found.  These  obsolete  hydatid  cysts  are  not  infrequently 
found  in  the  liver.  A  more  serious  termination  is  rupture,  which  may  take 
place  into  a  serous  sac,  or  perforation  may  take  place  externally,  when  the 
cysts  are  discharged,  as  into  the  bronchi  or  alimentary  canal  or  urinary 
passages.  More  unfavorable  are  the  instances  in  which  rupture  occurs  into 
the  bile-passages  or  into  the  inferior  cava.  Eecovery  ma}'  follow  the  rupture 
and  discharge  of  the  hydatids  externally.  Sudden  death  has  been  known  to 
follow  the  rupture.  A  third  and  very  serious  mode  of  termination  is  suppura- 
tion, which  may  occur  spontaneously  or  follow  rupture  and  is  found  most 
frequently  in  the  liver. 

Geographical  Distribution  op  the  Echinococcus. — The  disease  pre- 
vails most  extensively  in  those  countries  in  which  man  is  brought  into  close 
contact  with  the  dog,  particularly  when,  as  in  Australia,  the  dogs  are  used  for 
herding  sheep,  the  animal  in  which  the  larval  form  of  Tcenia  eehinococcus  is 
most  often  found.  In  Iceland  the  cases  are  very  numerous.  In  Europe  the 
disease  is  not  uncommon.  In  Great  Britain  and  in  North  America  it  is 
rare,  and  a  majority  of  the  cases  are  in  foreigners.  Statistics  of  the  preva- 
lence of  the  disease  in  America  have  been  published  by  Osier  (1882),  Som- 
mer  (1895-'96),  and  by  Lyon  (1902),  who  has  collected  211  cases.  Of  these, 
136  cases  were  in  foreigners;  in  92  the  nationality  was  not  stated;  10  were 
negroes;  2  Canadians,  and  only  1  a  native  American.  Fifty-six  cases  oc- 
curred in  Manitoba,  in  which  province  there  is  a  large  settlement  of  Icelanders, 
who  have  brought  the  disease  with  them.  Only  one  instance  is  known  in  a 
Canadian-born  ofl^spring  of  an  Icelandic  emigrant. 

Distribution  in  the  Body. — Of  1,634  cases  comprised  in  the  statistics 
of -Davaine,  Boeker,  Finsen,  and  Neisser,  the  parasite  existed  in  the  liver  in 
820;  in  the  lung  or  pleura  in  137;  in  the  abdominal  organs,  including  the 
kidneys,  bladder,  and  genitalia,  in  331 ;  in  the  nervous  system  in  122 ;  in  the 
circulatory  system  in  42;  in  other  organs  179.  Of  the  241  eases  in  Lyon's 
series  in  this  country  the  liver  was  the  seat  in  177,  and  the  omentum,  peri- 
toneal cavity,  and  mesentery  in  26.  In  11  cases  cysts  were  passed  per  rectum, 
in  7  cases  cysts  or  booklets  were  expectorated,  and  in  2  cases  passed  per 
urethram. 


DISEASES  CAUSED  BY  CESTODES.  35 

Symptoms. — 1.  Hydatids  of  the  Liver. — Small  cysts  may  cause  no  dis- 
turbance; large  and  growing  cysts  produce  signs  of  tumor  of  the  liver  with 
great  increase  in  the  size  of  the  organ.  Naturally  the  physical  signs  depend 
much  upon  the  situation  of  the  growth.  Near  the  anterior  surface  in  the 
epigastric  region  the  tumor  may  form  a  distinct  prominence  and  have  a  tense, 
firm  feeling,  sometimes  with  fluctuation.  A  not  infrequent  situation  is  to 
the  left  of  the  suspensory  ligament,  the  resulting  tumor  pushing  up  the  heart 
and  causing  an  extensive  area  of  dulness  in  the  lower  sternal  and  left  hypo- 
chondriac regions.  In  the  right  lobe,  if  the  tumor  is  on  the  posterior  sur- 
face, the  enlargement  of  the  organ  is  chiefly  upward  into  the  pleura  and  the 
vertical  area  of  dulness  in  the  posterior  axillary  line  is  increased.  Super- 
ficial cysts  may  give  what  is  known  as  the  hydatid  fremitus.  If  the  tumor 
is  palpated  lightly  with  the  fingers  of  the  left  hand  and  percussed  at  the  same 
time  with  those  of  the  right,  there  is  felt  a  vibration  or  trembling  movement 
which  persists  for  a  certain  time.  It  is  not  always  present,  and  it  is  doubtful 
whether  it  is  peculiar  to  the  hydatid  tumors  or  is  due,  as  Briangon  held,  to  the 
collision  of  the  daughter  cysts.  Very  large  cysts  are  accompanied  by  feelings 
of  pressure  or  dragging  in  the  hepatic  region,  sometimes  actual  pain.  The 
general  condition  of  the  patient  is  at  first  good  and  the  nutrition  little,  if  at 
all,  interfered  with.  Unless  some  of  the  accidents  already  referred  to  occur, 
the  symptoms  indeed  may  be  trifling  and  due  only  to  the  pressure  or  weight  of 
the  tumor. 

Historically,  one  of  the  most  interesting  cases  is  that  of  the  first  Lord 
Shaftesbury  (Achitopel),  who  had  a  tumor  below  the  costal  border  for  many 
years.  It  suppurated  and  was  opened  by  the  philosopher  John  Locke,  his 
physician,  who  describes  with  great  detail  the  escape  of  the  bladder-like  bodies. 
Among  the  Shaftesbury  papers  in  the  Eecord  Office  are  several  other  cases  col- 
lected by  Locke ;  the  disease  may  have  been  more  common  in  England  at  that 
period. 

Suppuration  of  the  cyst  changes  the  clinical  picture  into  one  of  pyaemia. 
There  are  rigors,  sweats,  more  or  less  jaundice,  and  rapid  loss  of  weight. 
Perforation  may  occur  into  the  stomach,  colon,  pleura,  bronchi,  or  exter- 
nally, and  in  some  instances  recovery  has  taken  place.  Perforation  has  occurred 
into  the  pericardium  and  inferior  vena  cava;  in  the  latter  case  the  daughter 
cysts  have  been  found  in  the  heart,  plugging  the  tricuspid  orifice  and  the 
pulmonary  artery.  Perforation  of  the  bile-passages  causes  intense  jaundice, 
and  may  lead  to  suppurative  cholangitis. 

An  interesting  symptom  connected  with  the  rupture  of  hydatid  cysts  is  the 
occurrence  of  urticaria,  which  may  also  follow  aspiration  of  the  cysts. 
Brieger  has  separated  a  highly  toxic  material  from  the  fluid,  and  to  it  the 
symptoms  of  poisoning  may  be  due. 

Diagnosis. — Cysts  of  moderate  size  may  exist  without  producing  symp- 
toms. Large  multiple  echinococci  may  cause  great  enlargement  with  irregu- 
larity of  the  outline,  and  such  a  condition  persisting  for  any  time  with  reten- 
tion of  the  health  and  strength  suggests  hydatid  disease.  An  irregular,  pain- 
less enlargement,  particularly  in  the  left  lobe,  or  the  presence  of  a  large, 
smooth,  fluctuating  tumor  of  the  epigastric  region  is  also  very  suggestive, 
and  in  this  situation,  when  accessible  to  palpation,  it  gives  a  sensation  of  a 
smooth  elastic  growth  and  possibly  also  the  hydatid  tremor.     When  suppu- 


36  DISEASES  DUE  TO  ANIMAL  PARASITES. 

ration  occurs  the  clinical  picture  is  really  that  of  abscess,  and  only  the  exist- 
ence of  previous  enlargement  of  the  liver  with  good  health  would  point  to  the 
fact  that  the  suppuration  was  associated  with  hydatids.  Syphilis  may  pro- 
duce irregular  enlargement  without  much  disturbance  in  the  health,  some- 
times also  a  very  definite  tumor  in  the  epigastric  region,  but  this  is  usually 
firm  and  not  fluctuating.  The  clinical  features  may  simulate  cancer  very 
closely.  In  a  case  which  I  reported  the  liver  was  greatly  enlarged  and  there 
were  many  nodular  tumors  in  the  abdomen.  The  post  mortem  showed  enor- 
mous suppurating  hydatid  cysts  in  the  left  lobe  of  the  liver  which  had 
perforated  the  stomach  in  two  places  and  also  the  duodenum.  The  omen- 
tum, mesentery,  and  pelvis  also  contained  numerous  cysts.  As  a  rule,  the 
clinical  course  of  the  disease  would  suffice  to  separate  it  clearly  from  cancer. 
Dilatation  of  the  gall-bladder  and  hydronephrosis  have  both  been  mistaken 
for  hydatid  disease.  In  the  former  the  mobility  of  the  tumor,  its  shape,  and 
the  mucoid  character  of  the  contents  suffice  for  the  diagnosis.  In  some  in- 
stances of  hydronephrosis  only  the  exploratory  puncture  could  distinguish 
between  the  conditions.  More  frequent  is  the  mistake  of  confounding  a 
hydatid  cyst  of  the  right  lobe  pushing  up  the  pleura  with  pleural  effusion  of 
the  right  side.  The  heart  may  be  dislocated,  the  liver  depressed,  and  dulness, 
feeble  breathing,  and  diminished  fremitus  are  present  in  both  conditions. 
Frerichs  lays  stress  upon  the  different  character  of  the  line  of  dulness ;  in  the 
echinococcus  cyst  the  upper  limit  presents  a  curved  line,  the  maximum  of 
which  is  usually  in  the  scapular  region.  Suppurative  pleurisy  may  be  caused 
by  the  perforation  of  the  cyst.  If  adhesions  result,  the  perforation  takes 
place  into  the  lung,  and  fragments  of  the  cysts  or  small  daughter  ejsts  may 
be  coughed  up.  For  diagnostic  purposes  the  exploratory  puncture  should 
be  used.  As  stated,  the  fluid  is  usually  perfectly  clear  or  slightly  opalescent, 
the  reaction  is  neutral,  and  the  specific  gravity  varies  from  1.005  to  1.009. 
It  is  non-albuminous,  but  contains  chlorides  and  sometimes  traces  of  sugar. 
Hooklets  may  be  found  either  in  the  clear  fluid  or  in  the  suppurating  cysts. 
They  are  sometimes  absent,  however,  as  the  cyst  may  be  sterile. 

2.  EcHixococcus  OF  THE  Eespikatory  System. — Of  809  cases  of  single 
hydatid  cyst  collected  by  Thomas  in  Australia,  the  lung  was  affected  in  134 
cases.  Of  241  American  cases,  in  16  the  pleura  or  lung  was  affected.  The 
larvas  may  develop  primarily  in  the  pleura  and  attain  a  large  size.  The 
s}Tnptoms  are  at  first  those  of  compression  of  the  lung  and  dislocation  of  the 
heart.  The  physical  signs  are  those  of  fluid  in  the  pleura.  The  line  of  dul- 
ness may  be  quite  irregular.  As  in  the  echinococcus  of  the  liver,  the  general 
condition  of  the  patient  may  be  excellent  in  spite  of  the  existence  of  extensive 
disease.  Pleurisy  is  rarely  excited.  The  cysts  may  become  inflamed  and 
perforate  the  chest  wall.  Cary  and  Lyon  have  analyzed  40  cases  of  primary 
echinococcus  cjst  of  the  pleura;  death  results  in  a  majority  of  the  cases  from 
the  toxgemia  following  the  rupture  and  the  absorption  of  the  fluid  or  from 
the  sepsis  following  suppuration. 

Echinococci  occur  more  frequentty  in  the  lung  than  in  the  pleura.  If 
small,  they  may  exist  for  some  time  without  causing  serious  s}TiLptoms.  In 
their  growth  they  compress  the  lung  and  sooner  or  later  lead  to  inflamma- 
tory processes,  often  to  gangrene,  and  the  formation  of  cavities  which  connect 
with  the  bronchi.    Fragments  of  membrane  or  small  cysts  may  be  expectorated. 


DISEASES  CAUSED  BY  CESTODES.  37 

HEemorrhage  is  not  infrequent.  Perforation  into  the  pleura  with  empyema 
is  common.  A  majority  of  tlie  cases  are  regarded  during  life  as  either  phthi- 
sis or  gangrene,  and  it  is  only  the  detection  of  the  characteristic  membranes 
or  the  booklets  which  leads  to  the  diagnosis.  Of  a  series  of  21  cases,  17  recov- 
ered; 5  of  the  cases  suppurated  (C.  H.  Fleming,  Victoria,  personal  communi- 
cation) . 

3.  EcHiNOCOccus  OF  THE  KiDNEYS. — In  the  collected  statistics  referred 
to  above,  the  genito-urinary  system  comes  second  as  the  seat  of  hydatid  disease, 
though  here  the  affection  is  rare  in  comparison  with  that  of  the  liver.  '  Of 
the  341  American  cases,  there  were  17  in  which  the  kidneys  or  bladder  were 
involved.  The  kidney  may  be  converted  into  an  enormous  cyst  resembling  a 
hydronephrosis. 

The  diagnosis  is  only  possible  by  puncture  and  examination  of  the  fluid. 
The  cyst  may  perforate  into  the  pelvis  of  the  kidney,  and  portions  of  the 
membrane  or  cj'^sts  may  be  discharged  with  the  urine,  sometimes  producing 
renal  colic.  I  have  reported  a  case  in  which  for  many  months  the  patient 
passed  at  intervals  numbers  of  small  cysts  with  the  urine.  The  general  health 
was  little  if  at  all  disturbed,  except  by  the  attacks  of  colic  during  the  passage 
of  the  parasites. 

4.  EcHiNOCOCCUS  OF  THE  Kervous  System. — The  common  cystic  disease 
of  the  choroidal  plexuses  has  been  mistaken  for  hydatids.  Davies  Thomas,  of 
Australia,  has  tabulated  97  cases,  including  some  of  the  Cysticercus  cellu- 
loses. According  to  his  statistics,  the  cyst  is  more  common  on  the  right  than 
on  the  left  side,  and  is  most  frequent  in  the  cerebrum. 

The  symptoms,  very  indefinite,  as  a  rule,  are  those  of  tumor.  Persistent 
headache,  convulsions,  either  limited  or  general,  and  gradually  developing 
blindness  have  been  prominent  features  in  many  cases. 

Multilocular  Echinococcus. — This  form  merits  a  brief  separate  descrip- 
tion, as  it  differs  so  remarkably  from  the  usual  type.  It  has  been  met 
with  only  in  Bavaria,  Wlirtemberg,  the  adjacent  districts  of  Switzerland,  and 
in  the  Tyrol.  Possett  has  reported  13  cases  from  von  Eokitansky's  clinic  at 
Innsbruck.  In  the  United  States  six  cases  have  been  described,  chiefly  in  Ger- 
mans. Delafield  and  Prudden's  patient  had  lived  there  five  years,  and  for  a 
year  before  his  death  had  been  jaundiced.  A  fluctuating  tumor  was  found 
in  the  right  flank,  apparently  connected  with  the  liver.  This  was  opened,  and 
death  followed  from  haemorrhage.  In  Oertel's  case  the  patient  had  lived  there 
ten  years.  He  was  deeply  jaundiced,  and  had  a  tumor  mass  at  the  right  bor- 
der of  the  liver,  which  was  enlarged.  Bacon  resected  a  cyst  from  the  left  lobe 
of  the  liver.  The  primary  tumor  presents  irregularly  formed  cavities  sepa- 
rated from  each  other  by  strands  of  connective  tissue,  and  lined  with  the 
echinococcus  membrane.  The  cavities  are  filled  with  a  gelatinous  material,  so 
that  the  tumor  has  very  much  the  appearance  of  an  alveolar  colloid  cancer. 
It  is  quite  possible  that  a  special  form  of  taenia  echinococcus  represents  the 
adult  type  of  this  peculiar  parasite.  This  form  is  almost  exclusively  confined 
to  the  liver,  and  the  symptoms  resemble  more  those  of  tumor  or  cirrhosis. 
The  liver  is,  as  a  rule,  enlarged  and  smooth,  not  irregular  as  in  presence  of 
the  ordinary  echinococcus.  Jaundice  is  a  common  symptom.  The  spleen  is 
usually  enlarged,  there  is  progressive  emaciation,  and  toward  the  close  hsem- 
orrhages  are  common. 


38  DISEASES  DUE  TO  ANIMAL  PARASITES. 

Treatment  of  Echinococcus  Disease. — Medicines  are  of  no  avail.  Post- 
mortem reports  show  that  in  a  considerable  number  of  cases  the  parasite 
dies  and  the  cyst  becomes  harmless.  Operative  measures  should  be  resorted 
to  when  the  cyst  is  large  or  troublesome.  The  simple  aspiration  of  the  con- 
tents has  been  successful  in  a  large  number  of  cases,  and  as  it  is  not  in  any 
way  dangerous,  it  may  be  tried  before  the  more  radical  procedure  of  incision 
and  evacuation  of  the  cysts.  Suppuration  has  occasionally  followed  the  punc- 
ture. Injections  into  the  sac  should  not  be  practised.  With  modern  methods 
surgeons  now  open  and  evacuate  the  echinococcus  cysts  with  great  boldness, 
and  the  Australian  records,  which  are  the  most  numerous  and  important  on 
this  subject,  show  that  recovery  is  the  rule  in  a  large  proportion  of  the  cases. 
Suppurative  cysts  in  the  liver  should  be  treated  as  abscess.  ISTaturally  the 
outlook  is  less  favorable.  The  practical  treatment  of  h3'datid  disease  has  been 
greatly  advanced  by  Australian  surgeons.  The  works  of  the  Australian 
physicians  James  Graham  and  Thomas  may  be  consulted  for  interesting 
details  in  diagnosis  and  treatment. 


E.    DISEASES   CAUSED  BY  NEMATODES. 

I.    ASCARIASIS. 

Ascaris  Lumbricoides,  the  most  common  human  parasite,  is  found  chiefly 
in  children.  The  female  is  from  7  to  12  inches  in  length,  the  male  from 
4  to  8  inches.  In  form  it  is  cylindrical,  pointed  at  both  ends,  with  a  yel- 
lowish-brown, sometimes  a  slightly  reddish  color.  Four  longitudinal  bands 
can  be  seen,  and  it  is  striated  transverseh''.  The  ova,  which  are  sometimes 
found  in  large  numbers  in  the  faeces,  are  small,  brownish-red  in  color,  elliptical, 
and  have  a  very  thick  covering.  They  measure  0.075  mm.  in  length  and  0.058 
mm.  in  width.  The  life  history  has  been  demonstrated  to  be  "  direct " — i.  e., 
without  intermediate  host.  The  parasite  occupies  the  upper  portion  of  the 
small  intestine.  Usually  not  more  than  one  or  two  are  present,  but  occasion- 
ally they  occur  in  enormous  numbers.  The  migrations  are  peculiar.  They 
may  pass  into  the  stomach,  whence  thej^  may  be  ejected  by  vomiting,  or  they 
may  crawl  up  the  oesophagus  and  enter  the  phar^mx,  from  which  they  may  be 
withdrawn.  A  child  under  my  care  in  the  small-pox  department  of  the 
Montreal  General  Hospital,  during  convalescence,  withdrew  in  this  way  more 
than  thirty  round  worms  within  a  few  weeks.  In  other  instances  the  worm 
reaches  the  larynx,  and  has  been  known  to  produce  fatal  asphyxia,  or,  passing 
into  the  trachea,  to  cause  gangrene  of  the  lung.  They  may  go  through  the 
Eustachian  tube  and  appear  at  the  external  meatus.  The  worms  have  been 
found  in  extraordinary  numbers  in  the  bile-ducts.  Eemarkable  specimens 
exist  in  the  Dupuytren,  the  Wistar-Horner  (Philadelphia),  and  the  N'etley 
Museums.  Chalmers  (Ceylon)  and  Leys  (U.  S.  jST.)  have  called  attention  to 
their  importance  in  causing  abscess  of  the  liver.  Ebstein  reports  certain 
markings,  strangulations,  on  the  round  worm,  as  if  they  had  been  nipped  in 
the  bile-ducts  !  The  bowel  may  be  blocked,  or  in  rare  instances  an  ulcer  may  be 
perforated.    Even  the  healthy  bowel  wall  may  be  penetrated  (Apostolides). 

A  peculiarly  irritating  substance,  often  evident  to  the  sense  of  smell  in 


DISEASES  CAUSED  BY  NEMATODES.  39 

handling  specimens,  is  formed  by  the  round  worms.  Peiper  and  others  sug- 
gest that  the  nervous  symptoms,  sometimes  resembling  those  of  meningitis, 
are  due  to  this  poison.  Chauffard,  Marie,  and  Tauchon  have  gone  still  fur- 
ther, and  report  a  remarkable  condition  of  fever,  intestinal  symptoms,  foul 
breath,  and  intermittent  diarrhoea  in  connection  with  the  presence  of  lum- 
bricoides.  They  call  it  typho-lumbricosis.  The  febrile  condition  may  con- 
tinue for  a  month  or  more.  There  may  be  eosinophilia  to  25  per  cent  to  30 
per  cent,  and  in  some  cases  a  marked  anaemia.  The  question  of  the  toxins 
produced  by  intestinal  parasites  is  still  an  open  one. 

A  few  parasites  may  cause  no  disturbance.  In  children  there  are  irrita- 
tive symptoms  usually  attributed  to  worms,  such  as  restlessness,  irritability, 
picking  at  the  nose,  grinding  of  the  teeth,  twitchings,  or  convulsions. 

Treatment. — Santonin  can  be  given,  mixed  with  sugar,  in  doses  of  from 
one  half  to  one  grain  for  a  child  and  two  to  three  grains  for  an  adult,  fol- 
lowed by  a  calomel  or  a  saline  purge.  The  dose  may  be  given  for  three  or 
four  days.  An  unpleasant  consequence  which  sometimes  follows  the  admin- 
istration of  this  drug  is  xanthopsia  or  yellow  vision. 

Oxyuris  Vermicularis  (Thread-worm;  Pin-worm). — This  common  para- 
site occupies  the  rectum  and  colon.  The  male  measures  about  4  mm.  in 
length,  the  female  about  10  mm.  They  produce  great  irritation  and  itching, 
particularly  at  night,  symptoms  which  become  intensely  aggravated  by  the 
nocturnal  migration  of  the  parasites.  The  oxyuris  may  traverse  the  intes- 
tinal wall,  and  has  been  found  in  the  peritoneal  cavity,  where  they  may  form 
verminous  tubercles  in  Douglas's  fossa  or  peri-rectal  abscesses. 

The  patients  become  extremely  restless  and  irritable,  the  sleep  is  often 
disturbed,  and  there  may  be  loss  of  appetite  and  ansemia.  Though  most 
common  in  children,  the  parasite  occurs  at  all  ages. 

The  worm  is  readily  detected  in  the  faeces.  Infection  probably  takes  place 
through  the  water,  or  possibly  through  salads,  such  as  lettuce  and  cresses.  A 
person  the  subject  of  the  worms  passes  ova  in  large  numbers  in  the  faeces,  and 
the  possibility  of  reinfection  must  be  scrupulously  guarded  against. 

The  treatment  is  simple,  though  occasionally  there  are  instances  in  which 
all  forms  of  medication  are  resisted.  A  case  is  mentioned  of  a  gentleman, 
aged  forty,  who  had  suffered  from  childhood  and  had  failed  to  obtain  any 
benefit  from  prolonged  treatment  by  many  helminthologists.  Santonin  may 
be  used  in  small  doses,  and  mild  purgatives,  particularly  rhubarb.  Large 
injections  containing  carbolic  acid,  vinegar,  quassia,  aloes,  or  turpentine  may 
be  employed.  In  children  the  use  of  cold  injections  of  strong  salt  and  water 
is  usually  efficacious.  They  should  be  repeated  for  at  least  ten  days.  In 
giving  the  injection  care  should  be  taken  to  have  the  hips  well  elevated,  so 
that  the  fluid  can  be  retained  as  long  as  possible.  For  the  intense  itching 
and  irritation  at  night,  vaseline  may  be  freely  used,  or  belladonna  ointment. 
The  "  cat "  ascaris  and  the  "  dog "  ascaris  are  occasional  parasites  in  man. 

II.     TRICHINIASIS. 

The  Trichina  spiralis  in  its  adult  condition  lives  in  the  small  intestine. 
The  disease  is  produced  by  the  embryos,  which  pass  from  the  intestines  and 
reach  the  voluntary  muscles,  where  they  finally  become  encapsulated  larvae — ■ 


40  DISEASES  DUE  TO  ANIMAL  PARASITES. 

muscle  trichina.  It  is  in  the  migration  of  the  embryos  (possibly  from  poisons 
produced  by  them)  that  the  group  of  symptoms  known  as  trichiniasis  is 
produced. 

The  ovoid  cysts  were  described  in  human  muscle  by  Tiedemann  in  1833, 
and  by  Hilton  in  1833;  the  parasite  was  figured  and  named  by  Kichard  Owen. 
Leidy  in  1845  described  it  in  the  pig.  For  a  long  time  the  trichina  was  looked 
upon  as  a  pathological  curiosity;  but  in  1860  Zenker  discovered  in  a  girl  in 
the  Dresden  Hospital,  who  had  sjonptoms  of  typhoid  fever,  both  the  intestinal 
and  muscle  forms,  and  established  their  connection  with  a  serious  and  often 
fatal  disease. 

Description  of  the  Parasites. —  (a)  Adult  or  intestinal  form.  The  female 
measures  from  3  to  4  mm.;  the  male,  1.5  mm.,  and  has  two  little  projections 
from  the  hinder  end. 

(b)  The  larva  or  muscle  trichina  is  from  0.6  to  1  mm.  in  length  and  lies 
coiled  in  an  ovoid  capsule,  which  is  at  first  translucent,  but  subsequently 
opaque  and  infiltrated  with  lime  salts.  The  worm  presents  a  pointed  head 
and  a  somewhat  rounded  tail. 

When  flesh  containing  the  trichinse  is  eaten  by  man  or  by  any  animal  in 
which  the  development  can  take  place,  the  capsules  are  digested  and  the 
trichinas  set  free.  They  pass  into  the  small  intestine,  and  about  the  third 
day  attain  their  full  growth  and  become  sexually  mature.  Virchow's  experi- 
ments have  shown  that  on  the  sixth  or  seventh  day  the  embryos  are  fully 
developed.  The  young  produced  by  each  female  trichina  have  been  estimated 
at  several  hundred.  Leuckart  thinks  that  various  broods  are  developed  in 
succession,  and  that  as  many  as  a  thousand  embryos  may  be  produced  by  a 
single  worm.  The  time  from  the  ingestion  of  the  flesh  containing  the  muscle 
trichina  to  the  development  of  the  brood  of  embryos  in  the  intestines  is  from 
seven  to  nine  days.  The  female  worm  penetrates  the  intestinal  wall  and  the 
embryos  are  probably  discharged  directly  into  the  IjTnph  spaces  (Askanazy), 
thence  into  the  venous  system,  and  by  the  blood  stream  to  the  muscles,  which 
constitute  their  seat  of  election.  J.  Y.  Graham  reviewed  the  question  of  the 
mode  of  transmission  in  an  exhaustive  monograph,  and  he  gives  strong  argu- 
ments in  favor  of  the  transmission  through  the  blood  stream.  After  a  pre- 
liminary migration  in  the  intermuscular  connective  tissue  they  penetrate  the 
primitive  muscle-fibres,  and  in  about  two  weeks  develop  into  the  full-grown 
muscle  form.  In  this  process  an  interstitial  myositis  is  excited  and  gradually 
an  ovoid  capsule  develops  about  the  parasite.  Two,  occasionally  three  or  four, 
worms  may  be  seen  within  a  single  capsule.  This  process  of  encapsulation 
has  been  estimated  to  take  about  six  weeks.  Within  the  muscles  the  parasites 
do  not  undergo  further  change.  Gradually  the  capsule  becomes  thicker,  and 
ultimately  lime  salts  are  deposited  within  it.  This  change  may  take  place  in 
man  within  four  or  five  months.  In  the  hog  it  may  be  deferred  for  many 
years.  The  calcification  renders  the  cyst  visible,  and  since  first  seen  by  Tiede- 
mann and  Hilton,  these  small,  opaque,  oat-shaped  bodies  have  been  familiar 
objects  to  demonstrators  of  normal  and  morbid  anatomy.  The  trichina  may 
live  within  the  muscles  for  an  indefinite  period.  They  have  been  found  alive 
and  capable  of  developing  as  late  as  twenty  or  even  twenty-five  years  after 
their  entrance  into  the  system.  In  many  instances,  however,  the  worms  are 
completely  calcified.    The  trichina  has  been  found  or  "  raised  "  in  twenty-six 


DISEASES  CAUSED  BY  NEMATODES.  41 

different  species  of  animals  (Stiles).  Medical  literature  abounds  in  refer- 
ences to  its  presence  in  fish,  earthworms,  etc.,  but  these  parasites  belong  to 
other  genera.  In  fsecal  examinations  for  the  parasite  it  is  well  to  remember 
that  the  "  cell  body  "  of  the  anterior  portion  of  the  intestine  is  a  diagnostic 
criterion  of  the  T.  spiralis.  Experimentally,  guinea-pigs  and  rabbits  are  read- 
ily infected  by  feeding  them  with  muscle  containing  the  larval  form.  Dogs 
are  infected  with  difficulty ;  cats  more  readily.  Experimentally,  animals  some- 
times die  of  the  disease  if  large  numbers  of  the  parasites  have  been  eaten.  In 
the  hog  the  trichinae,  like  the  cysticerci,  cause  few  if  any  symptoms.  An  animal 
the  muscles  of  which  are  swarming  with  living  trichinge  may  be  well  nourished 
and  healthy-looking.  An  important  point  also  is  the  fact  that  in  the  hog  the 
capsule  does  not  readily  become  calcified,  so  that  the  parasites  are  not  visible 
as  in  the  human  muscles. 

Incidence. — Man  is  infected  by  eating  the  flesh  of  trichinous  hogs.  In 
Germany,  where  a  thorough  and  systematic  microscopic  examination  of  all 
swine  flesh  is  made,  the  proportion  of  trichinous  hogs  is  about  1  in  1,852.  At 
the  Berlin  abattoir,  where  the  microscopic  examination  is  conducted  by  a 
staff  of  over  eighty  men  and  women,  two  portions  are  taken  from  the  abdom- 
inal muscles,  from  the  diaphragm,  and  from  the  intercostal  muscles,  and  one 
piece  from  the  muscles  of  the  larynx  and  tongue.  A  special  compressor  is 
used  to  flatten  the  fragments  of  the  muscle,  and  the  examination  is  made 
with  a  magnifying  power  of  from  70  to  100  diameters.  Statistics  are  not 
available  in  England.  In  America  inspections  have  been  made  since  1893. 
The  percentage  of  animals  found  infected  has  ranged  from  1.04  to  1.95. 

In- 1883,  in  conjunction  with  A.  W.  Clement,  I  examined  1,000  hogs  at 
the  Montreal  abattoir,  and  found  only  4  infected. 

Modes  of  Infection. — The  danger  of  infection  depends  entirely  upon 
the  mode  of  preparation  of  the  flesh.  Thorough  cooking,  so  that  all  parts 
of  the  meat  reach  the  boiling  point,  destroys  the  parasites ;  but  in  large  joints 
the  central  portions  are  often  not  raised  to  this  temperature.  The  frequency 
of  the  disease  in  different  countries  depends  largely  upon  the  habits  of  the 
people  in  the  preparation  of  pork.  In  North  Germany,  where  raw  ham  and 
Wurst  are  freely  eaten,  the  greatest  number  of  instances  have  occurred.  In 
South  Germany,  France,  and  England  cases  are  rare.  In  the  United  States 
the  greatest  number  of  persons  attacked  have  been  Germans.  Salting  and 
smoking  the  flesh  are  not  always  sufficient,  and  the  Havre  experiments  showed 
that  animals  are  readily  infected  when  fed  with  portions  of  the  pickled  or 
the  smoked  meat  as  prepared  in  America.  Carl  Fraenkel,  however,  states 
that  the  experiments  on  this  point  have  been  negative,  and  that  it  is  very 
doubtful  if  any  cases  of  trichiniasis  in  Germany  have  been  caused  by  Amer- 
ican pork.  Germany  has  yet  to  show  a  single  case  of  trichiniasis  due  to  pork 
of  unquestioned  American  origin. 

Frequency  of  Infection. — H.  U.  Williams,  of  Buffalo,  made  a  thorough 
study  of  the  muscle  from  505  unselected  autopsies,  and  found  27  cases  of 
trichiniasis,  5.3  per  cent.  The  subjects  had  all  died  of  causes  other  than 
trichiniasis.  This  important  study  shows  how  wide-spread  is  the  disease, 
and  that  in  reality  we  frequently  overlook  the  sporadic  form,  a  mistake  which 
is  now  less  often  made,  owing  to  T.  E.  Brown's  discovery  of  the  associated 
eosinophilia. 


42  DISEASES  DUE   TO  AXIMAL  PARASITES. 

The  disease  often  occurs  in  epidemics,  a  large  number  of  persons  being 
infected  from  a  single  source.  Among  the  best  known  of  these,  one  occurred 
at  Hedersleben,  in  which  there  were  337  persons  affected,  and  another  at 
Emersleben,  in  which  there  were  250  persons  attacked.  The  extensive  out- 
breaks of  this  sort  have  been,  with  few  exceptions,  in  jSTorth  Germany,  and 
they  are  a  comment  on  the  inefficiency  of  the  inspection.  The  statistics  on 
the  subject  in  the  United  States  by  Alfred  Mann,  by  the  late  F.  A.  Packard, 
of  Philadelphia,  and  more  exhaustively  by  C.  W.  Stiles,  who  states  that  up 
to  1893  there  was  a  total  of  709  cases;  since  then  he  says,  in  a  letter,  1898, 
there  have  been  40  or  50  cases  reported.  He  thinks  that  900  would  cover 
the  total  number  reported  to  that  date.  According  to  States,  New  York 
heads  the  list  with  129  cases;  Illinois  shows  119;  Massachusetts,  115;  Iowa, 
108,  Xo  doubt  many  cases  escape  detection,  and  the  disease  is  not  very  un- 
common. The  sporadic  cases  are  often  overlooked.  Seven  cases  occurred  in 
my  wards  within  a  few  years. 

Symptoms. — The  ingestion  of  trichinous  flesh  is  not  necessarily  followed 
by  the  disease.  When  a  limited  number  are  eaten  only  a  few  embryos  pass  to 
the  muscles  and  may  cause  no  symptoms.  Well-characterized  cases  present 
a  gastro-intestinal  period  and  a  period  of  general  infection. 

In  the  course  of  a  few  days  after  eating  the  infected  meat  there  are  signs 
of  gastro-intestinal  disturbance — pain  in  the  abdomen,  loss  of  appetite,  vomit- 
ing, and  sometimes  diarrhoea.  The  preliminary  symptoms,  however,  are  by 
no  means  constant,  and  in  some  of  the  large  epidemics  cases  have  been  ob- 
served in  which  they  have  been  absent.  In  other  instances  the  gastro-intestinal 
features  have  been  marked  from  the  outset,  and  the  attack  has  resembled 
cholera  nostras.  Pain  in  different  parts  of  the  body,  general  debility,  and 
weakness  have  been  noted  in  some  of  the  epidemics. 

The  invasion  s^Tuptoms  occur  betAveen  the  seventh  and  the  tenth  day, 
sometimes  not  until  the  end  of  the  second  week.  There  is  fever,  except  in 
very  mild  cases.  Chills  are  not  common.  The  thermometer  may  register 
102°  or  104°,  and  the  fever  is  usually  remittent  or  intermittent.  The  migra- 
tion of  the  parasites  into  the  muscles  excites  a  more  or  less  intense  myositis, 
which  is  characterized  by  pain  on  pressure  and  movement,  and  by  swelling  and 
tension  of  the  muscles,  over  which  the  skin  may  be  oedematous.  The  limbs 
are  placed  in  the  positions  in  which  the  muscles  are  in  least  tension.  The 
involvement  of  the  muscles  of  mastication  and  of  the  larynx  may  cause  diffi- 
cult)'  in  chewing  and  swallowing.  In  severe  cases  the  involvement  of  the  dia- 
phragm and  intercostal  muscles  may  lead  to  intense  dyspnoea,  which  sometimes 
proves  fatal.  CEdema,  a  feature  of  great  importance,  may  be  early  in  the  face, 
particularly  about  the  eyes.  Later  it  occurs  in  the  extremities  when  the  swell- 
ing and  stiffness  of  the  muscles  are  at  their  height.  Profuse  sweats,  tingling 
and  itching  of  the  skin,  and  in  some  instances  urticaria,  have  been  described. 

Blood. — A  marked  leucoc}i:osis,  which  may  reach  above  30.000,  is  present. 
A  special  feature  is  the  extraordinary  increase  in  the  number  of  eosinophilic 
cells,  which  may  comprise  more  than  50  per  cent  of  all  the  leucocytes.  There 
were  in  four  years,  in  the  Jolins  Hopkins  Hospital,  7  cases  in  which  this  eosin- 
ophilia  was  most  pronounced.  In  4  of  them  the  diagnosis  was  actually  sug- 
gested by  the  great  increase  in  the  eosinophiles ;  in  1  case  they  reached  68 
per  cent  of  the  total  number  of  leucocytes. 


DISEASES  CAUSED  BY  NEMATODES.  43 

The  general  nutrition  is  much  disturbed  and  the  patient  becomes  emaci- 
ated and  often  anaemic,  particularly  in  the  protracted  cases.  The  patellar 
tendon  reflex  may  be  absent.  The  patients  are  usually  conscious,  except  in 
cases  of  very  intense  infection,  in  which  the  delirium,  dry  tongue,  and  tremor 
give  a  picture  suggesting  typhoid  fever.  In  addition  to  the  dyspnoea  present 
in  the  severer  infections,  there  may  be  bronchitis,  and  in  the  fatal  cases  pneu- 
monia or  pleurisy.  In  some  epidemics  polyuria  has  been  a  common  symptom. 
Albuminuria  is  frequent. 

The  intensity  and  duration  of  the  symptoms  depend  entirely  upon  the 
grade  of  infection.  In  the  mild  cases  recovery  is  complete  in  from  ten  to 
fourteen  days.  In  the  severe  forms  convalescence  is  not  established  for  six 
or  eight  weeks,  and  it  may  be  months  before  the  patient  recovers  the  muscular 
strength.  One  case  in  the  Hedersleben  epidemic  was  weak  eight  years  after 
the  attack. 

Of  73  fatal  cases  in  the  Hedersleben  epidemic,  the  greatest  mortality  oc- 
curred in  the  fourth  and  fifth  and  sixth  weeks ;  namely,  53  cases.  Two  died 
in  the  second  week  with  severe  choleraic  symptoms. 

The  mortality  has  ranged  in  difl:erent  outbreaks  from  1  or  3  per  cent  to 
30  per  cent.  In  the  Hedersleben  epidemic  101  persons  died.  Among  456 
cases  reported  in  the  United  States  there  were  133  deaths. 

The  anatomical  changes  are  chiefly  in  the  voluntary  muscles.  The  tri- 
chinae enter  the  primitive  muscle  bundles,  which  undergo  granular  degenera- 
tion with  marked  nuclear  proliferation.  There  is  a  local  myositis,  and 
gradually  about  the  parasite  a  cyst  wall  is  formed.  These  changes,  as  well 
as  the  remarkable  alterations  in  the  blood,  have  been  described  in  full  by 
Thomas  R.  Brown.  Cohnheim  has  described  a  fatty  degeneration  of  the 
liver  and  enlargement  of  the  mesenteric  glands.  At  the  time  of  death  in 
the  fourth  or  fifth  week  or  later,  the  adult  trichinae  are  still  found  in  the 
intestines. 

The  prognosis  depends  much  upon  the  quantity  of  infected  meat  which  has 
been  eaten  and  the  number  of  trichinae  which  mature  in  the  intestines.  In 
children  the  outlook  is  more  favorable.  Early  diarrhoea  and  moderately 
intense  gastro-intestinal  symptoms  are,  as  a  rule,  more  favorable  than  con- 
stipation. 

Diagnosis. — The  disease  should  always  be  suspected  when  a  large  birth- 
day party  or  Fest  among  Germans  is  followed  by  cases  of  apparent  typhoid 
fever.  The  parasites  may  be  found  in  the  remnants  of  the  ham  or  sausages 
used  on  the  occasion.  The  worms  may  be  discovered  in  the  stools.  The  stools 
should  be  spread  on  a  glass  plate  or  black  background  and  examined  with  a 
low-power  lens,  when  the  trichinas  are  seen  as  small,  glistening,  silvery  threads. 
In  doubtful  cases  the  diagnosis  may  be  made  by  the  removal  of  a  small  frag- 
ment of  muscle.  A  special  harpoon  has  been  devised  for  this  purpose,  by 
means  of  which  a  small  portion  of  the  biceps  or  of  the  pectoral  muscle  may 
be  readily  removed.  Under  cocaine  anaesthesia  an  incision  may  be  made  and 
a  small  fragment  removed.  The  disease  may  be  mistaken  for  acute  rheuma- 
tism, particularly  as  the  pains  are  so  severe  on  movement,  but  there  is  no 
special  swelling  of  the  joints.  The  great  increase  in  the  eosinophiles  in  the 
blood  is,  as  mentioned  above,  a  most  suggestive  point  in  diagnosis.  The 
tenderness  is  in  the  muscles  both  on  pressure  and  on  movement.    The  intensity 


44  DISEASES  DUE  TO  ANIMAL  PARASITES. 

of  the  gastro-intestinal  symptoms  in  some  cases  has  led  to  the  diagnosis  of 
cholera.  Many  of  the  former  epidemics  were  doubtless  described  as  typhoid 
fever,  which  the  severer  cases,  owing  to  the  prolonged  fever,  the  sweats,  the 
delirium,  dry  tongue,  and  gastro-intestinal  symptoms,  somewhat  resemble. 
The  pains  in  the  muscles,  with  tension  and  swelling,  oedema,  particularly 
about  the  eyes,  and  shortness  of  breath,  are  the  most  important  diagnostic 
points. 

Prophylaxis. — It  is  not  definitely  known  how  swine  become  diseased. 
It  has  been  thought  that  they  are  infected  from  rats  about  slaughter-houses, 
but  it  is  just  as  reasonable  to  believe  that  the  rats  are  infected  by  eating 
portions  of  the  trichinous  flesh  of  swine.  The  swine  should,  as  far  as  possible, 
be  grain-fed,  and  not,  as  is  so  common,  allowed  to  eat  offal.  The  most  satis- 
factory prophylaxis  is  the  complete  cooking  of  pork  and  sausages,  and  to  this 
custom  in  England,  France,  South  Germany,  and  the  United  States,  immu- 
nity is  largely  due. 

Treatment. — If  it  has  been  discovered  within  twenty-four  or  thirty-six 
hours  that  a  large  number  of  persons  have  eaten  infected  meat,  the  indications 
are  to  thoroughly  evacuate  the  gastro-intestinal  canal.  Purgatives  of  rhubarb 
and  senna  may  be  given,  or  an  occasional  dose  of  calomel.  Glycerin  has  been 
recommended  in  large  doses,  in  order  that  by  pa^ssing  into  the  intestines  it  may 
by  its  hygroscopic  properties  destroy  the  worm.  Male-fern,  kamala,  santonin, 
and  thymol  have  all  been  recommended  in  this  stage.  Turpentine  may  be 
tried  in  full  doses.  There  is  no  doubt  that  diarrhoea  in  the  first  week  or  ten 
days  of  the  infection  is  distinctly  favorable.  The  indications  in  the  stage 
of  invasion  are  to  relieve  the  pains,  to  secure  sleep,  and  to  support  the  pa- 
tient's strength.  There  are  no  medicines  which  have  any  influence  upon  the 
embryos  in  their  migration  through  the  muscles. 


III.    ANKYLOSTOMIASIS. 

(Uncinariasis ;  Hook- Worm  Disease ;  Miner's  Ansemia ;  Egyptian  Chlorosis,  etc.) 

History. — In  1843  Dubini  first  described  the  hook-worm  in  man.  Grie- 
singer  demonstrated  its  connection  with  the  Egyptian  chlorosis,  a  disease 
which  Sandwith  states  is  mentioned  by  the  old  Egyptian  writers  of  between 
three  and  four  thousand  years  ago.  Subsequently  the  disease  was  described 
in  the  tunnel-workers  at  St.  Gothard,  and  from  this  time  on  has  been  recog- 
nized as  an  important  cause  of  tropical  anaemia  and  the  anaemia  of  miners, 
brick-workers,  and  tunnel-workers. 

Incidence. — The  parasite  is  widely  spread  in  tropical  and  subtropical 
countries,  and  is  one  of  the  most  fatal  of  all  parasitic  diseases.  In  Porto 
Eico,  in  1906-7  more  than  89,000  cases  were  treated  by  the  permanent  com- 
mission. An  attempt  is  being  made  to  stamp  out  the  disease,  which  causes 
thousands  of  deaths,  usually  by  a  progressive  anaemia  with  anasarca.  While  it 
was  known  that  a  few  cases  occurred  in  the  United  States,  it  was  not  until  the 
interest  aroused  in  tropical  diseases  by  the  Spanish-American  War  and  the 
work  of  Ashf ord  in  Porto  Eico  that  the  attention  of  American  physicians  was 
called  to  the  disease.  Eeports  of  cases  were  published  in  1901  and  1902,  and 
in  the  latter  year  Stiles  took  up  the  study  of  the  problem  and  dem^onstrated  to 


DISEASES  CAUSED  BY  NEMATODES.  45 

the  astonishment  of  the  profession  that  the  disease  was  endemic  in  many 
places,  and  was  tlie  cause  of  the  common  anasmia  of  the  Southern  States. 
It  has  been  found  among  the  miners  in  Pennsylvania,  but  fortunately  not 
to  any  great  extent.  In  the  Philippines  it  is  not  uncommon.  Among  the 
miners  of  Germany  and  Austro-Hungary  the  disease  has  increased  very  much 
of  late  years.  The  disease  is  very  prevalent  in  Westphalia.  During  the  year 
1903,  3,000  patients  were  treated  for  ankylostomiasis  in  the  Bochum  Hospital. 
In  England  much  interest  was  aroused  in  the  discovery  by  Haldane  that  the 
ansemia  of  the  Cornish  miners  was  due  to  the  ankylostoma.  In  Egypt  the  dis- 
ease is  very  prevalent,  not .  only  among  the  natives,  but  among  the  Indian 
coolies.  The  superb  monograph  of  Loos  of  the  Government  school,  Cairo, 
may  be  referred  to  for  details  of  the  biology  of  the  parasite.  It  prevails 
extensively  in  Queensland. 

Parasite. — The  worm  is  a  strongyle,  occurring  in  two  forms,  the  Old- 
World  Ankylostoma  duodenale  and  the  New- World  Uncinaria  americana,  de- 
scribed by  Stiles.  Loos  and  Stiles  now  believe  that  the  American  species 
should  not  be  classed  with  Uncinaria,  and  the  new  name  of  Necator  ameri- 
canus  is  suggested.  The  parasites  have  the  same  general  characters ;  the  males 
are  7  to  11  mm.  in  length,  the  females  10  to  18  mm.  The  American  worm  is 
the  longer,  and  has  well-marked  specific  peculiarities.  The  mouth  is  provided 
with  a  heavy  armature  of  sharp  teeth,  with  which  they  pierce  the  mucosa 
of  the  bowel,  and  by  means  of  a  strong  muscular  oesophagus  suck  the  blood. 
The  male  has  a  prominent  caudal  expansion  or  bursa.  The  eggs  are  64  to 
76  ^  by  36  to  40  /a  in  the  American  form,  and  52  to  60  /*  by  32  ju,  in  the  Euro- 
pean form;  they  are  laid  in  segmentation,  forming  very  characteristic  bodies 
in  the  faeces  of  infected  persons. 

The  development  is  direct  without  an  intermediate  host.  The  embryo 
lives  in  the  water  or  moist  ground  and  passes  through  the  rhabditiform  stage. 
The  mode  of  entrance  into  the  body  has  been  much  discussed.  The  larvae  may 
live  for  months  in  the  mud  and  water  of  the  mines.  It  may  be  taken  into  the 
body  with  the  drinking-water  or  with  the  dirt  from  the  hands  of  the  miners 
and  tunnel-workers,  or  in  the  soil  deliberately  eaten  in  some  instances  by 
the  earth  feeders — the  geophagi — in  the  Southern  States.  Loos  showed  that 
the  embryo  worms  readily  enter  the  skin  and  are  carried  by  the  veins  to  the 
right  side  of  the  heart  and  to  the  lungs.  Escaping  from  the  pulmonary  ves- 
sels into  the  air  spaces,  they  pass  up  the  bronchi  and  trachea  to  the  pharynx 
and  so  down  the  gullet  to  the  stomach  and  intestines.  These  remarkable  obser- 
vations of  Loos  have  been  confirmed  by  Schaudinn.  Bentley,  Allen  J.  Smith, 
and  others  have  suggested  that  the  "  ground-itch  "  of  the  tropics,  a  peculiar 
form  of  dermatitis,  may  be  due  to  the  penetration  of  the  skin  by  the  anky- 
lostoma embryos,  and  Boycott  and  Haldane  think  that  the  skin  eruption 
known  as  the  "  bunches  "  in  the  Cornish  miners  may  be  associated  with  the 
entrance  of  the  worms. 

The  adult  worm  lives  in  the  small  intestine,  chiefly  in  the  jejunum,  but 
it  may  be  found  in  the  duodenum  or  in  the  colon,  rarely  in  the  stomach.  The 
duration  of  life  in  the  bowel  has  not  been  determined.  It  is  probably  a 
matter  of  years.     The  liability  to  reinfection  is  of  course  very  great. 

Symptoms. — The  following  factors,  referred  to  by  Stiles  in  his  monograph 
(Hygienic  Laboratory  Bulletin,  No.  10,  Washington,  1903),  have  to  be  con- 


46  DISEASES  DUE  TO  ANIMAL  PARASITES. 

sidered:  The  constant  drain  on  the  system  by  the  sucking  of  blood  can  no 
longer  as  formerly  be  regarded  as  the  chief  cause  of  the  anaemia.  Through  the 
wounds  bacterial  infection  may  take  place;  the  wall  of  the  bowel  may  be 
much  thickened  and  degenerated,  so  that  its  functions  are  interfered  with; 
and,  lastly,  it  is  quite  possible  that  toxic  substances  are  produced  by  the  para- 
sites which  act  injuriously  upon  the  patient.  Blood  is  rarely  found  in  the 
stools. 

A  considerable  number  of  parasites  must  be  present  to  cause  any  symp- 
toms. The  investigations  of  many  physicians  in  the  Southern  States  have 
shown  that  in  some  districts  a  very  considerable  percentage  of  even  compara- 
tively healthy  children  have  the  ova  in  the  stools.  Among  miners  the  anaemia 
may  be  absent,  as  sho-woi  by  the  studies  of  Haldane  and.  Boycott  in  Cornwall. 
Stiles  groups  the  cases  into  the  three  divisions  of  light,  medium,  and  severe. 
At  the  onset  in  the  stage  of  incubation  there  may  be  gastro-intestinal  irrita- 
tion, and,  according  to  Sandwith,  fever.  In  the  advanced  condition  anaemia 
is  the  most  characteristic  feature.  The  skin  is  of  a  dirty,  muddy  hue,  some- 
times of  a  waxy  white  color.  In  the  Southern  States  it  is  known  as  the 
Florida  complexion.  There  is  a  lack  of  lustre  in  the  eyes  and  a  dull,  heavy 
expression,  and  Stiles  tliinks  there  is  something  very  characteristic  about  the 
blank,  lack-lustre  stare  in  this  disease.  In  children  there  is  much  interfer- 
ence in  the  growth,  so  that  they  are  stunted  and  ill-developed.  As  the  dis- 
ease advances  and  the  anemia  becomes  more  pronounced,  the  liver  and  the 
spleen  become  somewhat  enlarged,  and  there  is  an  effusion  into  the  abdomen, 
so  that  there  is  a  pot-bellied  condition,  due  partly  to  the  causes  just  men- 
tioned and  partly  to  the  flatulent  distention.  OEdema  of  the  feet  is  not 
uncommon.  The  cardio-vascular  features  are  those  of  severe  anaemia — palpi- 
tation, shortness  of  breath,  cardiac  bruits.  In  a  very  characteristic  case  in 
my  wards  from  Xorth  Carolina,  in  which  the  blood  was  carefully  studied 
by  Boggs,  the  red  blood-corpuscles  were  2,742,000,  hasmoglobin  37  per  cent, 
leucocytes  55,000.  The  differential  count  gave  pol}Tiuclear  neutrophiles  51.8; 
small  mononuclears  26.4;  large  mononuclears  15.4;  eosinophiles  4.6;  mast- 
cells  1.8.  The  eosinophilia  is  a  most  important  feature  of  the  disease,  being 
present  in  94  per  cent  of  the  cases  (Boycott  and  Haldane). 

Diagnosis. — The  diagnosis  is  very  simple.  The  eggs  are  characteristic. 
It  is  well  to  examine  the  stools  after  the  use  of  the  thjTnol.  Stiles  states 
that  the  blotting-paper  test  is  useful  when  a  microscopical  examination 
can  not  be  made.  A  portion  of  the  faeces  is  placed  upon  white  blotting- 
paper,  and  if  allowed  to  stand  for  about  an  hour  there  is  a  reddish- 
bro-^Ti  staiu  suggestive  of  blood.  Eosinophilia  is  a  most  valuable  diag- 
nostic sign. 

Some  idea  of  the  intensity  of  the  infection  may  be  gained  by  the  number 
of  ova  in  the  cubic  centimetre  of  faeces.  Grasse,  quoted  by  Manson,  states  that 
from  150  to  180  eggs  per  cubic  centimetre  indicates  an  infection  of  about 
1,000  worms. 

Prophylaxis. — In  the  rural  districts  of  the  Southern  States  the  disease 
is  associated  with  the  absence  of  proper  sanitary  conditions,  particularly 
latrines,  etc.  The  infection  is  more  common  in  the  summer  than  in  the  win- 
ter, and  whites  appear  to  be  relatively  more  frequently  attacked  than  the 
blacks.    In  infected  regions  the  wearing  of  shoes  should  be  made  compulsory. 


DISEASES  CAUSED  BY  NEMATODES.  47 

The  prophylaxis  in  miners  is  an  important  national  problem.  New  miners 
should  j)ass  a  careful  medical  examination.  Infected  miners  before  resuming 
work  should  present  a  certificate  of  freedom  from  the  disease.  Each  working 
colliery  should  provide  suitable  closet  accommodation,  in  infected  mines,  1  to 
every  20  men  of  the  total  staff.  They  are  to  be  emptied  and  disinfected  daily. 
These  regulations,  adopted  in  Hungary,  as  given  by  Oliver,  will  do  much  to 
limit  the  spread  of  the  disease. 

Prognosis. — The  prognosis  is  good,  except  in  the  advanced  cases  of  anae- 
mia. The  figures  already  stated  from  Porto  Rico  indicate  its  fatality  under 
suitable  conditions.  Ashford  and  King  estimate  that  at  least  30  per  cent 
of  the  deaths  are  due  to  it. 

Treatment. — After  a  few  days'  preliminary  dieting  the  patient  is  given 
half  a  drachm  of  thymol,  repeated  in  two  hours,  and  then  two  hours  later  a 
dose  of  castor  oil.  Sandwith  states  that  about  a  drachm  of  thymol  in  the 
twenty-four  hours  is  perfectly  efficacious.  He  recommends  giving  the  thymol 
in  brandy  or  whisky.  In  very  debilitated  patients  it  should  be  given  in  smaller 
doses  and  over  a  longer  period.  The  stools  should  be  carefully  examined 
at  intervals  of  a  few  days,  and  the  treatment  should  be  repeated  if  the  ova  are 
still  present.  The  worms  are  not  always  easy  to  destroy.  Male-fern  may  be 
given  in  doses  of  from  a  drachm  to  two  drachms,  followed  by  a  saline  purge. 
The  general  treatment  is  that  of  anaemia. 

IV.    FILARIASIS. 

For  a  full  discussion  of  the  zoological  relations  of  this  important  group, 
see  Stiles'  article  in  my  "  System  of  Medicine,'.'  Vol.  I. 

Under  the  general  term  Filaria  sanguinis  Jiominis  three  species  of  nema- 
todes are  included: 

Filaria  bancrofti,  Cobold,  1877.  This  is  the  ordinary  blood  filaria.  The 
embryos  are  found  in  the  peripheral  circulation  only  during  sleep  or  at  night. 
The  mosquito  is  the  intermediate  host.  The  embryos  measure  270  to  340  fi 
long  by  7  to  11  /I.  broad ;  tail  pointed.  The  adult  male  measures  83  mm.  long 
by  0.407  mm.  broad ;  the  tail  forms  two  turns  of  a  spiral.  The  adult  female 
measures  155  mm.  long  by  0.715  mm.  broad;  vulva  2.56  nun.  from  anterior 
extremity;  eggs  38  fi  by  14  ju,.  This  is  the  species  to  which  the  haematochy- 
luria  and  elephantiasis  are  attributed. 

Filaria  diurna,  Manson,  1891.  The  larvs  agree  with  the  preceding, 
except  that  Manson  indicates  the  absence  of  granules  in  the  axis  of  the  body. 
The  worms  occur  in  the  peripheral  circulation  only  during  the  day,  or  when 
the  patient  stays  awake.  Manson  suspects  that  the  Filaria  loa  represents  the 
adult  stage. 

Filaria  perstans,  Manson,  1891.  Only  the  embryos  are  known.  These 
are  much  smaller  than  the  preceding — 200  yu  long,  posterior  extremity  obtuse, 
anterior  extremity  with  a  sort  of  retractile  rostellum. 

Manson  is  inclined  to  regard  the  Filaria  perstans  as  the  cause  of  craw- 
craw,  a  papillo-pustular  skin  eruption  of  the  west  coast  of  Africa,  which  is 
probably  the  same  as  Nielly's  dcrmatose  parasitaire,  the  parasite  of  which  was 
called  by  Blanchard  Rhahditis  Nielhji.  Manson  has  shown  that  in  the  blood 
of  the  aboriginal  Indians  in  British  Guiana  there  are  two  forms  of  filarial 


48  DISEASES  DUE  TO  ANIMAL  PARASITES. 

embryos  which  differ  somewhat  from  the  ordinary  types.  Daniels  and  Ozzard 
have  shown  the  extraordinary  prevalence  of  these  parasites  in  the  aborigines — 
fully  58  per  cent.  Daniels  has  found  the  mature  filariae  in  two  subjects  in  the 
upper  part  of  the  mesentery,  near  the  pancreas  and  in  the  subpericardial  fat. 

The  most  important  of  these  is  the  Filaria  Bancrofti,  which  produces  the 
haematochyluria  and  the  lymph-scrotum. 

The  female  produces  an  extraordinary  number  of  embryos,  which  enter  the 
blood  current  through  the  lymphatics.  Each  embryo  is  within  its  shell,  which 
is  elongated,  scarcely  perceptible,  and  in  no  way  impedes  the  movements. 
They  are  about  the  ninetieth  part  of  an  inch  in  length  and  the  diameter  of 
a  red  blood-corpuscle  in  thickness,  so  that  they  readily  pass  through  the 
capillaries.  They  move  with  the  greatest  activity,  and  form  very  striking  and 
readily  recognized  objects  in  a  blood-drop  under  the  microscope.  A  remark- 
able feature  is  the  periodicity  in  the  occurrence  of  the  embryos  in  the  blood. 
In  the  daytime  they  are  almost  or  entirely  absent,  whereas  at  night,  in  typical 
cases,  they  are  present  in  large  numbers.  If,  however,  as  Stephen  Mackenzie 
has  shown,  the  patient,  reversing  his  habits,  sleeps  during  the  daj^,  the  peri- 
odicity is  reversed.  In  the  case  reported  by  Lothrop  and  Pratt  the  number 
of  embryos  per  cubic  centimetre  of  blood  was  calculated  hourly  during 
the  night;  it  rose  steadily  from  four  o'clock  in  the  afternoon  till  midnight, 
when  3,100  per  c.cm.  were  present,  then  fell,  none  being  found  at  ten  o'clock 
the  following  morning.  The  further  development  of  the  embryos  is  associated 
with  the  mosquito,  which  at  night  sucks  the  blood  and  in  this  way  frees  them 
from  the  body.  After  developing  a  little  it  was  thought  that  they  were  set 
free  in  the  water  by  the  death  of  the  host.  S.  P.  James  has  found  them  in 
the  tissues  of  the  proboscis  of  the  mosquito,  and  the  infection  is  probably 
direct,  as  in  malaria.  The  filariae  may  be  present  in  the  body  without  causing 
any  symptoms.  In  the  blood  of  animals  filariee  are  very  common  and  rarely 
cause  inconvenience.  It  is  only  when  the  adult  worms  or  the  ova  block  the 
lymph  channels  that  certain  definite  symptoms  occur,  Manson  suggests  that 
it  is  the  ova  (prematurely  discharged),  which  are  considerably  shorter  and 
thicker  than  the  full-grown  embryos,  which  block  the  lymph  channels  and  pro- 
duce the  conditions  of  haematochyluria,  elephantiasis,  and  lymph-scrotum. 

The  parasite  is  widely  distributed,  particularly  in  tropical  and  subtropical 
countries.  Guiteras  has  shown  that  the  disease  prevails  extensively  in  the 
Southern  States,  and  since  his  paper  appeared  contributions  have  been  made 
by  Matas,  of  New  Orleans,  Mastin,  of  Mobile,  De'Saussure,  of  Charleston, 
and  Opie. 

The  effects  produced  may  be  described  under  the  following  conditions: 

1.  H^MATOCHYLURiA.  —  Without  any  external  manifestations,  and  in 
many  cases  without  special  disturbance  of  health,  the  subject  from  time  to 
time  passes  urine  of  an  opaque  white,  milky  appearance,  or  bloody,  or  a  chy- 
lous fiuid  which  on  settling  shows  a  slightly  reddish  clot.  The  urine  may  be 
normal  in  quantity  or  increased.  The  condition  is  usually  intermittent,  and 
the  patient  may  pass  normal  urine  for  weeks  or  months  at  a  time.  Micro- 
scopically, the  chylous  urine  contains  minute  molecular  fat  granules,  usually 
red  blood-corpuscles  in  various  amounts.  The  embryos  were  first  discovered 
by  Demarquay,  at  Paris  (1863),  and  in  the  urine  by  Wucherer,  at  Bahia,  in 
1866.     It  is  remarkable  for  how  long  the  condition  may  persist  without  seri- 


.  DISEASES  CAUSED  BY  NEMATODES.  49 

ous  impairment  of  the  health.  A  patient,  sent  to  me  by  Dawson,  of  Charles- 
ton, has  had  hsematochyluria  intermittently  for  eighteen  years.  The  only 
inconvenience  has  been  in  the  passage  of  the  blood-clots  which  collect  in  the 
bladder.  At  times  he  has  also  uneasy  sensations  in  the  lumbar  region.  The 
embryos  are  present  in  his  blood  at  night  in  large  numbers.  Chyluria  is  not 
always  due  to,  the  filaria.  The  non-parasitic  form  of  the  disease  is  considered 
elsewhere. 

Opportunities  for  studying  the  anatomical  condition  of  these  cases  rarely 
occur.  In  the  case  described  by  Stephen  Mackenzie  the  renal  and  peritoneal 
lymph  plexuses  were  enormously  enlarged,  extending  from  the  diaphragm  to 
the  pelvis.     The  thoracic  duct  above  the  diaphragm  was  impervious. 

2.  Lymph-Scrotum  and  certain  forms  of  elephantiasis  are  also  caused 
by  the  filaria.  In  the  former  the  tissues  of  the  scrotum  are  enormously 
thickened  and  the  distended  lymph-vessels  may  be  plainly  seen.  A  clear, 
sometimes  a  turbid,  fluid  follows  puncture  of  the  skin.  The  question  of  the 
relation  of  filarise  to  the  forms  of  tropical  elephantiasis  has  been  reopened, 
and  it  seems  doubtful  if  all  depend  upon  filarise. 

Treatment. — So  far  as  I  know,  no  drug  destroys  the  embryos  in  the  blood. 
In  infected  districts  the  drinking-water  should  be  boiled  or  filtered.  In 
cases  of  chyluria  the  patients  should  use  a  dry  diet  and  avoid  all  excess  of 
fat.  The  chyle  may  disappear  quite  rapidly  from  the  urine  under  these  meas- 
ures, but  it  does  not  necessarily  indicate  that  the  case  is  cured.  So  long  as 
clots  and  albumin  are  present  the  leak  in  the  lymphoid  varix  is  not  healed, 
although  the  fat,  not  being  supplied  to  the  chyle,  may  not  be  present.  A 
single  tumblerful  of  milk  will  at  once  give  ocular  proof  of  the  patency  or 
otherwise  of  the  rupture  in  the  varix  (Manson). 

The  surgical  treatment  of  some  of  these  cases  is  most  successful,  particu- 
larly in  the  removal  of  the  adult  filarise  from  the  enlarged  lymph-glands, 
especially  in  the  groin.  Maitland  states  that  during  seven  years  25  opera- 
tions of  this  kind  have  been  performed  without  serious  symptoms.  In  a 
case  of  Primrose's,  of  Toronto,  the  parasites  were  absent  from  the  blood  six 
and  a  half  months  after  operation. 

V.    DRACONTIASIS    (Guinea-worm    Disease). 

The  Filaria  or  Dracunculus  medinensis  is  a  widely  spread  parasite  in 
parts  of  Africa  and  the  East  Indies.  In  the  United  States  instances  occa- 
sionally occur.  Jarvis  reports  a  case  in  a  post  chaplain  who  had  lived  at 
Fortress  Monroe,  Va.,  for  thirty  years.  Van  Harlingen's  patient,  a  man 
aged  forty-seven,  had  never  lived  out  of  Philadelphia,  so  that  the  worm 
must  be  included  among  the  parasites  of  this  country.  A  majority  of  the 
cases  reported  in  American  journals  have  been  imported. 

Only  the  female  is  known.  It  develops  in  the  subcutaneous  and  inter- 
muscular connective  tissues  and  produces  vesicles  and  abscesses.  In  the 
large  majority  of  the  cases  the  parasite  is  found  in  the  leg.  Of  181  cases, 
in  124  the  worm  was  found  in  the  feet,  33  times  in  the  leg,  and  11  times  in 
the  thigh.  It  is  usually  solitary,  though  there  are  cases  on  record  in  which 
six  or  more  have  been  present.  It  is  cylindrical  in  form,  about  2  mm.  in 
diameter,  and  from  50  to  80  cm.  in  length. 


50  DISEASES  DUE  TO  ANIMAL  PARASITES. 

The  worm  gains  entrance  to  the  system  through  the  stomach,  not  through 
the  skin,  as  was  formerly  supposed.  It  is  probable  that  both  male  and 
female  are  ingested;  but  the  former  dies  and  is  discharged,  while  the  latter 
after  impregnation  penetrates  the  intestine  and  attains  its  full  development 
in  the  subcutaneous  tissues,  where  it  may  remain  quiescent  for  a  long  time 
and  can  be  felt  beneath  the  skin  like  a  bundle  of  string.  The  worm  con- 
tains an  enormous  number  of  living  embryos,  and  to  enable  them  to  escape 
she  travels  slowly  downward  head  first,  and,  as  mentioned,  usually  reaches 
the  foot  or  ankle.  The  head  then  penetrates  the  skin  and  the  epidermis 
forms  a  little  vesicle,  which  ruptures,  and  a  small  ulcer  is  left,  at  the  bottom 
of  which  the  head  often  protrudes.  The  distended  uterus  ruptures  and 
the  embryos  are  discharged  in  a  whitish  fluid.  After  getting  rid  of  them 
the  worm  will  spontaneously  leave  her  host.  In  the  water  the  embryos 
develop  in  the  cyclops — a  small  crustacean — and  it  seems  likely  that  man 
is  infected  by  drinking  the  water  containing  these  developed  larvae. 

When  the  worm  first  appears  it  should  not  be  disturbed,  as  after  par- 
turition she  may  leave  spontaneously.  When  the  worm  begins  to  come  out 
a  common  procedure  is  to  roll  it  round  a  portion  of  smooth  wood  and  in 
this  way  prevent  the  retraction,  and  each  day  wind  a  little  more  until  the 
entire  worm  is  withdrawn.  It  is  stated  that  special  care  must  be  taken  to 
prevent  tearing  of  the  worm,  as  disastrous  consequences  sometimes  follow, 
probably  from  the  irritation  caused  by  the  migration  of  the  embryos. 

The  parasite  may  be  excised  entire,  or  killed  by  injections  of  bichloride 
of  mercury  (1  to  1,000).  It  is  stated  that  the  leaves  of  the  plant  called 
amarpattee  are  almost  a  specific  in  the  disease.  Asafcetida  in  full  doses  is 
said  to  kill  the  worm. 

In  East  Africa  Kolb  states  that  he  found  in  the  abdominal  cavity  of 
a  recently  killed  native  Massai  several  large  nematode  worms  believed  to 
be  allied  to  the  filaria  medinensis.  He  thinks  this  parasite  is  possibly  asso- 
ciated with  what  is  known  as  the  Massai  disease,  characterized  by  attacks  of 
fever  lasting  some  three  days,  with  tenderness  of  the  abdomen  and  vomit- 
ing. Kolb  thinks  that  in  these  cases  the  filariae  which  have  become  encysted 
about  the  liver  "  as  a  normal  event  in  their  life  history  burst  their  cysts,  the 
contents  escaping  into  the  peritoneal  cavity,  thereby  giving  rise  to  the  symp- 
toms."    The  subject  is  one  which  requires  further  investigation. 

VI.     OTHER   NEMATODES. 

Filariae. — Among  less  important  filarian  worms  parasitic  in  man  the 
following  may  be  mentioned :  Filaria  loa,  which  is  a  cylindrical  worm  of 
about  3  cm.  in  length  and  whose  habitat  is  beneath  the  conjunctiva.  It  has 
been  found  on  the  West  African  coast,  in  Brazil,  and  in  the  West  Indies. 
Filaria  lentis,  which  has  been  found  in  a  cataract.  Three  specimens  have 
been  found  together.  Filaria  lahialis,  which  has  been  found  in  a  pustule 
in  the  upper  lip.  Filaria  liominis  oris,  which  was  described  by  Leidy,  from 
the  mouth  of  a  child.  Filaria  hroncliialis,  which  has  been  found  occasion- 
ally in  the  trachea  and  bronchi.  This  parasite  has  been  seen  in  a  few 
cases  in  the  bronchioles  and  in  the  lungs.  There  is  no  evidence  that  it  ever 
produces  an  extensive  verminous  bronchitis  similar  to  that  which  I  haye 


DISEASES  CAUSED  BY  NEMATODES.  51 

described  in  dogs.  Filaria  i7nmitis — the  common  Filaria  sanguinis  of  the 
dog — of  which  Bowlby  has  described  two  cases  in  man.  In  one  case  with 
haeraaturia  female  worms  were  found  in  the  portal  vein,  and  the  ova  were 
present  in  the  thickened  bladder  wall  and  in  the  ureters. 

Trichocephalus  dispar  (Whip- worm). — This  parasite  is  not  infrequently 
found  in  the  csecum  and  large  intestine  of  man.  It  measures  from  4  to  5  cm. 
in  length,  the  male  being  somewhat  shorter  than  the  female.  The  worm  is 
readily  recognized  by  the  remarkable  difference  between  the  anterior  and 
posterior  portions.  The  former,  which  forms  at  least  three  fifths  of  the 
body,  is  extremely  thin  and  hair-like  in  contrast  to  the  thick  hinder  por- 
tion of  the  body,  which  in  the  female  is  conical  and  pointed,  and  in  the 
male  more  obtuse  and  usually  rolled  like  a  spring.  The  eggs  are  oval,  lemon- 
shaped,  0.05  mm.  in  length,  and  each  is  provided  with  a  button-like  pro- 
jection. 

The  number  of  the  worms  found  is  variable,  as  many  as  a  thousand  hav- 
ing been  counted.  It  is  a  widely  spread  parasite.  In  parts  of  Europe  it 
occurs  in  from  10  to  30  per  cent  of  all  bodies  examined,  but  in  the  United 
States  it  is  not  so  common.  The  trichocephalus  rarely  causes  symptoms. 
French  and  Boycott  found  ova  in  40  of  500  Guy's  Hospital  patients.  They 
found  no  etiological  relationship  of  the  parasite  to  appendicitis.  Several  cases 
have  been  reported  in  which  profound  anaemia  has  occurred  in  connection 
with  this  parasite,  usually  with  diarrhoea.  Enormous  numbers  may  be  pres- 
ent, as  in  Eudolph's  case,  without  producing  any  symptoms. 

The  diagnosis  is  readily  made  by  the  examination  of  the  faeces,  which  con- 
tain, sometimes  in  great  abundance,  the  characteristic  lemon-shaped,  hard, 
dark-brown  eggs. 

Dicotophyme  gigas  (Eustrongylus  gigas). — This  enormous  nematode, 
the  male  of  which  measures  about  a  foot  in  length  and  the  female  about 
three  feet,  occurs  in  very  many  animals  and  has  occasionally  been  met  with 
in  man.  It  is  usually  found  in  the  renal  region  and  may  entirely  destroy 
the  kidney. 

Anguillula  aceti. — The  Anguillula  aceti,  or  vinegar  eel,  is  sometimes 
present  in  the  urine  (in  one  case  it  is  said  from  the  bladder).  It  is  most 
probably  a  contamination  from  a  dirty  bottle  in  which  the  urine  is  col- 
lected. 

Strongyloides  intestinalis. — ^Under  this  name  are  now  included  the  small 
nematode  worms  found  in  the  faeces  and  formerly  described  as  Anguillula 
stercoralis,  Anguillula  intestinalis,  and  Rhahdonema  intestinale.  This  para- 
site occurs  abundantly  in  the  stools  of  the  endemic  diarrhoea  of  hot  countries, 
and  has  been  specially  described  by  the  French  in  the  diarrhoea  of  Cochin- 
China.  It  has  been  found  in  Manila  by  Strong,  and  three  cases  have  been 
reported  from  my  clinic  by  W.  S.  Thayer.  It  is  stated  that  the  worms  occupy 
all  parts  of  the  intestines,  and  have  even  been  found  in  the  biliary  and  pan- 
creatic duets.  It  is  only  when  they  are  in  very  large  numbers  that  they  pro- 
duce severe  diarrhoea  and  anaemia. 

Acanthocephala  (Thorn-headed  Worms). — The  Gigantorhynchus  or 
Echinorhynclius  gigas  is  a  common  parasite  in  the  intestine  of  the  hog  and 
attains  a  large  size.  The  larvae  develop  in  cockchafer  grubs.  The  Ameri- 
can intermediate  host   is   the   June   bug    (Stiles).     Lambl   found  a   small 


52  DISEASES  DUE   TO  ANIMAL  PARASITES. 

Echinorhynclius  in  the  intestine  of  a  boy.  Welch's  specimen,  which  was 
found  encysted  in  the  intestine  of  a  soldier  at  Netley,  is  stated  by  Cobbold 
probably  not  to  have  been  an  Echinorhynclius.  Eecently  a  case  of  Echino- 
rhynchus  moniliformis  has  been  described  in  Italy  by  Grassi  and  Calandruccio. 


F.    PARASITIC   ARACHNIDA  AND   TICKS. 

Pentastomes. — 1.  Lixguatula  ehinaria  {Pentastoma  tcenioides)  has  a 
somewhat  lancet-shaped  body,  the  female  being  from  3  to  4  inches  in  length, 
the  male  about  an  inch  in  length.  The  body  is  tapering  and  marked  by 
numerous  rings.  The  adult  worm  infests  the  frontal  sinuses  and  nostrils 
of  the  dog,  more  rarely  of  the  horse.  The  larval  form,  which  is  known  as 
the  Linguatula  serrata  {Pentastomum  denticulatum) ,  is  seen  in  the  internal 
organs,  particularly  the  liver,  but  has  also  been  found  in  the  kidney.  The 
adult  worm  has  been  f  OTind  in  the  nostril  of  man,  but  is  very  rare  and  seldom 
occasions  any  inconvenience.  The  larvae  are  by  no  means  uncommon,  par- 
ticularly in  parts  of  Germany. 

2.  The  Poeocephalus  con"STRICTUS  (Pentastomum  constrictum),  which  is 
about  the  length  of  half  an  inch,  with  twenty-three  rings  on  the  abdomen, 
was  found  by  Aitken  in  the  liver  and  lungs  of  a  soldier  of  a  West  Indian 
regiment. 

The  parasite  is  very  rare.  Flint  refers  to  a  Missouri  case  in  which  from 
75  to  100  of  the  parasites  were  expectorated.  The  liver  was  enlarged  and 
the  parasites  probably  occupied  this  region.  In  1869  I  saw  a  specimen  which 
had  been  passed  with  the  urine  by  a  patient  of  James  H.  Eichardson,  of 
Toronto. 

Demodex  (Acarus)  folliculomni  (var.  hominis). — A  minute  parasite,  from 
0.3  mm.  to  0.4  mm.  in  length,  which  lives  in  the  sebaceous  follicles,  particu- 
larly of  the  face.  It  is  doubtful  whether  it  produces  any  s5anptoms.  Pos- 
sibly when  in  large  numbers  they  may  excite  inflammation  of  the  follicles, 
leading  to  acne. 

Sarcoptes  (Acarus)  scabiei  (Itch  Insect). — This  is  the  most  important 
of  the  arachnid  parasites,  as  it  produces  troublesome  and  distressing  skin 
eruptions.  The  male  is  0.23  mm.  in  length  and  0.19  mm.  in  breadth;  the 
female  is  0.45  mm.  in  length  and  0.35  mm.  in  width.  The  female  can  be 
seen  readily  with  the  naked  eye  and  has  a  pearly-white  color.  It  is  not  so 
common  a  parasite  in  the  United  States  and  Canada  as  in  Europe. 

The  insect  lives  in  a  small  burrow,  about  1  cm.  in  length,  which  it  makes 
for  itself  in  the  epidermis.  At  the  end  of  this  burrow  the  female  lives. 
The  male  is  seldom  found.  The  chief  seat  of  the  parasite  is  in  the  folds 
where  the  skin  is  most  delicate,  as  in  the  web  between  the  fingers  and  toes, 
the  backs  of  the  hands,  the  axilla,  and  the  front  of  the  abdomen.  The  head 
and  face  are  rarely  involved.  The  lesions  which  result  from  the  presence 
of  the  itch  insect  are  very  numerous  and  result  largely  from  the  irritation 
of  the  scratching.  The  commonest  is  a  papular  and  vesicular  rash,  or,  in 
children,  an  ecthymatous  eruption.  The  irritation  and  pustulation  which 
follow  the  scratching  may  completely  destroy  the  burrows,  but  in  typical 
cases  there  is  rarely  doubt  as  to  the  diagnosis. 


PARASITIC  INSECTS.  53 

The  treatment  is  simple.  It  should  consist  of  warm  haths  with  a  thor- 
ough use  of  a  soft  soap,  after  which  the  skin  should  be  anointed  with  sul- 
phur ointment,  which  in  the  case  of  children  should  be  diluted.  An  oint- 
ment of  naphthol  (drachm  to  the  ounce)  is  very  efficacious. 

Leptus  autumnalis  (Harvest  Bug). — This  reddish-colored  parasite,  about 
half  a  millimetre  in  size,  is  often  found  in  large  numbers  in  fields  and  in 
gardens.  They  attach  themselves  to  animals  and  man  with  their  sharp 
proboscides,  and  the  hooklets  of  their  legs  produce  a  great  deal  of  irritation. 
They  are  most  frequently  found  on  the  legs.  They  are  readily  destroyed  by 
sulphur  ointment  or  corrosive-sublimate  lotions. 

Ixodiasis  (Tick-fever). — In  South  Africa,  particularly  in  the  western 
provinces  of  the  Uganda  Protectorate,  the  western  districts  of  German  East 
Africa  and  the  eastern  regions  of  the  Congo  Free  State,  there  is  a  disease 
known  by  this  name,  believed  to  be  transmitted  by  a  tick — the  Ornithodorus 
or  Argas  moubata.  Christy  states  that  the  bite  of  the  0.  Savignyi  does  not 
produce  any  ill  effects.  The  ticks  live  in  old  houses,  and  their  habits  are 
very  much  like  those  of  the  common  bedbug.  The  symptoms  are  pains  in 
the  head,  back  and  limbs,  vomiting,  fever  and  diarrhoea,  which  may  last  for 
from  two  to  four  weeks.  Death  may  occur  between  the  tenth  and  fifteenth 
days.  A  majority  of  the  cases  recover.  A  spirillum  has  been  described  in 
the  blood  by  P.  H,  Eoss  and  Milne. 

The  Dermacentor  occidentaUs  is  present  in  the  Northwestern  States  from 
California  to  Montana.  The  bites  may  cause  severe  lymphangitis.  It  appears 
to  be  the  medium  of  transmission  of  the  Eocky  Mountain  spotted  fever,  which 
is  described  on  p.  368. 

In  Arizona  and  other  parts  of  the  Southwestern  States,  a  tick — Ornitho- 
dorus megnini — is  occasionally  found  in  the  ear  and  in  the  nose,  causing 
suppuration  and  intense  suffering. 

Several  other  varieties  of  ticks  are  occasionally  found  on  man — ^the  Ixodes 
ricinus  and  the  Dermacentor  Americanus,  which  are  met  with  in  horses 
and  oxen. 

G.    PARASITIC  INSECTS. 

Pediculi  (Phthiriasis;  Pediculosis). — There  are  three  varieties  of  the 
body  louse,  which  are  found  only  in  persons  of  uncleanly  habits. 

Pediculus  capitis. — The  male  is  from  1  to  1.5  mm.  in  length  and  the 
female  nearly  3  mm.  The  color  varies  somewhat  with  the  different  races 
of  men.  It  is  light  gray  with  a  black  margin  in  the  European,  and  very 
much  darker  in  the  negro  and  Chinese.  They  are  oviparous,  and  the 
female  lays  about  sixty  eggs,  which  mature  in  a  week.  The  ova  are 
attached  to  the  hairs,  and  can  be  readily  seen  as  white  specks,  known 
popularly  as  nits.  The  symptoms  are  irritation  and  itching  of  the  scalp. 
When  numerous,  the  insects  may  excite  an  eczema  or  a  pustular  derma- 
titis, which  causes  crusts  and  scabs,  particularly  at  the  back  of  the  head. 
In  the  most  extreme  cases  the  hair  becomes  tangled  in  these  crusts  and 
matted  together,  forming  at  the  occiput  a  firm  mass  which  is  known  as 
plica  polonica,  as  it  was  not  infrequent  among  the  Jewish  inhabitants  of 
Poland. 


54  DISEASES  DUE  TO  AXLMAL  PARASITES. 

Pediculus  coepoeis  (vestimentorum) . — Tliis  is  considerably  larger  than 
the  head  louse.  It  lives  on  the  clothing,  and  in  sucking  the  blood  causes 
minute  hsemorrhagic  specks,  which  are  very  common  about  the  neck,  back, 
and  abdomen.  The  irritation  of  the  bites  may  cause  urticaria,  and  the 
scratching  is  usually  in  linear  lines.  In  long-standing  cases,  particularly 
in  old  dissipated  characters,  the  skin  becomes  rough  and  greatly  pigmented, 
a  condition  which  has  been  termed  the  vagabond's  disease — morbus  erronum 
— and  which  may  be  mistaken  for  the  bronzing  of  Addison's  disease.  The 
pigmentation  in  some  cases  may  be  extreme  and  extend  to  the  face  and 
buccal  mucosa. 

Phthieius  pubis  differs  somewhat  from  the  other  forms,  and  is  found 
in  the  parts  of  the  body  covered  with  short  hairs,  as  the  pubes ;  more  rarely 
the  axilla  and  eyebrows. 

The  taclies  hJeuatres  or  peliomata,  excited  by  the  irritation  of  pediculi,  are 
peculiar  subcuticular  bluish  or  slate-colored  spots  from  5  to  10  mm,  in  diam- 
eter seen  about  the  abdomen  and  thighs,  particularly  in  febrile  cases.  They 
are  very  well  pictured  in  Murchison's  work  on  Fevers.  The  spots  are  more 
marked  on  white  thin  skins.  They  are  stains  caused  by  a  pigment  in  the 
secretion  of  the  salivary  glands  of  the  louse.  I  have  never  seen  these  macuIcB 
ceruJecE,  as  they  are  also  called,  without  finding  the  lice  or  their  nits. 

Treatment. — For  the  Pediculus  capitis,  when  the  condition  is  very  bad, 
the  hair  should  be  cut  short,  as  it  is  very  difficult  to  destroy  thoroughly  all 
the  nits.  Eepeated  saturations  of  the  hair  in  coal-oil  or  in  turpentine  are 
usually  efficacious,  or  with  lotions  of  carbolic  acid,  1  to  50.  Scrupulous 
cleanliness  and  care  are  sufficient  to  prevent  recurrence.  In  the  case  of  the 
Pediculus  corporis,  the  clothing  should  be  placed  for  hours  in  a  disinfecting 
oven.  To  allay  the  itching  a  warm  bath  containing  4  or  5  ounces  of  bicar- 
bonate of  soda  is  useful.  The  skin  may  be  rubbed  with  a  lotion  of  carbolic 
acid,  2  drachms  to  the  pint,  with  2  ounces  of  glycerin.  For  the  Phthirius 
pubis  wliite  precipitate  or  ordinary  mercurial  ointment  should  be  used,  and 
the  parts  should  he  thoroughly  washed  two  or  three  times  a  day  with  soft  soap 
and  water. 

Cimex  lectularius  (Common  Bedbug). — The  tropical  and  subtropical 
variety  is  Cimex  rotundalius  (W.  S.  Patton).  It  lives  in  the  crevices  of  the 
bedstead  and  in  the  cracks  in  the  floor  and  in  the  walls.  It  is  nocturnal  in 
its  habits.  The  peculiar  odor  of  the  insect  is  caused  by  the  secretion  of  a 
special  gland.  The  parasite  possesses  a  long  proboscis,  with  which  it  sucks 
the  blood.  Individuals  differ  remarkably  in  the  reaction  to  the  bite  of  this 
insect:  some  are  not  disturbed  in  the  slightest  by  them,  in  others  the  irrita- 
tion causes  hyperemia  and  often  intense  urticaria.  Fumigation  with  sul- 
phur or  scouring  with  corrosive-sublimate  solution  or  kerosene  destroys  them. 
Iron  bedsteads  should  be  used. 

Pulex  irritans  (Commox  Flea). — The  male  is  from  2  to  2.5  mm.  in 
length,  the  female  from  3  to  4  mm.  The  flea  is  a  transient  parasite  on 
man.  The  bite  causes  a  circular  red  spot  of  hyperemia  in  the  centre  of 
which  is  a  little  speck  where  the  boring  apparatus  has  entered.  The  amount 
of  irritation  caused  by  the  bite  is  variable.  Many  persons  suffer  intensely 
and  a  diffuse  erythema  or  an  irritable  urticaria  develops;  others  suffer  no 
inconvenience  whatever. 


PARASITIC  FLIES.  55 

The  Pulex  penetrans  (sand-flea;  jigger)  is  found  in  tropical  countries, 
particularly  in  the  West  Indies  and  South  America.  It  is  much  smaller 
than  the  common  flea,  aud  not  only  penetrates  the  skin,  but  burrows  and 
produces  an  inflammation  with'  pustular  or  vesicular  swelling.  It  most  fre- 
quently attacks  the  feet.  It  is  readily  removed  with  a  needle.  Where  they 
exist  in  large  numbers  the  essential  oils  are  used  on  the  feet  as  a  preventive. 


H.    PARASITIC   FLIES. 

MYIASIS  (Myiosis). 

The  accidental  invasion  of  the  body  cavities  and  of  the  skin  by  the  larvag 
of  the  diptera  is  known  as  myiasis. 

The  larvae  of  the  Lucilia  macellaria,  the  so-called  screw-worm,  have  been 
found  in  the  nose,  in  wounds,  and  in  the  vagina  after  delivery.  They  can 
be  removed  readily  with  the  forceps ;  if  there  is  any  difficulty,  thorough 
cleansing  and  the  application  of  an  antiseptic  bandage  is  sufficient  to  kill 
them.  The  ova  of  the  blue-bottle  fly  may  be  deposited  in  the  nostrils,  the 
ears,  or  the  conjunctiva — the  myiasis  narium,  aurium,  conjunctivEe.  This 
invasion  rarely  takes  place  unless  these  regions  are  the  seat  of  the  disease. 
In  the  nose  and  in  the  ear  the  larvae  may  cause  serious  inflammation.  Even 
the  urethra  has  not  been  spared  in  these  dipterous  invasions. 

Gastro-intestinal  myiasis  may  result  from  the  swallowing  of  the  larvae  of 
the  common  house-fly  or  of  species  of  the  genus  Antliomyia.  There  are  many 
cases  on  record  in  which  the  larvge  of  the  Musca  domestica  have  been  dis- 
charged by  vomiting.  Instances  in  which  dipterous  larvae  have  been  passed 
in  the  fseces  are  less  common.  Finlayson,  of  Glasgow,  has  reported  an  inter- 
esting ease  in  a  physician,  who,  after  protracted  constipation  and  pain  in 
the  back  and  sides,  passed  large  numbers  of  the  larvae  of  the  flower-fly — 
Antliomyia  canicularis.  Among  other  forms  of  larvae  or  gentles,  as  they  are 
sometimes  called,  which  have  been  found  in  the  faeces,  are  those  of  the  com- 
mon house-fly,  the  blue-bottle  fly,  and  the  Techomyza  fusca.  The  larvae  of 
other  insects  are  extremely  rare.  It  is  stated  that  the  caterpillar  of  the 
taby  moth  has  been  found  in  the  faeces. 

A  specimen  of  the  Homalomyia  scalaris,  one  of  the  privy  flies,  was  sent 
to  me  by  Dr.  Hartin,  of  Kaslo  City,  British  Columbia,  the  larvee  of  which 
were  passed  in  large  numbers  in  the  stools  of  a  man  aged  twenty-four,  a 
native  of  Louisiana.  They  Were  present  in  the  stools  from  May  1  to  July 
15,  1897. 

Although  no  grave  results  necessarily  follow  the  invasion  of  the  alimen- 
tary tract  by  these  larvae,  yet  they  may  be  the  cause  of  serious  intestinal  ulcer- 
ation manifesting  itself  by  a  dysenteric  disease  with  fatal  result. 

Cutaneous  Myiasis. — The  most  common  form  of  cutaneous  myiasis  is  that 
in  which  an  external  wound  becomes  "  living,"  as  it  is  called.  This  myiasis 
vulnerum  is  caused  by  the  larvae  of  either  the  blue-bottle  or  the  common 
flesh-fly. 

The  skin  may  also  be  infected  by  the  larvae  of  the  Musca  vomitoria,  but 
more  commonly  by  the  bot-flies  of  the  ox  and  sheep  which  occasionally  attack 
man.     This  condition  is  rare  in  temperate  climates.     Matas  has  described  a 


56  DISEASES  DUE   TO  ANIMAL  PARASITES. 

case  in  which  oestrus  larvse  were  found  in  the  gluteal  region.  In  parts  of 
Central  America  the  eggs  of  another  bot-fly,  the  Dermatobia,  are  not  infre- 
quently deposited  in  the  skin  and  produce  a  swelling  very  like  the  ordi- 
nary boil. 

Dermamyiasis  linearis  migrans  CEstrosa  is  a  remarkable  cutaneous  condi- 
tion, observed  particularly  in  Eussia  and  occasionally  in  other  countries,  in 
which  the  larva  of  GastropMlus  equi  (Samson),  the  horse  bot-fly,  makes  a 
slightly  raised  pale  red  "  line  "  which  travels  over  the  body  surface,  sometimes 
with  great  rapidity.  It  has  been  referred  to  as  Larva  migrans  and  as  Creep- 
ing Eruption.     (See  Hamburger,  Journal  of  Cutaneous  Disease.s,  1904.) 

In  Africa  the  larvas  of  the  Cayor  fly  are  not  uncommonly  found  beneath 
the  skin  in  little  boils.  In  the  Congo  region.  Button,  Todd,  and  Christy 
found  a  troublesome  blood-sucking  dipterous  larva,  known  as  the  floor  maggot, 
the  fly  of  which  is  the  Anclimeromyia  luteola. 

Caterpillar  Bash. — In  some  districts  in  Europe  the  hairs  of  the  proces- 
sion caterpillar,  particularly  of  the  species  Cnethocampa,  cause  an  intense 
urticaria,  the  so-called  U.  epidemica.  There  are  districts  in  Switzerland 
which  have  been  rendered  uninhabitable  in  consequence  of  the  skin  rashes 
caused  by  the  caterpillars.  Of  late  years  in  New  England  and  some  other 
parts  of  the  United  States  the  caterpillar  of  the  brown-tailed  moth  has  caused 
much  discomfort.  The  hairs  are  widely  distributed  by  the  wind,  and  the  barbs 
are  so  arranged  that  they  readily  work  into  the  skin.  Wliole  families  have 
been  affected  by  an  intense  eruption  which  has  been  mistaken  for  that  of 
small-pox.  In  England,  Thresh  has  called  attention  to  the  frequency  of  these 
caterpillar  rashes  due  to  the  yellow-tailed  moth,  Portkesia  similis. 

Harvest  Rash  (Erythema  Autumxale). — In  parts  of  England  during 
the  autumn  many  people  are  attacked  by  the  harvest  bug  or  harvesters,  which 
may  cause  a  very  obstinate  and  distressing  malady.  Usually  attributed  to 
the  harvest  spider,  it  is  in  reality  caused  by  a  mite,  parasitic  upon  it,  the 
hexapod  larva  of  the  silky  trombidian.  It  is  so  small  as  to  be  scarcely  visible 
and  is  brick-red  in  color.  They  chiefly  attack  persons  with  delicate  skins 
on  the  ankles  and  legs,  but  they  may  also  attack  the  arms  and  the  neck. 
The  mite  attaches  itself  to  the  skin  by  its  claws,  sucks  the  blood,  and  the 
swollen  red  abdomen  may  sometimes  be  seen  as  a  bright-red  dot.  A  papulo- 
vesicular, sometimes  a  pustular  eruption  is  caused  by  it  with  an  intolerable 
itching.  So  intense  may  the  eruption  be,  with  perhaps  an  entire  family 
attacked  at  once,,  that  suspicion  of  poisoning  may  be  aroused.  The  parasite 
is  readily  killed  by  benzine. 


SECTION   11. 
SPECIFIC   II^FECTIOUS  DISEASES. 

I.     TYPHOID  FEVER. 

Definition. — A  general  infection  caused  by  bacillus  typhosus,  character- 
ized anatomically  by  hyperplasia  and  ulceration  of  the  intestinal  lymph-folli- 
cles, swelling  of  the  mesenteric  glands  and  spleen,  and  parenchymatous 
changes  in  the  other  organs.  There  are  cases  in  which  the  local  changes  are 
slight  or  absent,  and  there  are  others  with  intense  localization  of  the  poison 
in  the  lungs,  spleen,  kidneys,  or  cerebro-spinal  system.  Clinically  the  disease 
is  marked  by  fever,  a  rose-colored  eruption,  diarrhoea,  abdominal  tenderness, 
tympanites,  and  enlargement  of  the  spleen ;  but  these  symptoms  are  extremely 
inconstant,  and  even  the  fever  varies  in  its  character. 

Historical  Note. — Huxham,  in  his  remarkable  Essay  on  Fevers,  had 
"  taken  notice  of  the  very  great  difference  there  is  between  the  putrid  malig- 
nant and  the  slow  nervous  fever."  In  1813  Pierre  Bretonneau,  of  Tours, 
distinguished  "  dothienenterite  "  as  a  separate  disease ;  and  Petit  and  Serres 
described  entero-mesenteric  fever.  In  1839  Louis'  great  work  appeared,  in 
which  the  name  "  typhoid  "  was  given  to  the  fever.  At  this  period  typhoid 
fever  alone  prevailed  in  Paris  and  many  European  cities,  and  it  was  univer- 
sally believed  to  be  identical  with  the  continued  fever  of  Great  Britain,  where 
in  reality  typhoid  and  typhus  coexisted.  The  intestinal  lesion  was  regarded 
as  an  accidental  occurrence  in  the  course  of  ordinary  typhus.  Louis'  stu- 
dents returning  to  their  homes  in  different  countries  had  opportunities  for 
studying  the  prevalent  fevers  in  the  thorough  and  systematic  manner  of  their 
master.  Among  these  were  certain  young  American  physicians,  to  one  of 
whom,  Gerhard,  of  Philadelphia,  is  due  the  great  honor  of  having  first 
clearly  laid  down  the  differences  between  the  two  diseases.  His  papers  in 
the  American  Journal  of  the  Medical  Sciences,  1837,  are  the  first  which 
give  a  full  and  satisfactory  account  of  their  clinical  and  anatomical  distinc- 
tions. The  studies  of  James  Jackson,  Sr.  and  Jr.,  of  Enoch  Hale  and  of 
George  C.  Shattuck,  of  Boston,  and  of  Alfred  Stille  and  Austin  Flint  made 
the  subject  very  familiar  in  American  medicine.  In  1842  Elisha  Bartlett's 
work  appeared,  in  which,  for  the  first  time  in  a  systematic  treatise,  typhoid 
and  typhus  fever  were  separately  considered  with  admirable  clearness.  In 
Great  Britain  the  recognition  of  the  difference  between  the  two  diseases  was 
very  slow,  and  was  due  largely  to  A.  P.  Stewart,  and,  finally,  to  the  careful 
studies  of  Jenner  between  1849  and  1850. 

Etiology. — Geneeal  Prevalence. — Typhoid  fever  prevails  especially  in 
temperate  climates,  in  which  it  constitutes  the  most  common  continued  fever, 

57 


58  SPECIFIC  INFECTIOUS  DISEASES. 

Widely  distributed  throughout  all  parts  of  the  world,  it  probably  presents 
eyerywhere  the  same  essential  characteristics,  and  is  everywhere  an  index  of 
the  sanitary  intelligence  of  a  community.  Imperfect  sewerage  and  contam- 
inated water-supply  are  two  special  conditions  favoring  the  distribution  of 
the  bacilli;  filth,  overcrowding,  and  had  ventilation  are  accessories  in  lower- 
ing the  resistance  of  the  individuals  exposed.  While  from  an  infected  person 
the  disease  may  be  spread  by  fingers,  food,  and  flies. 

In  England  and  Wales  in  1906  the  disease  was  fatal  to  3,169  persons,  a 
mortality  of  92  per  million  of  living  persons.  It  destroys  more  lives  in 
proportion  to  population  in  towns  than  in  the  country.  The  rate  was  lower 
ia  1906  than  in  any  year  but  one  since  1869.  Compared  with  the  quinquennial 
average,  there  was  a  very  marked  reduction  (Tatham). 

In  India  the  disease  is  very  prevalent;  no  race  or  creed  is  exempt,  and 
80  per  cent  of  the  cases  of  continued  fever  lasting  three  weeks  prove  to 
be  enteric  (L.  Eogers), 

In  the  United  States  typhoid  fever  continues  to  be  disgracefully  prevalent. 
From  1900  to  1904  the  death  rate  in  the  registration  areas  was  33.8  per  100,000. 
It  is  estimated  that  from  35,000  to  40,000  persons  die  of  it  every  year,  so 
that  at  a  moderate  estimate  nearly  one  half  million  people  are  attacked  an- 
nually. It  is  more  prevalent  in  country  districts  than  in  cities,  and,  as  Fulton 
has  sho"«Ti,  the  propagation  is  largely  from  the  country  to  the  town.  What  is 
needed  both  in  Canada  and  the  United  States  is  a  realization  by  the  public 
that  certaia  primary  laws  of  health  must  be  obeyed. 

In  Germany  the  larger  cities  have  comparatively  little  tj^hoid  fever. 
The  story  of  Hamburg,  as  told  by  Eeincke  (Lancet,  i,  1904),  should  be  read 
by  all  interested  in  the  disease.  During  the  past  twenty-five  years  the  death 
rate  from  enteric  in  Prussia  has  been  reduced  from  an  average  of  over  6  to 
less  than  2  per  10,000  of  the  population.  It  is  still  very  prevalent  in  some 
of  the  country  districts. 

Typhoid  fever  has  been  one  of  the  great  scourges  of  the  armies,  and  kills 
and  maims  more  than  powder  and  shot.  The  story  of  the  recent  wars  forms 
a  sad  chapter  in  human  inefficiency. 

In  the  Spanish- American  War  the  report  of  the  Commission  (Eeed, 
Yauglian,  and  Shakespeare)  shows  that  one  fifth  of  the  soldiers  in  the  national 
encampments  had  typhoid  fever — among  107,973  men  there  were  20,738 
cases,  with  1,580  deaths.  In  90  per  cent  of  the  volunteer  regiments 
the  disease  broke  out  within  eight  weeks  after  going  into  camp.  In 
the  opinion  of  the  Commission  the  most  important  factors  were  camp  pollu- 
tion, flies  as  carriers  of  contagion,  and  the  contamination  through  the  air  in 
the  form  of  dust. 

In  the  South  African  War  the  British  army,  557,653  officers  and  men, 
had  57,684  cases  of  enteric  fever,  with  8,225  deaths  (Simpson),  while  only 
7,582  men  died  of  wounds  received  in  battle.  As  in  America,  the  disease  was 
essentially  one  of  the  standing  camps;  troops  constantly  on  the  move  were 
rarely  much  affected.  While  contaminated  water  was  no  doubt  an  important 
factor,  as  it  always  is  in  camp  pollution,  yet  certain  of  the  conditions  in  Africa 
were  peculiar.  Fjecal  and  urinary  contamination  must  have  been  very  com- 
mon, as  in  the  cooking,  performed  in  the  open  air,  sand  "  entered  largely  into 
every  article  of  food."    As  there  was  a  perfect  plague  of  flies,  they  were  with- 


TYPHOID  FEVER.  59 

out  doubt  a  very  important  factor  in  the  infection  of  both  food  and  drink. 

On  the  other  hand,  the  Japanese  and  Kussian  War  demonstrated  the  re- 
markable efficiency  of  modern  hygiene,  if  carried  out  in  an  intelligent  man- 
ner. The  Japanese  returns  are  not  yet  published,  but  no  great  war  has  ever 
been  conducted  with  such  forethought  for  the  preservation  of  the  fighting 
unit,  and  in  consequence  the  mortality  from  typhoid  fever  and  dysentery  was 
exceptionally  low. 

Season. — Almost  without  exception  the  disease  is  everywhere  more  preva- 
lent in  the  autumn,  hence  the  old  popular  name  autumnal  fever.  The  exhaust- 
ive study  of  this  question  by  Sedgwick  and  Winslow  shows  everywhere  a  strik- 
ing parallelism  between  the  monthly  variations  in  temperature  and  the 
prevalence  of  the  disease.  In  a  few  cities,  notably  Paris,  Philadelphia,  Chi- 
cago, and  Dresden,  the  curves  are  irregular,  showing,  in  addition  to  the  usual 
summer  rise,  two  secondary  maxima  in  the  winter  and  spring,  and  these 
authors  suggest  that  epidemics  at  these  seasons  are  characteristic  of  cities 
whose  water-supply  is  most  subject  to  pollution.  In  their  opinion  "  the  most 
reasonable  explanation  of  the  seasonal  variations  of  typhoid  fever  is  a  direct 
effect  of  the  temperature  upon  the  persistence  in  nature  of  the  germs  which 
proceed  from  previous  victims  of  the  disease." 

Of  1,500  cases  at  the  Johns  Hopkins  Hospital  (upon  the  study  of  which 
this  section  is  based),  840  were  in  August,  September,  and  October. 

Sex. — Males  and  females  are  equally  liable  to  the  disease,  but  males  are 
much  more  frequently  admitted  into  hospitals,  2.4  to  1  in  our  series. 

Age. — Typhoid  fever  is  a  disease  of  youth  and  early  adult  life.  The 
greatest  susceptibility  is  between  the  ages  of  fifteen  and  twenty-five.  Of 
1,500  cases  treated  in  my  wards  at  the  Johns  Hopkins  Hospital  there  were 
under  fifteen  years  of  age,  231;  between  fifteen  and  twenty,  253;  between 
twenty  and  thirty,  680;  between  thirty  and  forty,  237;  between  forty  and 
fifty,  88;  between  fifty  and  sixty,  8;  above  sixty,  11;  age  not  given,  1.  Cases 
are  rare  over  sixty,  although  Manges  believes  that  they  are  more  common 
than  the  records  show.  As  the  course  is  often  atypical  the  diagnosis  may  be 
uncertain  and  the  disease  not  recognized  until  autopsy.  It  is  not  very  infre- 
quent in  childhood,  but  infants  are  rarely  attacked.  Murchison  saw  a  case 
at  the  sixth  month.  There  is  no  evidence  that  the  disease  is  congenital  even 
in  cases  in  which  the  mother  has  contracted  it  late  in  pregnancy. 

Immunity. — Not  all  exposed  to  the  infection  take  the  disease.  Some  fam- 
ilies seem  more  susceptible  than  others.  One  attack  usually  protects.  Two 
attacks  have  been  described  within  a  year.  "  Of  2,000  cases  of  enteric  fever 
at  the  Hamburg  General  Hospital,  only  14  persons  were  affected  twice  and 
only  1  person  three  times"  (Dreschfeld).  It  is  well  known  that  usually 
within  a  short  time  after  recovery  the  immune  substances  disappear  from  the 
blood,  yet  in  most  cases  the  relative  immunity  lasts  a  long  time,  frequently 
for  life.  An  experimental  explanation  for  this  fact  has  been  given  in  the 
demonstration  that  animals  which  have  once  reacted  to  the  typhoid  infec- 
tion, react  in  throwing  out  immune  substances  more  quickly  and  in  larger 
amounts  when  danger  again  threatens  (Cole). 

Bacillus  typhosus. — The  researches  of  Eberth,  Koch,  Gaffky,  and  others 
have  shown  that  there  is  a  special  micro-organism  constantly  associated  with 
typhoid  fever,     (a)   General  Characters. — It  is  a  rather  short,  thick,  flagel- 


60  SPECIFIC  INFECTIOUS  DISEASES. 

lated,  motile  bacillus,  with  rounded  ends,  in  one  of  whicli,  sometimes  in  both 
(particularly  in  cultures),  there  can  be  seen  a  glistening  round  body,  at  one 
time  believed  to  be  a  spore;  but  these  polar  structures  are  probably  only 
areas  of  degenerated  protoplasm.  It  grows  readily  on  various  nutritive  media, 
and  can  now  be  differentiated  from  Bacillus  coli,  with  which,  and  with  certain 
other  bacilli,  it  is  apt  to  be  confounded.  This  organism  now  fulfills  all  the 
requirements  of  Koch's  law — it  is  constantly  present,  and  it  grows  outside  the 
body  in  a  specific  manner;  the  third  requirement,  the  production  of  the 
disease  experimentally,  has  been  successfully  met  by  Griinbaum,  of  Leeds,  who 
has  produced  the  disease  in  chimpanzees.  The  bacilli  or  their  toxins  inocu- 
lated in  large  quantities  into  the  blood  of  rabbits  are  pathogenic,  and  in 
some  instances  ulcerative  and  necrotic  lesions  in  the  intestine  may  be  pro- 
duced. But  similar  intestinal  lesions  may  be  caused  by  other  bacteria,  includ- 
ing Bacillus  coli. 

Cultures  are  killed  within  ten  minutes  by  a  temperature  of  60°  C.  They 
may  live  for  eighteen  weeks  at  —  5°  C,  although  most  die  within  two  weeks, 
and  all  within  twenty-two  weeks  (Park).  The  typhoid  bacillus  resists  ordi- 
nary drying  for  months,  unless  in  very  thin  layers,  when  it  is  killed  in  five 
to  fifteen  days.  The  direct  rays  of  the  sun  completely  destroy  them  in  from 
four  to  ten  hours'  exposure.  Bouillon  cultures  are  destroyed  by  carbolic  acid, 
1  to  200,  and  by  corrosive  sublimate,  1  to  2,500. 

(6)  Distribution  in  the  Body. — During  recent  years  our  ideas  in  regard 
to  the  distribution  of  the  typhoid  bacilli  have  been  much  modified,  owing  to 
the  demonstration  that  in  practically  all  cases  the  bacilli  enter  the  circulat- 
ing blood  and  are  carried  throughout  the  body.  During  life  they  may  be 
demonstrated  in  the  circulating  blood  in  a  large  proportion  of  cases,  in 
75  per  cent  of  604  collected  cases  (Coleman  and  Buxton).  They  occur  in" 
the  urine  in  from  25  to  30  per  cent  of  the  cases.  They  may  be  isolated  from 
the  stools  in  practically  all  cases  at  some  stage.  They  are  probably  always 
present  in  the  rose  spots.  They  are  reported  to  have  been  cultivated  from 
the  sweat,  and  they  undoubtedly  occur  with  considerable  frequency  in  the 
sputum  (Eichardson,  Rau,  and  others).  At  autopsy  they  are  found  widely 
distributed,  most  numerous  and  constant  usually  in  the  mesenteric  glands, 
spleen,  and  gall-bladder,  but  are  found  in  almost  all  organs,  even  the  mus- 
cles, uterus,  and  lungs  (von  Drigalski).  Cultures  made  from  the  intestines 
at  autopsy  (according  to  Jurgens,  and  also  von  Drigalski)  show  that  they 
are  very  few  or  can  not  be  cultivated  from  the  rectum  up  to  the  caecum,  but 
above  this  they  increase  in  number,  being  very  numerous  in  the  duodenum 
and  jejunum,  and  practically  constant  in  cultures  made  from  the  mucous 
membrane  of  the  stomach.  They  are  also  present  in  the  oesophagus  and 
frequently  on  the  tongue  and  tonsils.  From  endocardial  vegetations,  from 
meningeal  and  pleural  exudates  and  from  foci  of  suppuration  in  various 
parts  of  the  body,  the  bacilli  have  also  been  isolated.  A  most  important  and 
remarkable  fact  is  that  at  times  they  may  be  present  in  the  stools  of  persons 
who  show  no  symptoms  of  typhoid  fever,  but  who  have  lived  in  very  close  asso- 
ciation with  typhoid-fever  patients.     This  is  especially  true  of  children. 

(c)  The  Bacilli  Outside  the  Body. — In  sterile  water  the  bacilli  retain 
their  vitality  for  weeks,  but  under  ordinary  conditions,  in  competition  with 
saprophytes,  disappear  within  a  few  days.    The  question  of  the  longevity  of 


TYPHOID  FEVER.  61 

the  typhoid  bacillus  in  water  is  of  great  importance,  and  has  been  much 
discussed  in  connection  with  the  supposed  pollution  of  the  waters  of  the  Mis- 
sissippi by  the  Chicago  drainage  canal.  The  experiments  of  E.  0.  Jordan 
would  indicate  that  the  vitality  was  retained  as  a  rule  not  longer  than  three 
days  after  infection.  Whether  an  increase  can  occur  in  water  is  not  finally 
settled.  Their  detection  in  the  water  is  difficult,  and  although  they  undoubt- 
edly have  been  found,  many  such  discoveries  previously  reported  are  not  cer- 
tain on  account  of  the  inaccurate  differentiation  of  the  typhoid  bacillus  and 
varieties  of  the  intestinal  bacillus  closely  resembling  it.  Both  Prudden  and 
Ernst  have  found  it  in  water  filters. 

There  are  cities  deriving  their  ice  supply  from  polluted  streams  with 
low  death  rates  from  typhoid  fever.  Sedgwick  and  Winslow  conclude  from 
their  careful  study  that  very  few  typhoid  germs  survive  in  ice.  The  Ogdens- 
burg  epidemic  in  1903-03  was  apparently  due  to  infection  from  ice. 
Typhoid  bacilli  were  grown  from  frozen  material  in  it  (Hutchins  and 
Wheeler). 

In  milh  the  bacilli  undergo  rapid  development  without  changing  its 
appearance.  They  may  persist  for  three  months  in  sour  milk,  and  may  live 
for  several  days  in  butter  made  from  infected  cream. 

Eobertson  has  shown  that  under  entirely  natural  conditions  typhoid  bacilli 
may  live  in  the  upper  layers  of  the  soil  for  eleven  months.  Yon  Drigalski 
says  if  stools  which  contain  typhoid  bacilli  are  kept  at  room  temperature  the 
B.  typhosus  disappears  in  a  few  days. 

The  direct  infection  by  dust  of  exposed  food-stuffs,  such  as  milk,  is  very 
probable.  The  bacilli  retain  their  vitality  for  many  weeks;  in  garden  earth 
twenty-one  days,  in  filter-sand  eighty-two  days,  in  dust  of  the  street  thirty 
days,  on  linen  sixty  to  seventy  days,  on  wood  thirty-two  days ;  on  thread  kept 
under  suitable  conditions  for  a  year. 

Modes  OF  Conveyance. —  (a)  Contagion. — Direct  aerial  transmission  does 
not  seem  probable.  Each  case  should  be  regarded  as  a  possible  source  of 
infection,  and  in  houses,  hospitals,  schools,  and  barracks  a  widespread  epi- 
demic may  arise  from  it.  Fingers,  food,  and  flies  are  the  chief  means  of 
local  propagation.  It  is  impossible  for  a  nurse  to  avoid  finger  contamination, 
and  without  scrupulous  care  the  germs  may  be  widely  distributed  in  a  ward 
or  throughout  a  house.  Cotton  or  rubber  gloves  are  used  in  some  institu- 
tions. Even  with  special  precautions  and  an  unusually  large  proportion  of 
nurses  to  patients,  we  have  not  been  able  to  avoid  "  house  "  infection  at  the 
Johns  Hopkins  Hospital.  T.  B.  Futcher  has  analyzed  the  31  cases  contracted 
in  the  hospital  among  our  first  1,500  cases;  physicians,  5  *  among  a  total  of 
288;  nurses,  15  of  a  total  of  407;  patients,  8  out  of  a  total  of  47,956  admis- 
sions; 4  of  these  occurred  in  a  small  ward  epidemic.  Two  orderlies  were 
infected  while  caring  for  typhoid  patients,  and  one  woman  in  charge  of  a 
supply  room,  where  she  only  handled  clean  linen.  Newman  concludes  from 
his  study  of  enteric  in  London  that  direct  personal  infection,  and  infection 
through  food  are  the  two  common  channels  for  its  propagation. 

(&)  Infection  of  water  is  the  most  common  source  of  wide-spread  epi- 
demics, many  of  which  have  been  shown  to  originate  in  the  contamination 

*Only  three  of  these  were  in  attendance  on  typhoid  cases.    Two  of  the  five  died — - 
Oppenheimer  and  Ochsner. 


62  •  SPECIFIC  INFECTIOUS  DISEASES. 

of  a  well  or  a  spring.  A  very  striking  one  occurred  at  Plymouth,  Pa.,  in 
1885,  which  was  investigated  by  Shakespeare.  The  town,  with  a  population 
of  8,000,  was  in  part  supplied  with  drinking-water  from  a  reservoir  fed  by 
a  mountain  stream.  During  January,  February,  and  March,  in  a  cottage 
by  the  side  of  and  at  a  distance  of  from  60  to  80  feet  from  this  stream,  a 
man  was  ill  with  typhoid  fever.  The  attendants  were  in  the  habit  at  night 
of  throwing  out  the  evacuations  on  the  gi'ound  toward  the  stream.  During 
these  months  the  ground  was  frozen  and  covered  with  snow.  In  the  latter 
part  of  March  and  early  in  April  there  was  considerable  rainfall  and  a  thaw, 
in  which  a  large  part  of  the  three  months'  accumulation  of  discharges  was 
washed  into  a  brook,  not  60  feet  distant.  At  the  very  time  of  this  thaw 
the  patient  had  numerous  and  copious  discharges.  About  the  10th  of  April 
cases  of  typhoid  fever  broke  out  in  the  town,  appearing  for  a  time  at  the 
rate  of  fifty  a  day.  In  all  about  1,200  people  were  attacked.  An  immense 
majority  of  all  the  cases  were  in  the  part  of  the  town  which  received  water 
from  the  infected  reservoir. 

The  experience  of  Maidstone  in  1897  illustrates  the  wide-spread  and  seri- 
ous character  of  an  epidemic  when  the  Avater-supply  becomes  badly  contami- 
nated. The  outbreak  began  about  the  middle  of  September,  and  within  the 
first  two  weeks  509  cases  were  reported.  By  October  27th  there  were  1,748 
cases,  and  by  November  17th  1,848  cases.  In  all,  in  a  population  of  35,000, 
about  1,900  persons  were  attacked. 

(c)  Typhoid  Carriers. — The  bacilli  may  persist  for  years  in  the  bile 
passages  and  intestines  of  persons  in  good  health.  They  have  been  found  by 
Young  in  the  urinary  bladder,  and  by  Hunner  in  the  gall-bladder,  ten  and 
twenty  years  after  the  fever,  and  there  have  been  cases  of  typhoid  bone  lesion 
from  which  the  bacilli  were  isolated  many  years  after  the  primary  attack. 
Within  the  past  few  years  the  work  of  Strassburg  observers  has  called  attention 
to  a  groujj  of  chronic  typhoid  carriers  of  the  first  importance  in  the  spread 
of  the  disease.  One  woman,  a  baker,  had  typhoid  fever  ten  years  previously. 
The  bacilli  were  found  in  large  numbers  in  her  stools.  Every  new  employee 
in  the  bakery  sooner  or  later  became  seriously  ill  with  typhoid-like  symptoms, 
and  in  two  persons  the  disease  proved  fatal.  Several  localized  epidemics  have 
been  traced  to  these  carriers,  particularly  in  asylums,  as  determined  by  the 
Strassburg  observers.  Ledingham,  in  one  of  the  Scotch  asylums  at  which 
since  1893  small  outbreaks  of  typhoid  fever  had  occurred,  reported  31  cases 
with  9  fatal.  Nothing  abnormal  could  be  determined  in  the  water  or  in  the 
milk.  Three  typhoid  carriers  were  detected.  Soper  reports  an  instance  in 
which  a  cook,  apparently  in  perfect  health,  but  in  whose  stools  bacilli  had 
been  present  in  large  numbers,  had  been  responsible  for  the  occurrence  of 
typhoid  in  seven  households  in  five  years.  Apparently  there  is  no  limit  to 
the  length  of  time  in  which  the  bacilli  may  remain  in  the  bile  passages  and 
pass  into  the  stools.  Dean  reports  a  case  of  a  carrier  of  twenty-nine  years' 
standing,  and  instances  of  even  longer  duration  are  recorded. 

(d)  Infection  of  Food. — Milk  may  be  the  source  of  infection.  One  of 
the  most  thoroughly  studied  epidemics  due  to  this  cause  was  that  investigated 
by  Ballard  in  Islington.  The  milk  may  be  contaminated  by  infected  water 
iised  in  cleaning  the  cans.  The  milk  epidemics  have  been  collected  by  Ernest 
Hart  and  by  Kober, 


TYPHOID  FEVER.  63 

The  germs  may  be  conveyed  in  ice,  salads  of  various  sorts,  etc.  The 
danger  of  eating  celery  and  other  uncooked  vegetables,  which  have  grown 
in  soil  on  which  infected  material  has  been  used  as  a  fertilizer;,  must  not 
be  forgotten. 

Oysters. — Much  attention  has  been  paid  of  late  years  to  the  oyster  as  a 
source  of  infection.  In  several  epidemics,  such  as  that  in  Middletown, , 
reported  by  Conn,  that  in  Naples,  by  Lavis,  and  in  the  outbreak  which 
occurred  at  Winchester,  the  chain  of  circumstantial  evidence  seems  com- 
plete. Most  suggestive  sporadic  cases  have  also  been  recorded  by  Broadbent 
and  others.  Foote  showed  that  oysters  taken  from  the  feeding-grounds  in 
rivers  contain  a  larger  number  of  micro-organisms  of  all  sorts  than  those  from 
the  sea.  Chantemesse  found  typhoid  bacilli  in  oysters  which  had  lain  in 
infected  sea-water,  even  after  they  had  been  transferred  to  and  kept  in  fresh 
water  for  a  time.  C.  W.  Field,  working  in  the  laboratories  of  the  Department 
of  Health,  New  York  (1904),  confirms  the  observations  of  both  Foote  and 
Chantemesse,  but  he  could  not  determine  that  the  bacilli  were  able  to  mul- 
tiply within  the  oysters.  Mosny,  in  his  report  to  the  French  Glovernment 
(1900),  admits  the  possibility  of  oyster  infection,  but  he  thinks  that  the  oyster 
plays  a  very  small  role  in  relation  to  the  total  morbidity  of  the  disease.  Mus- 
sels have  also  been  found  contaminated  with  typhoid  bacilli,  and  it  is  stated 
that  dried  fish  have  carried  the  infection. 

(e)  Flies. — The  importance  of  flies  in  the  transmission  of  the  disease 
was  brought  out  very  strongly  in  the  Spanish-American  War  in  1898.  The 
Eeport  of  the  Commission  (Eeed,  Vaughan,  and  Shakespeare)  states  that 
"  flies  were  undoubtedly  the  most  active  agents  in  the  spread  of  typhoid  fever. 
Flies  alternately  visited  and  fed  on  the  infected  faecal  matter  and  the  food 
in  the  mess-tent.  .  .  .  Typhoid  fever  was  much  less  frequent  among  members 
of  messes  who  had  their  mess-tents  screened  than  it  was  among  those  who 
took  no  such  precautions."  In  the  South  African  War  there  was  a  perfect 
plague  of  flies,  particularly  in  the  enteric  fever  tents,  and  among  the  army 
surgeons  the  opinion  was  universal  that  they  had  a  great  deal  to  do  with  the 
dissemination  of  the  disease.  Firth  and  Horrocks  demonstrated  the  readi- 
ness with  which  flies,  after  feeding  on  typhoid  stools  or  fresh  cultures  of 
typhoid  bacilli,  could  infect  sterile  media.  One  of  the  most  interesting 
studies  on  the  question  was  made  in  the  Chicago  epidemic  of  1902  by  Alice 
Hamilton.  Flies  caught  in  two  undrained  privies,  on  the  fences  of  two  yards, 
on  the  walls  of  two  houses,  and  in  the  room  of  a  typhoid-fever  patient,  were 
used  to  inoculate  eighteen  tubes,  and  from  five  of  these  tubes  typhoid  bacilli 
were  isolated. 

(/)  Contamination  of  the  Soil. — Filth,  bad  sewers,  or  cesspools  can  not 
in  themselves  cause  typhoid  fever,  but  they  furnish  the  conditions  suitable 
for  the  preservation  of  the  bacillus,  and  possibly  for  its  propagation. 

Dust  may  be  an  important  factor,  though  it  has  been  shown  that  the 
bacilli  die  very  quickly  when  desiccated.  In  the  dust  storms  during  the  South 
African  War  the  food  was  often  covered  with  dust.  Possibly,  too,  as  Bar- 
ringer  suggests,  the  dust  on  the  railway  tracks  may  become  contaminated. 
Men  working  on  the  tracks  are  very  liable  to  infection. 

Modes  of  Infection. — While  the  bacillus  has  its  primary  seat  of  action 
in  the  lymphatic  tissues  of  the  intestines,  the  fever  is  very  largely  due  to 


64  SPECIFIC  INFECTIOUS  DISEASES. 

its  growth  in  tlie  internal  organs.  As  Maclagan  ybtj  well  puts  it,  the  action 
is  dual,  one  a  local  specific  action  of  the  parasite  on  the  glands  of  the  intes- 
tines, and  a  general  action  of  the  organism  on  the  blood  and  tissues.  A  single 
bacillus  in  ten  days,  as  he  says,  might  produce  a  billion,  and  the  incubation 
represents  the  period  during  which  the  bacilli  are  being  reproduced. 

We  may  recognize  the  following  groups :  1.  Ordinary  typhoid  fever  with 
marlced  enteric  lesions.  An  immense  majority  of  all  the  cases  are  of  this 
character;  and  while  the  spleen  and  mesenteric  glands  are  involved  the  lym- 
phatic apparatus  of  the  intestinal  walls  bears  the  brunt  of  the  attack.  2. 
Cases  in  ivhich  the  intestinal  lesions  are  very  slight,  and  may  be  found  only 
after  a  very  careful  search.  In  reviewing  the  cases  of  "  tj'phoid  fever  with- 
out intestinal  lesions,"  Opie  and  Bassett  call  attention  to  the  fact  that  in 
many  negative  cases  slight  lesions  really  did  exist,  while  in  others  death 
occurred  so  late  that  the  lesions  might  have  healed.  In  some  cases  the 
disease  is  a  general  septicemia  with  symptoms  of  severe  intoxication  and  high 
fever  and  delirium.  In  others  the  main  lesions  may  be  in  organs — liver, 
gall-bladder,  pleura,  meninges,  or  even  the  endocardium.  3.  Cases  in  which 
the  typhoid  hacillus  enters  the  body  without  causing  any  lesion  of  the  intes- 
tine. In  a  number  of  the  earlier  cases  reported  as  such  the  demonstration 
of  the  typhoid  bacillus  was  inconclusive.  In  others  the  intestine  showed 
tuberculous  ulcers,  through  which  the  organisms  may  have  entered.  But 
after  excluding  all  these,  a  few  cases  remain  in  which  the  demonstration  of 
the  typhoid  bacillus  was  conclusive,  cases  in  which  death  occurred  early,  and 
yet  after  a  very  careful  search  no  intestinal  lesions  could  be  found.  There 
were  4  cases  in  this  series.  Undoubtedly  the  intestinal  lesions  may  be  so 
slight  as  not  to  be  recognizable  at  autopsy.  There  is  no  conclusive  evi- 
dence that  typhoid  bacilli  ever  enter  the  body  except  through  the  intestinal 
tract.  4.  Mixed  infections.  It  is  well  to  distinguish,  as  Dreschfeld  points 
out,  between  double  infections,  as  with  bacillus  tuberculosis,  the  diphtheria 
bacillus,  and  the  plasmodia  of  Laveran,  in  which  two  different  diseases  are 
present  and  can  be  readily  distinguished,  and  the  true  mixed  or  secondary 
infections,  in  which  the  conditions  induced  by  one  organism  favor  the  growth 
of  other  pathogenic  forms;  thus  in  the  ordinary  typhoid-fever  cases  sec- 
ondary infection  with  the  colon  bacillus,  the  streptococcus,  staphylococcus, 
or  the  pneumococcus,  is  quite  conmion.  5.  Para-typhoid  infections.  In 
1898  GwjTi  reported  a  remarkable  case  from  my  clinic,  which  presented  all 
of  the  clinical  features  of  typhoid  fever,  but  in  which  no  serum  reaction  with 
B.  typhosus  was  present.  From  the  blood  of  this  patient  he  isolated  in  pure 
culture  a  bacillus,  differing  from  B.  typhosus,  but  having  properties  inter- 
mediate between  B.  typhosus  and  B.  coli.  This  organism  resembled  one 
which  was  isolated  in  1897  by  Widal  from  an  oesophageal  abscess,  and  which 
he  called  a  para-colon  bacillus.  In  1900  Gushing  reported  from  the  Johns 
Hopkins  Hospital  the  cultivation  of  a  similar  organism  from  a  costo-chon- 
dral  abscess  following  an  attack  resembling  typhoid  fever.  These  organisms 
belong  in  a  group  which  also  contains  B.  enteritidis,  described  as  the  cause 
of  meat  poisoning,  and  also  several  varieties  causing  diseases  in  animals. 
Since  1900,  following  the  introduction  of  more  accurate  bacteriological 
methods,  similar  organisms  have  been  cultivated  from  numerous  cases  (now 
many  hundreds)    clinically  like  mild  typhoid.     Enlargement  of  the  spleen 


TYPHOID  FEVER.  65' 

has  been  quite  constantly  present,  while  rose  spots  have  been  frequently  seen, 
and  intestinal  symptoms,  even  haemorrhages,  have  occurred,  but  perforation 
has  not  been  met  with.  Many  cases  have  a  very  brief  but  acute  course,  re- 
sembling food  poisoning.  The  sequelae  of  ordinary  typhoid  fever  may  occur, 
and  the  para-typhoid  organism  has  been  isolated  from  the  lesions  of  osteo- 
myelitis, an  inflamed  testis,  and  a  chondrosternal  abscess.  In  the  ordinary 
work  of  a  medical  clinic  the  cases  are  not  very  common.  There  were  only  8  in 
the  last  500  cases  in  my  series.  There  have  been  about  15  autopsies  (Birt), 
usually  with  enteric  lesions.  There  is  nothing  in  the  clinical  or  anatomical 
features  to  differentiate  it  from  ordinary  typhoid,  and  for  practical  pur- 
poses they  may  be  considered  the  same  disease.  The  question  is  a  bacterio- 
logical one,  and  the  diagnosis  rests  upon  the  cultural  peculiarities  of  the 
organism  isolated  from  the  blood  or  stools,  and  upon  the  agglutination  tests. 
6.  Local  infections.  The  typhoid  bacillus  may  cause  a  local  abscess,  cystitis, 
or  cholecystitis  without  evidence  of  a  general  infection.  7.  Terminal  typhoid 
infections.  In  rare  instances  the  bacillus  causes  a  fatal  infection  towards  the 
end  of  other  diseases.  The  subjects  may,  of  course,  be  typhoid  carriers.  In 
two  cases  of  malignant  disease  at  the  Johns  Hopkins  Hospital  the  bacilli 
were  isolated  from  the  blood,  and  there  were  no  intestinal  lesions. 

Products  of  the  Growth  of  the  Bacilli. — Brieger  isolated  from  cultures 
a  poison  belonging  to  the  group  of  ptomaines — typhotoxin.  Later  he  and 
Fraenkel  isolated  a  poison  belonging  to  the  group  of  toxalbumins.  Accord- 
ing to  Pfeiffer,  the  chief  poison  belongs  to  the  intracellular  group  of  toxins. 
Sidney  Martin  has  isolated  a  poison  which  is  in  the  nature  of  a  secretion, 
but  does  not  differ  from  that  contained  within  the  bacterial  cell.  Injected 
into  animals  it  causes  lowering  of  temperature,  diarrhoea,  loss  of  weight,  and 
degeneration  of  the  myocardium.  Its  chemical  nature  is  not  known.  Sim- 
ilar, but  weaker,  poisons  may  also  be  isolated  from  cultures  of  Bacillus  coli 
and  other  members  of  this  group.  No  toxins  have  yet  been  isolated  which 
cause  changes  in  animals  at  all  comparable  to  typhoid  fever  in  human  beings. 
Macfadyen  and  Eowland,  by  mechanically  breaking  up  the  bacilli  after  they 
had  been  frozen  by  means  of  liquid  air  obtained  toxins,  which  injected  into 
monkeys  had  both  antitoxic  and  antibacterial  properties. 

Morbid  Anatomy. — Intestines. — A  catarrhal  condition  exists  through- 
out the  small  and  large  bowel.  Specific  changes  occur  in  the  lymphoid  ele- 
ments, chiefly  at  the  lower  end  of  the  ileum.  The  alterations  which  occur 
are  most  conveniently  described  in  four  stages : 

1.  Hyperplasia,  which  involves  the  glands  of  Peyer  in  the  jejunum  and 
ileum,  and  to  a  variable  extent  those  in  the  large  intestine.  The  follicles 
are  swollen,  grayish-white,  and  the  patches  may  project  3  to  5  mm.,  or  may  be 
still  more  prominent.  The  solitary  glands,  which  range  in  size  from  a  pin's 
head  to  a  pea,  are  usually  deeply  imbedded  in  the  submucosa,  but  project  to 
a  variable  extent.  Occasionally  they  are  very  prominent,  and  may  be  almost 
pedunculated.  Microscopical  examination  shows  at  the  outset  a  condition  of 
hyperaemia  of  the  follicles.  Later  there  is  a  great  increase  and  accumula- 
tion of  cells  of  the  lymph- tissue  which  may  even  infiltrate  the  adjacent 
mucosa  and  the  muscularis;  and  the  blood-vessels  are  more  or  less  com- 
pressed, which  gives  the  whitish,  anaemic  appearance  to  the  follicles.  The 
cells  have  all  the  characters  of  ordinary  lymph-corpuscles.  Some  of  them, 
6 


66  SPECIFIC  INFECTIOUS  DISEASES. 

however,  are  larger,  epithelioid,  and  contain  several  nuclei.  Occasionally 
cells  containing  red  blood-corpnscles  are  seen.  This  so-called  medullary  infil- 
tration, which  is  always  more  intense  toward  the  lower  end  of  the  ileum, 
reaches  its  height  from  the  eighth  to  the  tenth  day  and  then  undergoes  one 
of  two  changes,  resolution  or  necrosis.  Death  very  rarely  takes  place  at  this 
stage.  Eesolution  is  accomplished  by  a  fatty  and  granular  change  in  the 
cells,  which  are  destroyed  and  absorbed.  A  curious  condition  of  the  patches 
is  produced  at  this  stage,  in  which  they  have  a  reticulated  appearance,  the 
plaques  a  surface  reticulee.  The  swollen  follicles  in  the  patch  undergo  reso- 
lution and  shrink  more  rapidly  than  the  surrounding  framework,  or  what  is 
more  probable  the  follicles  alone,  owing  to  the  intense  hyperplasia,  become 
necrotic  and  disintegrate,  leaving  the  little  pits.  In  this  process  superficial 
hsemorrhages  may  result,  and  small  ulcers  may  originate  by  the  fusion  of 
these  superficial  losses  of  substance. 

Except  histologically  there  is  nothing  distinctive  in  the  h}q3erplasia  of  the 
lymph-follicles;  but  apart  from  enteric  we  rarely  see  in  adults  a  marked 
affection  of  these  glands  with  fever.  In  children,  however,  it  is  not  uncom- 
mon when  death  has  occurred  from  intestinal  affections,  and  it  is  also  met 
with  in  measles,  diphtheria,  and  scarlet  fever. 

2.  Necrosis  and  Sloughing. — When  the  hyperplasia  of  the  lymph-follicles 
reaches  a  certain  grade,  resolution  is  no  longer  possible.  The  blood-vessels- 
become  choked,  there  is  a  condition  of  aneemic  necrosis,  and  sloughs  form 
which  must  be  separated  and  thrown  off.  The  necrosis  is  probably  due  in 
great  part  to  the  direct  action  of  the  bacilli.  According  to  Mallory,  there 
occurs  a  proliferation  of  endothelial  cells  due  to  the  action  of  a  toxin.  These 
cells  are  phagocytic  in  character,  and  the  swelling  of  the  intestinal  lymphoid 
tissue  is  due  almost  entirely  to  their  formation.  The  necrosis,  he  thinks,. 
is  due  to  the  occlusion  of  the  veins  and  capillaries  by  fibrinous  thrombi,  which 
owe  their  origin  to  degeneration  of  phagocytic  cells  beneath  the  lining  endo- 
thelium of  the  vessels.  The  process  may  be  superficial,  affecting  only  the 
upper  part  of  the  mucous  coat,  or  it  may  extend  to  and  involve  the  submu- 
cosa.  The  "  slough "  may  sometimes  lie  upon  the  Peyer's  patch,  scarcely 
involving  more  than  the  epithelium  (Marchand).  It  is  always  more  intense 
toward  the  ileo-cascal  valve,  and  in  very  severe  cases  the  greater  part  of  the 
mucosa  of  the  last  foot  of  the  ileum  may  be  converted  into  a  brownish-black 
eschar.  The  necrotic  area  in  the  solitary  glands  forms  a  yellowish  cap 
which  often  involves  only  the  most  prominent  point  of  a  follicle.  The  extent 
of  the  necrosis  is  very  variable.  It  may  pass  deep  into  the  muscular  coat,, 
reaching  to  or  even  perforating  the  peritonaeum. 

3.  Ulceration. — The  separation  of  the  necrotic  tissue — the  sloughing — 
is  gradually  effected  from  the  edges  inward,  and  results  in  the  formation 
of  an  ulcer,  the  size  and  extent  of  which  are  directly  proportionate  to  the 
amount  of  necrosis.  If  this  be  superficial,  the  entire  thickness  of  the  mucosa 
may  not  be  involved  and  the  loss  of  substance  may  be  small  and  shallow. 
More  commonly  the  slough  in  separating  exposes  the  submucosa  and  mus- 
cularis,  particularly  the  latter,  which  forms  the  floor  of  a  majority  of  all 
typhoid  ulcers.  It  is  not  common  for  an  entire  Peyer's  patch  to  slough 
away,  and  a  perfectly  ovoid  ulcer  opposite  to  the  mesentery  is  rarely  seen. 
Irregularly  oval  and  rounded  forms  are  most  common.     A  large  patch  may 


TYPHOID  FEVER.  67 

present  three  or  four  ulcers  divided  by  septa  of  mucous  membrane.  The 
terminal  6  or  8  inches  of  the  mucous  membrane  of  the  ileum  may  form  a 
large  ulcer,  in  which  are  here  and  there  islands  of  mucosa.  The  edges  of 
the  ulcer  are  usually  swollen,  soft,  sometimes  congested,  and  often  under- 
mined. At  a  late  period  the  ulcers  near  the  valve  may  have  very  irregular 
sinuous  borders.  The  base  of  a  typhoid  ulcer  is  smooth  and  clean,  being , 
usually  formed  of  the  submucosa  or  of  the  muscularis. 

There  may  be  large  ulcers  near  the  valve  and  swollen  hypersemic  patches 
of  Peyer  in  the  upper  part  of  the  ileum. 

4.  Healing. — This  begins  with  the  development  of  a  thin  granulation 
tissue  which  covers  the  base.  Occasionally  an  appearance  is  seen  as  if  an 
ulcer  had  healed  in  one  place  and  was  extending  in  another.  The  mucosa 
gradually  extends  from  the  edge,  and  a  new  growth  of  epithelium  is  formed. 
The  glandular  elements  are  reformed ;  the  healed  ulcer  is  somewhat  depressed 
and  is  usually  pigmented.  In  death  during  relapse  healing  ulcers  may  be 
seen  in  some  patches  with  fresh  ulcers  in  others. 

We  may  say,  indeed,  that  healing  begins  with  the  separation  of  the 
sloughs,  as,  when  resolution  is  impossible,  the  removal  of  the  necrosed  part 
is  the  first  step  in  the  process  of  repair.  In  fatal  cases,  we  seldom  meet  with 
evidences  of  cicatrization,  as  the  majority  of  deaths  occur  before  this  stage 
is  reached.  It  is  remarkable  that  no  matter  how  extensive  the  ulceration  has 
been,  healing  is  never  associated  with  stricture,  and  typhoid  fever  does  not 
appear  as  one  of  the  causes  of  intestinal  obstruction.  Within  a  very  short 
time  all  traces  of  the  old  ulcers  disappear. 

Large  Intestine. — The  csecum  and  colon  are  affected  in  about  one  third 
of  the  cases.  Sometimes  the  solitary  glands  are  greatly  enlarged.  The 
ulcers  are  usually  larger  in  the  caecum  than  in  the  colon. 

Perfoeation  oe  the  Bowel. — Incidence  at  Autopsy. — J.  A.  Scott's 
figures,  embracing  9,713  cases  from  recent  English,  Canadian,  and  American 
sources,  give  351  deaths  from  perforation  among  1,037  deaths  from  all 
causes,  a  percentage  of  33.8  of  the  deaths  and  3.6  of  the  cases.  The  German 
statistics  give  a  much  lower  proportion  of  deaths  from  perforation;  Munich 
in  2,000  autopsies,  5.7  per  cent  from  perforation;  Basle  in  2,000  autopsies, 
1.3  per  cent  from  perforation;  Hamburg  in  3,686  autopsies,  1.2  per  cent 
from  perforation  (Hector  Mackenzie,  Lancet,  1903).  At  the  Johns  Hopkins 
Hospital  among  1,500  cases  of  typhoid  fever  there  were  43  with  perforation. 
Twenty  of  these  were  operated  upon,  with  7  recoveries.  One  other  case  died 
of  the  toxaemia  on  the  eighth  day  after  operation.  At  the  Pennsylvania  Hos- 
pital there  were  50  cases  of  perforation  among  1,948  cases.  Chomel  remarks 
that  "  the  accident  is  sometimes  the  result  of  ulceration,  sometimes  of  a  true 
eschar,  and  sometimes  it  is  produced  by  the  distention  of  the  intestine,  caus- 
ing the  rupture  of  tissues  weakened  by  disease."  As  a  rule,  sloughs  are 
adherent  about  the  site  of  perforation.  The  site  is  usually  in  the  ileum, 
232  times  in  Hector  Mackenzie's  collection  of  264  cases;  the  jejunum  twice, 
the  large  intestine  22  times,  and  the  appendix  9  times  in  his  series.  As  a 
rule,  the  perforation  occurs  within  twelve  inches  of  the  ileo-cffical  valve. 
There  may  be  two  or  three  separate  perforations.  J.  A.  Scott  describes  two 
distinct  varieties:  first,  the  more  common  single,  circular,  pin-point  in  size, 
due  to  the  extension  of  a  necrotic  process  through  the  base  of  a  small  ulcer. 


68  SPECIFIC  INFECTIOUS  DISEASES. 

The  second  variet}^,  produced  by  a  large  area  of  tissue  becoming  necrotic, 
ranges  in  size  from  the  finger-tip  to  3  cm.  in  diameter. 

Death  from  hcemorrhage  occurred  in  99  of  the  Munich  cases,  and  in  12 
of  137  deaths  in  my  1,500  cases.  The  bleeding  seems  to  result  directly  from 
the  separation  of  the  sloughs.  I  was  not  able  in  any  instance  to  find  the 
bleeding  vessel.  In  one  case  only  a  single  patch  had  sloughed,  and  a  firm 
clot  was  adherent  to  it.  The  bleeding  may  also  come  from  the  soft  swollen 
edges  of  the  patch. 

The  mesenteric  glands  show  hypergemia  and  subsequently  become  greatly 
swollen.  Spots  of  necrosis  are  common.  In  several  of  my  cases  suppuration 
had  occurred,  and  in  one  a  large  abscess  of  the  mesentery  was  present.  The 
rupture  of  a  softened  or  suppurating  mesenteric  gland,  of  which  there  are 
only  five  or  six  cases  in  the  literature,  may  cause  either  fatal  hsemorrhage  or 
peritonitis.  LeConte  has  successfully  operated  upon  the  latter  condition.  The 
bunch  of  glands  in  the  mesentery,  at  the  lower  end  of  the  ileum,  is  especially 
involved.     The  retroperitoneal  glands  are  also  swollen. 

The  spleen  is  invariably  enlarged  in  the  early  stages  of  the  disease.  In 
11  of  my  series  it  exceeded  20  ounces  (600  grams)  in  weight,  in  one  900 
grams.  The  tissue  is  soft,  even  diffluent.  Infarction  is  not  infrequent.  Eup- 
ture  may  occur  spontaneously  or  as  a  result  of  injury.  In  the  Munich  autop- 
sies there  were  5  instances  of  rupture  of  the  spleen,  one  of  which  resulted 
from  a  gangrenous  abscess. 

The  hone-marrow  shows  changes  very  similar  to  those  in  the  lymphoid 
tissues,  and  there  may  be  foci  of  necrosis  (Longcope). 

The  liver  shows  signs  of  parenchymatous  degeneration.  Early  in  the  dis- 
ease it  is  hypergemic,  and  in  a  majority  of  instances  it  is  swollen,  somewhat 
pale,  on  section  turbid,  and  microscopically  the  cells  are  very  granular  and 
loaded  with  fat.  Nodular  areas  (microscopic)  occur  in  many  cases,  as 
described  by  Hanford.  Eeed,  in  Welch's  laboratory,  could  not  determiae 
any  relation  between  the  groups  of  bacilli  and  these  areas  (Studies  II).  Some 
of  the  nodules  are  lymphoid,  others  are  necrotic.  In  12  of  the  Munich  autop- 
sies liver  abscess  was  found,  and  in  3,  acute  yellow  atrophy.  In  2  of  this 
series  liver  abscess  occurred.  Pyleplilebitis  may  follow  abscess  of  the  mesen- 
tery or  perforation  of  the  appendix.  Affections  of  the  gall-bladder  are  not 
uncommon,  and  are  fully  described  under  the  clinical  features. 

Kidneys. — Cloudy  swelling,  with  granular  degeneration  of  the  cells  of 
the  convoluted  tubules,  less  commonly  an  acute  nephritis,  may  be  present. 
Eayer,  Wagner,  and  others  described  the  occurrence  of  numerous  small  areas 
infiltrated  with  round  cells,  which  may  have  the  appearance  of  lymphomata, 
or  may  pass  on  to  softening  and  suppuration,  producing  the  so-called  miliary 
abscesses,  of  which  there  were  7  cases  in  this  series.  The  typhoid  bacilli  have 
been  found  in  these  areas.  They  may  also  be  found  in  the  urine.  The  kid- 
neys in  cases  of  t}^hoid  bacilluria  may  show  no  changes  other  than  cloudy 
swelling.  Diphtheritic  inflammation  of  the  pelvis  of  the  kidney  may  occur. 
It  was  present  in  3  of  my  cases,  in  one  of  which  the  tips  of  the  papillae  were 
also  affected.  Catarrh  of  the  bladder  is  not  uncommon.  Diphtheritic  inflam- 
mation of  this  viscus  may  also  occur.     Orchitis  is  occasionally  met  with. 

Eespiratoet  Organs. — Ulceration  of  the  larjmx  occurs  in  a  certain  num- 
ber of  cases;  in  the  Munich  series  it  was  noted  107  times.     It  may  come  on 


TYPHOID  FEVER.  69 

at  the  same  time  as  the  ulceration  in  the  ileum.  It  occurs  in  the  posterior 
wall,  at  the  insertion  of  the  cords^  at  the  base  of  the  epiglottis,  and  on  the 
ary-epiglottidean  folds.  The  cartilages  are  very  apt  to  become  involved.  In 
the  later  periods  catarrhal  and  diphtheritic  ulcers  may  be  present. 

(Edema  of  the  glottis  was  present  in  20  of  the  Munich  cases,  in  8  of 
which  tracheotomy  was  performed.  Diphtheritis  of  the  pharynx  and  larynx 
is  not  very  uncommon.  It  occurred  in  a  most  extensive  form  in  2  of  my 
cases.  Lobar  pneumonia  may  be  found  early  in  the  disease  (see  Pneumo- 
TYPHUs),  or  it  may  be  a  late  event.  Hypostatic  congestion  and  the  con- 
dition of  the  lung  spoken  of  as  splenization  are  very  common.  Gangrene 
of  the  lung  occurred  in  40  cases  in  the  Munich  series;  abscess  of  the  lung 
in  14;  haemorrhagic  infarction  in  129.  Pleurisy  is  not  a  very  common  event. 
Fibrinous  pleurisy  occurred  in  about  6  per  cent  of  the  Munich  cases,  and 
empyema  in  nearly  2  per  cent. 

Changes  in  the  Circulatory  System. — Heart  Lesions. — Endocarditis, 
while  not  a  common  complication,  is  probably  more  frequent  than  is  generally 
supposed.  It  was  present  without  being  suspected  in  three  out  of  101  autop- 
sies in  this  series,  while  in  three  other  cases  of  my  series  the  clinical  S5nnp- 
toms  suggested  its  presence.  The  typhoid  bacilli  have  been  found  in  the 
vegetations.  Pericarditis  was  present  in  14  cases  of  the  Munich  autopsies. 
Myocarditis  is  not  very  infrequent.  In  protracted  cases  the  muscle-fibre  is 
usually  soft,  flabby,  and  of  a  pale  yellowish-brown  color.  The  softening  may 
be  extreme,  though  rarely  of  the  grade  described  by  Stokes  in  typhus  fever, 
in  which,  when  held  apex  up  by  the  vessels,  the  organ  collapsed  over  the  hand, 
forming  a  mushroom-like  cap.  Microscopically,  the  fibres  may  show  little 
or  no  change,  even  when  the  impulse  of  the  heart  has  been  extremely  feeble. 
A  granular  parenchymatous  degeneration  is  common.  Fatty  degeneration 
may  be  present,  particularly  in  long-standing  cases  with  ansemia.  The 
hyaline  change  is  not  common.  The  segmenting  myocarditis,  in  which  the 
.  cement  substance  is  softened  so  that  the  muscles  separate,  has  also  been 
found,  but  probably  as  a  post-mortem  change. 

Lesions  of  the  Blood-vessels. — Changes  in  the  arteries  are  not  infrequent. 
In  21  of  52  cases  in  our  series,  in  which  there  were  notes  on  the  state  of  the 
aorta,  fresh  endarteritis  was  present,  and  in  13  of  62  cases  in  which  the  condi- 
tion of  the  coronary  arteries  was  noted  similar  changes  were  found  (Thayer). 
Arteritis  of  a  peripheral  vessel  with  thrombus  formation  is  not  uncom- 
mon. Bacilli  have  been  found  in  the  thrombi.  The  artery  may  be  blocked 
by  a  thrombus  of  cardiac  origin — an  embolus — but  in  the  great  majority  of 
instances  they  are  autochthonous  and  due  to  arteritis,  obliterating  or  partial. 
Thrombosis  in  the  veins  is  very  much  more  frequent  than  in  the  arteries,  but 
is  not  such  a  serious  event.  It  is  most  frequent  in  the  femoral,  and  in  the 
left  more  often  than  the  right.  The  consequences  are  fully  considered  under 
the  symptoms. 

ISTervgus  System. — There  are  very  few  obvious  changes  met  with.  Men- 
ingitis is  extremely  rare.  It  occurred  in  only  11  of  the  2,000  Munich  cases. 
The  exudation  may  be  either  serous,  sero-fibrinous,  or  purulent,  and  typhoid 
bacilli  have  been  isolated.  Five  cases  of  serous  and  one  of  purulent  menin- 
gitis occurred  in  our  series  (Cole).  Optic  neuritis,  which  occurs  sometimes 
in  typhoid  fever,  has  not,  so  far  as  I  know,  been  described  in  connection  with 


70  SPECIFIC  INFECTIOUS  DISEASES. 

the  meningitis.  The  anatomical  lesion  of  the  aphasia — seen  not  infrequently 
in  children — is  not  known,  possibly  it  is  an  encephalitis.  Parenchymatous 
changes  have  been  met  with  in  the  peripheral  nerves,  and  appear  to  be  not 
very  uncommon,  even  when  there  have  been  no  symptoms  of  neuritis. 

The  voluntary  muscles  show,  in  certain  instances,  the  changes  described 
by  Zenker,  which  occur,  however,  in  all  long-standing  febrile  affections,  and 
are  not  peculiar  to  typhoid  fever.  The  muscle  substance  within  the  sarco- 
lemma  undergoes  either  a  granular  degeneration  or  a  hyaline  transformation. 
The  abdominal  muscles,  the  adductors  of  the  thighs,  and  the  pectorals  are 
most  commonly  involved.  Eupture  of  a  rectus  abdominis  has  been  found 
post  mortem.  Hemorrhage  may  occur.  Abscesses  ma}^  develop  in  the  mus- 
cles during  convalescence. 

Symptoms. — In  a  disease  so  complex  as  typhoid  fever  it  will  be  well  first 
to  give  a  general  description,  and  then  to  study  more  fully  the  symptoms, 
complications,  and  sequelae  according  to  the  individual  organs. 

General  Desceiption. — The  period  of  incubation  lasts  from  ''  eight  to 
fourteen  days,  sometimes  twenty- three "  (Clinical  Society),  during  which 
there  are  feelings  of  lassitude  and  inaptitude  for  work.  The  onset  is  rarely 
abrupt.  In  the  1,500  cases  there  occurred  at  onset  chills  in  334,  headache  in 
1,117,  anorexia  in  825,  diarrhoea  (without  purgation)  in  516,  epistaxis  in 
323,  abdominal  pain  in  443,  constipation  in  349,  pain  in  right  iliac  fossa 
in  10.  The  patient  at  last  takes  to  his  bed,  from  which  event,  in  a-  majority 
of  cases,  the  definite  onset  of  the  disease  may  be  dated.  During  the  first 
week  there  is,  in  some  cases  (but  by  no  means  in  all,  as  has  long  been  taught), 
a  steady  rise  in  the  fever,  the  evening  record  rising  a  degree  or  a  degree  and 
a  half  higher  each  day,  reaching  103°  or  104°.  The  pulse  is  rapid,  from  100 
to  110,  full  in  volume,  but  of  low  tension  and  often  dicrotic;  the  tongue  is 
coated  and  white;  the  abdomen  is  slightly  distended  and  tender.  Unless  the 
fever  is  high  there  is  no  delirium,  but  the  patient  complains  of  headache,  and 
there  may  be  mental  confusion  and  wandering  at  night.  The  bowels  may  be 
constipated,  or  there  may  be  two  or  three  loose  movements  daily.  Toward 
the  end  of  the  week  the  spleen  becomes  enlarged  and  the  rash  appears  in  the 
form  of  rose-colored  spots,  seen  first  on  the  skin  of  the  abdomen.  Cough  and 
bronchitic  symptoms  are  not  uncommon  at  the  outset. 

In  the  second  week,  in  cases  of  moderate  severity,  the  symptoms  become 
aggravated;  the  fever  remains  high  and  the  morning  remission  is  slight. 
The  pulse  is  rapid  and  loses  its  dicrotic  character.  There  is  no  longer  head- 
ache, but  there  are  mental  torpor  and  dulness.  The  face  looks  heavy;  the 
lips  are  dry;  the  tongue,  in  severe  cases,  becomes  dry  also.  The  abdominal 
symptoms,  if  present — diarrhoea,  tympanites,  and  tenderness — ^become  aggra- 
vated. Death  may  occur  during  this  week,  with  pronounced  nervous  symp- 
toms, or,  toward  the  end  of  it,  from  haemorrhage  or  perforation.  In  mild 
cases  the  temperature  declines,  and  by  the  fourteenth  day  may  be  normal. 

In  the  third  week,  in  cases  of  moderate  severity,  the  pulse  ranges  from 
110  to  130;  the  temperature  now  shows  marked  morning  remissions,  and 
there  is  a  gradual  decline  in  the  fever.  The  loss  of  flesh  is  now  more  notice- 
able, and  the  weakness  is  pronounced.  Diarrhoea  and  meteorism  may  now 
occur  for  the  first  time.  Unfavorable  symptoms  at  this  stage  are  the  pul- 
monary complications,  increasing  feebleness  of  the  heart,  and  pronounced 


TYPHOID  FEVER,-  71 

delirium  with  muscular  tremor.  Special  dangers  are  perforation  and  haem- 
orrhage. 

With  the  fourth  week,  in  a  majority  of  instances,  convalescence  begins. 
The  temperature  gradually  reaches  the  normal  point,  the  diarrhoea  stops, 
the  tongue  cleans,  and  the  desire  for  food  returns.  In  severe  cases  the  fourth 
and  even  the  fifth  week  may  present  an  aggravated  picture  of  the  third ;  the 
patient  grows  weaker,  the  pulse  is  more  rapid  and  feeble,  the  tongue  dry,  and 
the  abdomen  distended.  He  lies  in  a  condition  of  profound  stupor,  with  low 
muttering  delirium  and  subsultus  tendinum,  and  passes  the  fseces  and  urine 
involuntarily.  Heart-failure  and  secondary  complications  are  the  chief  dan- 
gers of  this  period. 

In  the  fifth  and  sixth  weeks  protracted  cases  may  still  show  irregular 
fever,  and  convalescence  may  not  set  in  until  after  the  fortieth  day.  In  this 
period  we  meet  with  relapses  in  the  milder  forms  or  slight  recrudescence  of 
the  fever.     At  this  time,  too,  occur  many  of  the  complications  and  sequelae. 

Special  Features  and  Symptoms. — Mode  of  Onset. — As  a  rule,  the 
symptoms  come  on  insidiously,  and  the  patient  is  unable  to  fix  definitely 
the  time  at  which  he  began  to  feel  ill.  The  following  are  the  most  important 
deviations  from  this  common  course : 

(a)  Onset  with  Pronounced,  sometimes  Sudden,  Nervous  Manifestations. 
— Headache,  of  a  severe  and  intractable  nature,  is  by  no  means  an  infrequent 
initial  symptom.  Again,  a  severe  facial  neuralgia  may  for  a  few  days  put 
the  practitioner  off  his  guard.  In  cases  in  which  the  patients  have  kept  about 
and,  as  they  say,  fought  the  disease,  the  very  first  manifestation  may  be  pro- 
nounced delirium.  Such  patients  may  even  leave  home  and  wander  about 
for  days.  In  rare  cases  the  disease  sets  in  with  the  most  intense  cerebro- 
spinal symptoms,  simulating  meningitis — severe  headache,  photophobia,  re- 
traction of  the  head,  twitching  of  the  muscles,  and  even  convulsions.  Occa- 
sionally drowsiness,  stupor,  and  signs  of  basilar  meningitis  may  exist  for  ten 
days  or  more  before  the  characteristic  symptoms  develop;  the  onset  may  be 
with  mania. 

(&)  With  Pronounced  Pulmonary  Symptoms. — The  initial  bronchial 
catarrh  may  be  of  great  severity  and  obscure  the  other  features  of  the  disease. 
More  striking  still  are  those  cases  in  which  the  disease  sets  in  with  a  single 
chill,  with  pain  in  the  side  and  all  the  characteristic  features  of  lobar  pneu- 
monia, or  of  acute  pleurisy;  or  tuberculosis  is  suspected. 

(c)  With  Intense  Gastro-intestinal  Symptoms. — The  incessant  vomiting 
and  pain  may  lead  to  a  suspicion  of  poisoning,  or  the  case  may  be  sent  to 
the  surgical  wards  for  appendicitis. 

(d)  With  symptoms  of  an  acute  nephritis,  smoky  or  bloody  urine,  with 
much  albumin  and  tube-casts. 

(e)  Ambulatory  Form. — Deserving  of  especial  mention  are  those  cases 
of  typhoid  fever  in  which  the  patient  keeps  about  and  attempts  to  do  work, 
or  perhaps  takes  a  long  journey  to  his  home.  He  may  come  under  observa- 
tion for  the  first  time  with  a  temperature  of  104°  or  105°,  and  with  the  rash 
well  out.  Many  of  these  cases  run  a  severe  course,  and  in  general  hospitals 
they  contribute  largely  to  the  total  mortality.  Finally,  there  are  rare  in- 
stances in  which  typhoid  is  unsuspected  until  perforation,  or  a  profuse  haem- 
orrhage from  the  bowels  occurs. 


72  SPECIFIC  INFECTIOUS  DISEASES.- 

Facial  Aspect, — Early  in  the  disease  the  cheeks  are  flushed  and  the  eyes 
bright.  Toward  the  end  of  the  first  week  the  expression  becomes  more  list- 
less, and  when  the  disease  is  well  established  the  patient  has  a  dull  and  heavy 
look.  There  is  never  the  rapid  anaemia  of  malarial  fever,  and  the  color  of  the 
lips  and  cheeks  may  be  retained  even  to  the  third  week. 

Fever. —  (a)  Regular  Course.  (Chart  II.) — In  the  stage  of  invasion  the 
fever  rises  steadily  during  the  first  five  or  six  days.  The  evening  temperature 
is  about  a  degree  or  a  degree  and  a  half  higher  than  the  morning  remission, 
so  that  a  temperature  of  104°  or  105°  is  not  uncommon  by  the  end  of  the  first 
week.  Having  reached  the  fastigium  or  height,  the  fever  then  persists  with 
very  slight  daily  remissions.  The  fever  may  be  singularly  persistent  and 
but  little  influenced  by  bathing  or  other  measures.  At  the  end  of  the  second 
and  throughout  the  third  week  the  temperature  becomes  more  distinctly  remit- 
tent. The  difference  between  the  morning  or  evening  record  may  be  3°  or  4°, 
and  the  morning  temperature  may  even  be  normal.  It  falls  by  lysis,  and  the 
temperature  is  not  considered  normal  until  the  evening  record  is  at  98.2°. 

(6)  Variations  from  the  typical  temperature  curve  are  common.  We  do 
not  always  see  the  gradual  step-like  ascent  in  the  early  stage;  the  cases  do 
not  often  come  under  observation  at  this  time.  When  the  disease  sets  in 
with  a  chill,  or  in  children  with  a  convulsion,  the  temperature  may  rise  at 
once  to  103°  or  104°.  In  many  cases  defervescence  occurs  at  the  end  of  the 
second  week  and  the  temperature  may  fall  rapidly,  reaching  the  normal 
within  twelve  or  twenty  hours.  An  inverse  type  of  temperature,  high  in  the 
morning  and  low  in  the  evening,  is  occasionally  seen  but  has  no  especial 
significance. 

Sudden  falls  in  the  temperature  may  occur;  thus,  as  shown  in  Chart  IV, 
a  drop  of  6.4°  may  follow  an  intestinal  haemorrhage,  and  the  fall  may  be  very 
apparent  even  before  the  blood  has  appeared  in  the  stools.  Sometimes  dur- 
ing the  anaemia  which  follows  a  severe  hemorrhage  from  the  bowels  there  are 
remarkable  oscillations  in  the  temperature.  Hyperpyrexia  is  rare.  In  only 
58  of  1,500  cases  did  the  fever  rise  above  106°.  Before  death  the  fever  may 
rise;  the  highest  I  have  known  was  109.5°. 

(c)  Post-typhoid  Variations.  (1)  Recrudescences. — After  a  normal  tem- 
perature of  perhaps  five  or  six  days,  the  fever  may  rise  suddenly  to  102°  or 
103°,  without  constitutional  disturbance,  furring  of  the  tongue,  or  abdomi- 
nal symptoms.  After  persisting  for  from  two  to  four  days  the  tempera- 
ture falls.  Of  1,500  cases,  92  presented  these  post-typhoid  elevations,  brief 
notes  of  which  are  given  in  the  Studies  on  Typhoid  Fever.  Constipation, 
errors  in  diet,  or  excitement  may  cause  them.  These  attacks  are  a  frequent 
source  of  anxiety  to  the  practitioner.  They  are  very  common,  and  it  is  not 
always  possible  to  say  upon  what  they  depend.  As  a  rule,  if  the  rise  in  tem- 
perature is  the  result  of  the  onset  of  a  complication,  such  as  pleurisy  or 
thrombosis,  there  is  an  increase  in  the  leucocytes.  Naturally  one  suspects 
at  the  outset  a  relapse,  but  there  is  an  absence  of  the  step-like  ascent,  and 
as  a  rule  the  fever  falls  afte*-  lasting  a  few  days. 

(2)  The  Suh-fehrile  Stage  of  Convalescence. — In  children,  in  very  nerv- 
ous patients,  and  in  cases  with  anaemia,  the  evening  temperature  may  keep 
up  for  weeks  after  the  tongue  has  cleaned  and  the  appetite  has  returned. 
This  may  usually  be  disregarded,  and  is  often  best  treated  by  allowing  the 


TYPHOID  FEVER. 


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74  SPECIFIC  INFECTIOUS  DISEASES. 

patient  to  get  up,  and  by  stopping  the  use  of  the  thermometer.  Of  course 
it  is  important  not  to  overlook  any  latent  complications. 

(3)  Hypothermia. — Low  temperatures  in  typhoid  fever  are  common, 
following  the  tubs,  or  spontaneously  in  the  third  and  fourth  week  in  the 
periods  of  marked  remissions,  and  following  haemorrhage.  An  interesting 
form  i€  the  persistent  hypothermia  of  convalescence.  For  ten  days  or  more, 
particularly  in  the  protracted  cases  with  great  emaciation,  the  temperature 
may  be  96.5°  or  97°.     It  is  of  no  special  significance. 

{d)  The  Fever  of  the  Relapse. — This  is  a  repetition  in  many  instances 
of  the  original  fever,  a  gradual  ascent  and  maintenance  for  a  few  days  at 
a  certain  height  and  then  a  gradual  decline.  It  is  shorter  than  the  original 
pjTexia,  and  rarely  continues  more  than  two  or  three  weeks.      (Chart  II.) 

(e)  Afebrile  Typhoid. — There  are  cases  described  in  which  the  chief  fea- 
tures of  the  disease  have  been  present  without  the  existence  of  fever.  They 
are  extremely  rare  in  this  country.  I  have  seen  a  case,  afebrile  at  the  thir- 
teenth day,  and  in  which  the  rose  spots  and  other  features  persisted  till  the 
twenty-eighth  day. 

(/)  Chills  occur  (a)  sometimes  with  the  fever  of  onset;  (&)  occasion- 
ally at  intervals  throughout  the  course  of  the  disease,  and  followed  by  sweats 
(so-called  sudoral  form)  ;  (c)  with  the  advent  of  complications,  pleurisy, 
pneumonia,  otitis  media,  periostitis,  etc.;  (d)  with  active  antipyretic  treat- 
ment by  the  coal-tar  remedies;  (e)  occasionally  during  the  period  of  defer- 
vescence without  relation  to  any  complication  or  sequel,  probably  due  to  a 
septic  infection;  (/)  according  to  Herringham,  chills  may  result  from  con- 
stipation. There  are  cases  in  which  throughout  the  latter  half  of  the  disease 
chills  recur  with  great  severity.     (See  Chills  in  Typhoid  Fever,  Studies  II.) 

Skin. — The  characteristic  rash  of  the  disease  consists  of  hj^ersemic  spots, 
which  appear  from  the  seventh  to  the  tenth  day,  usually  at  first  upon  the 
abdomen.  They  are  slightly  raised,  flattened  papules,  which  can  be  felt  dis- 
tinctly by  the  finger,  of  a  rose-red  color,  disappearing  on  pressure,  and  rang- 
ing in  diameter  from  2  to  4  mm.  They  were  present  in  93.3  per  cent  of  the 
white  patients  and  20.6  per  cent  of  the  colored.  They  come  out  in  successive 
crops,  and  after  persisting  for  two  or  three  days  they  disappear,  occasionally 
leaving  a  brownish  stain.  The  spots  may  be  present  upon  the  back,  and  not 
upon  the  abdomen.  The  eruption  may  be  very  abundant  over  the  whole  skin 
of  the  trunk,  and  on  the  extremities.  There  were  81  in  which  they  occurred 
on  the  arms,  IT  on  the  forearms,  43  on  the  thighs,  legs  15,  face  5,  hands  3. 
The  cases  with  very  abundant  eruption  are  not  necessarily  more  severe.  As 
already  noted,  the  t}^hoid  bacilli  have  been  found  in  the  spots.  Of  variations 
in  the  rash,  frequently  the  spots  are  capped  by  small  vesicles.  Cases  that 
have  not  been  carefully  sponged  ma}'  show  sweat  vesicles,  either  miliary  or 
sudaminal.  In  38  cases  in  my  series  there  were  purpuric  spots.  Three  of 
the  cases  were  true  hsemorrhagic  typhoid  fever.  The  rash  may  not  appear 
until  the  relapse.  In  21  cases  in  our  series  the  rose  spots  came  out  after  the 
patient  was  afebrile. 

A  branny  desquamation  is  not  rare  in  children,  and  common  in  adults 
after  hydrotherapy.     Occasionally  the  skin  peels  off  in  large  flakes. 

Among  other  skin  lesions  in  typhoid  fever  the  following  may  be  men- 
tioned : 


TYPHOID  FEVER.  75 

Erythema. — It  is  not  very  uncommon  in  the  first  week  of  the  disease  to 
find  a  diffuse  erythematous  blush — E.  typhosum.  Formerly  we  thought  this 
might  be  due  to  quinine. 

The  tache  cerebrale,  a  red  line  with  white  borders,  is  readily  produced 
by  drawing  the  nail  over  the  skin,  a  vaso-motor  phenomenon  of  no  special  sig- 
nificance. Sometimes  the  skin  may  have  a  peculiar  mottled  pink  and  white 
appearance.     E.  exudativum,  E.  nodosum,  and  urticaria  may  be  present. 

Herpes. — Herpes  is  certainly  rare  in  typhoid  fever  in  comparison  with 
its  great  frequency  in  malarial  fever  and  in  pneumonia.  It  was  noted  in 
20  of  our  1,500  cases,  usually  on  the  lips. 

The  taches  hleudtres — Peliomata — Maculce  cerulce. — These  are  pale-blue 
or  steel-gray  spots,  subcuticular,  fxom  4  to  10  mm.  in  diameter,  of  irregu- 
lar outline  and  most  abundant  about  the  chest,  abdomen,  and  thighs.  They 
sometimes  give  a  very  striking  appearance  to  the  skin.  They  are  due  to  lice 
(see  Pediculosis). 

STcin  Gangrene. — In  children  noma  may  occur;  as  reported  by  McFarland 
in  the  Philadelphia  epidemic  of  1898  there  were  many  cases  with  multiple 
areas  of  gangrene  of  the  skin.    The  nose,  ears,  and  genitals  may  be  attacked. 

Sweats. — At  the  height  of  the  fever  the  skin  is  usually  dry.  Profuse 
sweating  is  rare,  but  it  is  not  very  uncommon  to  see  the  abdomen  or  chest 
moist  with  perspiration,  particularly  in  the  reaction  which  follows  the  bath. 
Sweats  in  some  instances  constitute  a  striking  feature  of  the  disease.  They 
may  occasionally  be  associated  with  chilly  sensations  or  actual  chills.  Jac- 
coud  and  others  in  France  have  especially  described  this  sudoral  form  of 
typhoid  fever.  There  may  be  recurring  paroxysms  of  chill,  fever,  and  sweats 
(even  several  in  twenty-four  hours),  and  the  case  may  be  mistaken  for  one 
of  intermittent  fever.  The  fever  toward  the  end  of  the  second  week  and 
during  the  third  week  may  be  intermittent.  The  characteristic  rash  is  usu- 
ally present,  and,  if  absent,  the  negative  condition  of  the  blood  is  sufficient 
to  exclude  malaria.  The  sweating  may  occur  chiefly  in  the  third  and  fourth 
weeks. 

(Edema  of  the  skin  occurs:  1,  As  the  result  of  vascular  obstruction,  most 
commonly  of  a  vein,  as  in  thrombosis  of  the  femoral  vein.  2.  In  connection 
with  nephritis,  very  rarely.  3.  In  association  with  the  anaemia  and  cachexia. 
A  yellow  color  of  the  palms  of  the  hands  and  of  the  soles  of  the  feet  is  not 
uncommon.  The  hair  falls  out  after  the  attack,  but  complete  baldness  is  rare. 
I  have  once  seen  permanent  baldness.  The  nutrition  of  the  nails  suffers,  and 
during  and  after  convalescence  transverse  ridges  may  occur.  A  peculiar  odor 
is  exhaled  from  the  skin  in  some  cases.  Whether  due  to  a  cutaneous  exhala- 
tion or  not,  there  certainly  is  a  very  distinctive  smell  connected  with  many 
patients.  Nathan  Smith  describes  it  as  of  a  "  semi-cadaverous,  musty  char- 
acter." 

LinecB  atrophicce. — Lines  of  atrophy  may  appear  on  the  skin  of  the  abdo- 
men and  lateral  aspects  of  the  thighs,  similar  to  those  seen  after  pregnancy. 
They  have  been  attributed  to  neuritis,  and  Duckworth  has  reported  a  case 
in  which  the  skin  adjacent  to  them  was  hyperaesthetic. 

Bed-sores  are  not  uncommon  in  protracted  cases,  with  great  emaciation. 
As  a  rule,  they  result  from  pressure  and  are  seen  upon  the  sacrum,  more 
rarely  the  ilia,  the  shoulders,  and  the  heels.    These  are  less  common,  I  think. 


76  SPECIFIC  INFECTIOUS  DISEASES. 

since  the  introduction  of  hydrotherapy.  Scmpulous  care  and  watchftiliies& 
do  much  for  their  prevention,  but  it  is  to  be  remembered  that  in  cases  with 
profound  involvement  of  the  nerve  centres  acute  bed-sores  of  the  back  and 
heels  may  occur  with  very  slight  pressure,  and  with  astonishing  rapidity. 

Boils  constitute  a  common  and  troublesome  sequel  of  the  disease.  They 
appear  to  be  more  frequent  after  hydrotherapy. 

Circulatory  System. — The  hJood  presents  important  changes.  The  fol- 
lowing statements  are  based  on  studies  which  W.  S.  Thayer  has  made  in 
my  wards  (Studies  I  and  III)  :  During  the  first  two  weeks  there  may  be 
little  or  no  change  in  the  blood.  Profuse  sweats  or  copious  diarrhoea  may, 
as  Hayem  has  shown,  cause  the  corpuscles — as  in  the  collapse  stage  of  cholera. 
— ^to  rise  above  normal.  In  the  third  week  a  fall  usually  takes  place  in  cor- 
puscles and  hemoglobin,  and  the  number  may  sink  rapidly  even  to  1,300,000 
per  c.  mm.,  gradually  rising  to  normal  during  convalescence.  When  the- 
patient  first  gets  up,  there  may  be  a  slight  fall  in  the  number  of  corpuscles. 
The  average  maximum  loss  is  about  1,000,000  to  the  c.  mm. 

The  amount  of  hagmoglobin  is  always  reduced,  and  usually  in  a  greater 
relative  proportion  than  the  number  of  red  corpuscles,  and  during  recov- 
ery the  normal  color  standard  is  reached  at  a  later  period.  Leucopenia — 
hypoleucocytosis — is  present  throughout  the  course.  Cold  baths  increase 
temporarily  the  number  of  leucocytes  in  the  peripheral  circulation.  The 
absence  of  leucoc}i:osis  may  be  at  times  of  real  diagnostic  value  in  distinguish- 
ing typhoid  fever  from  various  septic  fevers  and  acute  inflammatory  processes. 
The  polymorphonuclear  leucoc}i;es  are  normal  in  number,  while  the  lympho- 
cytes are  relatively  increased.  When  an  acute  inflammatory  process  occurs  in 
typhoid  fever  the  leucoc}i;es  show  an  increase  in  the  pol}Tiuclear  forms,  and 
this  may  be  of  great  diagnostic  moment. 

The  accompanying  blood-chart  shows  these  changes  well.      (Chart  III.) 

The  post-t}^hoid  anaemia  may  reach  an  extreme  grade.  In  one  of  my 
cases  the  blood-corpuscles  sank  to  1,300,000  per  e.  mm.  and  the  hsemoglobin 
to  about  20  per  cent.  These  severe  grades  of  anaemia  are  not  common  in 
my  experience.  In  the  Munich  statistics  there  were  54  cases  with  general 
and  extreme  anaemia. 

Of  changes  in  the  blood  plasma  very  little  is  known. 

The  pulse  in  typhoid  fever  presents  no  special  characters.  It  is  increased 
in  rapidity,  but  not  always  in  proportion  to  the  height  of  the  fever,  and  this 
may  be  a  very  special  feature  in  the  early  stages.  As  a  rule,  in  the  first  week 
it  is  above  100,  full  in  volume  and  often  dicrotic.  There  is  no  acute  disease 
with  which,  in  the  early  stage,  a  dicrotic  pulse  is  so  frequently  associated. 
Even  with  high  fever  the  pulse  may  not  be  greatly  accelerated.  As  the  dis- 
ease progresses  the  pulse  becomes  more  rapid,  feebler,  and  small.  In  6  per 
cent  of  our  cases  the  pulse  rate  rose  above  140  (Thayer).  In  the  extreme 
prostration  of  severe  cases  it  may  reach  150  or  more,  and  is  a  mere  undula- 
tion— ^the  so-called  running  pulse.  The  lowered  arterial  pressure  is  mani- 
fest in  the  dusky  lividity  of  the  skin  and  coldness  of  the  hands  and  feet. 

During  convalescence  the  pulse  gradually  returns  to  normal,  and  occa- 
sionally becomes  very  slow.  Aiter  no  other  acute  fever  do  we  so  frequently 
meet  with  bradycardia.  I  have  counted  the  pulse  as  low  as  30,  and  in- 
stances are  on  record  of  still  fewer  beats  to  the  minute.     Tachycardia,  while 


TYPHOID  FEVER. 


11 


less  common,   may  be  a  very  troublesome   and  persistent  feature  of  con- 
valescence. 

Blood  Pressure. — This  is  usually  from  115-125  m.  m.  Hg.  (Riva-Eocci 
instrument)  in  systole.  The  diastolic  pressure  has  the  normal  relationship 
to  the  systolic,  and  averages  85-100  m.  m.  Hg.  There  is  a  gradual  fall  during 
the  course  to  about  100-110  m.  m.  Hg.  at  the  beginning  of  apyrexia.     In  two 


5,000,000 

DEC  ,  1890 

JANUARY,  .189.1 

FEBRUARY. 

MARCH                   1 

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27 

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23 

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MEAN  NORM. 
NUMBER  OF 

WHITE 
CORPUSCLES 


BLACK,  RED  CORPUSCLESi 


REDjHAEMOaLOBiri. 

Chart  III. 


BLUE,  COLORLESS  CORPUSCLES. 


or  three  weeks  later  the  pressure  has  usually  returned  to  normal.  Haemor- 
rhage usually  produces  a  marked  fall  both  in  the  systolic  and  diastolic  pres- 
sure. In  some  cases  of  perforation  there  is  a  sharp  rise  in  systolic  pressure. 
Tubs  and  ice  sponges  usually  cause  a  rise  of  10-20  m.  m.  Hg. 

The  heart-sounds  may  be  normal  throughout  the  course.  In  severe  cases, 
the  first  sound  becomes  feeble  and  there  is  often  to  be  heard,  at  the  apex  and 
-along  the  left  sternal  margin,  a  soft  systolic  murmur,  which  was  present  in 


78  SPECIFIC  INFECTIOUS  DISEASES. 

22  per  cent  of  our  cases.  Absence  of  the  first  sound  is  rare.  Gallop  rhythm 
is  not  uncommon.  In  the  extreme  feebleness  of  the  graver  forms,  the  first 
and  second  sound  become  very  similar^  and  the  long  pause  is  much  shortened 
(embryocardia). 

Of  cardiac  complications,  pericarditis  is  rare  and  has  been  met  with 
chiefly  in  children  and  in  association  with  pneumonia.  It  was  present  in 
three  of  my  series  and  occurred  in  only  14  of  the  2,000  Munich  post  mortems. 
Endocarditis  was  found  post  mortem  in  three  cases,  and  the  ph^^sical  signs 
suggested  its  presence  in  three  other  cases  in  the  series.  Myocarditis  is  more 
common,  and  is  indicated  by  a  progressive  weakening  of  the  heart-sound  and 
enfeeblement  of  the  action  of  the  organ. 

Complications  in  the  Arteries. — Arteritis  with  thrombus  formation  oc- 
curred in  four  cases  in  the  series,  one  in  the  branches  of  the  middle  cerebral, 
two  in  the  femoral,  and  one  in  the  brachial.  In  one  case  gangrene  of  the 
leg  followed.  I  saw  a  similar  case  with  Eoddick,  in  Montreal,  in  which 
obliteration  of  the  left  femoral  artery  occurred  on  the  sixteenth  day,  and  of 
the  vessel  on  the  right  side  on  the  twentieth  day,  with  gangrene  of  both  feet. 
Pain,  tenderness,  and  swelling  occur  over  the  artery,  with  diminution  of  dis- 
appearance of  the  pulsations  and  coldness  and  blueness  of  the  extremity. 
In  two  of  the  cases  these  s}Tnptoms  gradually  disappeared,  and  the  pulsation 
returned  not  only  in  the  peripheral,  but  in  the  affected  vessels  (Thayer). 
Keen  refers  to  46  cases  of  arterial  gangrene,  of  which  8  were  bilateral,  19  on 
the  right  side,  and  19  on  the  left. 

Tlirombi  in  the  Veins. — In  our  series  there  were  41  instances,  distributed 
in  the  following  veins :  femoral  23,  popliteal  5,  iliac  5,  veins  of  the  calf  5, 
internal  saphenous  3,  pulmonary  artery  alone  1,  pulmonary  artery  and  com- 
mon iliac  1,  axillary  vein  1  (Thayer).  I  saw  one  case  in  the  right  circum- 
flex iliac  vein.  Femoral  thrombosis  is  the  most  common,  and  almost  inva- 
riably in  the  left  vessel,  due,  as  Liebermeister  suggests,  to  the  fact  that  the 
left  iliac  vein  is  crossed  by  the  right  iliac  artery,  and  the  blood  flow  is  not 
so  free.  The  symptoms  of  this  complication  are  very  definite — ^the  fever  may 
increase  or  recur.  Chills  occurred  in  11  of  all  the  cases.  Pain  and  swelling 
at  the  site  are  constanth'  present,  and  the  thrombotic  mass  can  be  felt,  not 
always  at  first,  nor  is  it  well  to  feel  for  it.  Swelling  of  the  leg  follows  as  a 
rule,  but  it  is  rarely  so  extreme,  and  never,  I  think,  so  painful  as  the  puer- 
peral phlegmasia  alba  dolens.  In  the  iliac  thrombosis  the  pain  may  be  severe 
and  lead  to  the  suspicion  of  perforation,  as  in  one  of  our  cases.  Leucoc}^- 
tosis  is  usually  present,  in  12  cases  it  rose  above  10,000.  Five  of  the  39  cases 
died,  2  only  as  a  result  of  the  thrombus;  in  the  case  of  axillary  thrombosis 
from  pulmonary  embolism,  in  one  embolism  of  the  inferior  cava  and  right 
auricle  from  the  dislocation  of  a  piece  of  thrombus  from  the  left  iliac  vein. 
Thayer  examined  16  of  the  patients  at  varying  periods  after  convalescence, 
and  found  in  every  case  more  or  less  disability  from  the  varices  and  persist- 
ent swelling.    In  some  cases,  however,  the  recovery  is  complete. 

Digestive  System. — Loss  of  appetite  is  early,  and,  as  a  rule,  the  relish 
for  food  is  not  regained  until  convalescence.  Thirst  is  constant,  and  should 
be  fully  and  freely  gratified.  Even  when  the  mind  becomes  benumbed  and 
the  patient  no  longer  asks  for  water,  it  should  be  freely  given.  The  tongue 
presents  the  changes  inevitable  in  a  prolonged  fever.     Early  in  the  disease 


TYPHOID  FEVER.  79 

it  is  moist,  swollen,  and  coated  with  a  thin  white  fur,  which,  as  the  fever 
progresses,  becomes  denser.  It  may  remain  moist  throughout.  It  is  small 
in  size  and  tends  to  be  red  at  the  edges  and  tip.  In  severe  cases,  particu- 
larly those  with  delirium,  the  tongue  becomes  very  dry,  partly  owing  to  the 
fact  that  such  patients  breathe  with  the  mouth  open.  It  may  be  covered 
with  a  brown  or  brownish-black  fur,  or  with  crusts  between  which  are  cracks 
and  fissures.  Acute  glossitis  occurred  in  one  case  at  the  onset  of  the  relapse'. 
In  these  cases  the  teeth  and  lips  may  be  covered  with  a  dark  brownish  matter 
called  sordes — a  mixture  of  food,  epithelial  debris,  and  micro-organisms.  By 
keeping  the  mouth  and  tongue  clean  from  the  outset  the  fissures,  which  are 
extremely  painful,  may  be  prevented.  During  convalescence  the  tongue  grad- 
ually becomes  clean,  and  the  fur  is  thrown  off,  almost  imperceptibly  or  occa- 
sionally in  fiakes. 

The  secretion  of  saliva  is  often  diminished;  salivation  is  rare. 

Parotitis  was  present  in  45  of  the  2,000  Munich  cases.  It  occurred  in 
14  cases  in  my  series;  of  these,  5  died.  It  is  most  frequent  in  the  third 
week  in  very  severe  cases.  Extensive  sloughing  may  follow  in  the  tissues 
of  the  neck.  Usually  unilateral,  and  in  a  majority  of  cases  going  on  to  sup- 
puration, it  is  regarded  as  a  very  fatal  complication,  but  recovery  has  fol- 
lowed in  eight  of  my  cases.  It  undoubtedly  may  arise  from  extension  of 
infiammation  along  Steno's  duct.  This  is  probably  not  so  serious  a  form 
as  when  it  arises  from  metastatic  inflammation.  In  four  cases  the  submax- 
illary glands  were  involved  alone,  in  one  a  cellulitis  of  the  neck  extended 
from  the  gland  and  proved  fatal.  Parotitis  may  occur  after  the  fever  has 
subsided.  A  remarkable  localized  sweating  in  the  parotid  region  is  an  occa- 
sional sequel  of  the  abscess. 

The  pharynx  may  be  the  seat  of  slight  catarrh.  Sometimes  the  fauces 
are  deeply  congested.  Membranous  pharyngitis,  a  serious  and  fatal  com- 
plication, may  come  on  in  the  third  week.  Difficulty  in  swallowing  may 
result  from  ulcers  of  the  oesophagus,  and  in  one  of  our  cases  stricture  fol- 
lowed.*    Thyroiditis  may  occur  with  abscess  formation. 

The  gastric  symptoms  are  extremely  variable.  Nausea  and  vomiting  are 
not  common.  There  are  instances,  however,  in  which  vomiting,  resisting  all 
measures,  is  a  marked  feature  from  the  outset,  and  may  directly  cause  death 
from  exhaustion.  Vomiting  does  not  often  occur  in  the  second  and  third 
weeks,  unless  associated  with  some  serious  complication.  Ulcers  have  been 
found  in  the  stomach.     Hsematemesis  occurred  in  4  of  our  cases. 

Intestinal  Symptoms. — Diarrhoea  is  a  very  variable  symptom,  occurring 
in  from  20  to  30  per  cent  of  the  cases.  Of  1,500  cases,  516  had  diarrhoea  before 
entering,  260  during  their  stay  in  hospital.  The  small  percentage  may  be 
due  to  the  fact  that  we  use  no  purges  or  intestinal  antiseptics.  Its  absence 
must  not  be  taken  as  an  indication  that  the  intestinal  lesions  are  of  slight 
extent.  I  have  seen,  on  several  occasions,  the  most  extensive  infiltration  and 
ulceration  of  the  Peyer's  glands  of  the  small  intestine,  with  the  colon  filled 
with  solid  faeces.  The  diarrhoea  is  caused  less  by  the  ulcers  than  by  the  asso- 
ciated catarrh,  and,  as  in  tuberculosis,  it  is  probable  that  when  this  is  in  the 
large  intestine  the  discharges  are  more  frequent.     It  is  most  common  toward 

*  Mitchell,  CEsophageal  Complications  in  Typhoid  Fever  (Studies  II). 


80  SPECIFIC  INFECTIOUS  DISEASES. 

the  end  of  the  first  and  throughout  the  second  week,  but  it  ma)^  not  occur 
until  the  third  or  even  the  fourth  week.  The  number  of  discharges  ranges 
from  3  to  8  or  10  in  the  twenty-four  hours.  They  are  usually  abundant, 
thin,  grayish-yellow,  granular,  of  the  consistency  and  appearance  of  pea-soup, 
and  resemble  very  much,  as  Addison  remarked,  the  normal  contents  of  the 
small  bowel.  The  reaction  is  alkaline  and  the  odor  ofEensive.  On  standing, 
the  discharges  separate  into  a  thin  serous  layer,  containing  albumin  and  salts, 
and  a  lower  stratum,  consisting  of  epithelial  dehris,  remnants  of  food,  and 
numerous  crystals  of  triple  phosphates.  Blood  may  be  in  small  amount,  and 
only  recognized  b}"  the  microscope.  Sloughs  of  the  Peyer's  glands  occur 
either  as  grayish-j^ellow  fragments  or  occasionally  as  ovoid  masses,  an  inch  or 
more  in  length,  in  which  portions  of  the  bowel  tissue  may  be  found.  The 
bacilli  are  not  found  in  the  stools  until  the  end  of  the  first  or  the  middle  of 
the  second  week.     Constipation  was  present  in  51  per  cent  of  the  cases. 

Hwmorrliage  from  the  bowels  is  a  serious  complication,  occurring  in  from 
3  to  5  per  cent  of  all  cases.  It  had  occurred  in  99  of  the  2,000  fatal  Munich 
cases.  In  1,500  cases  treated  in  my  wards,  haemorrhage  occurred  in  118,  and 
in  12  death  occurred  directly  from  the  haemorrhage.  It  was  present  in  3.77 
per  cent  of  Murchison's  1,564  cases.  There  may  be  only  a  slight  trace  of 
blood  in  the  stools,  but  too  often  it  is  a  profuse,  free  hgemorrhage,  which 
rapidly  proves  fatal.  It  occurs  most  commonly  between  the  end  of  the  second 
and  the  beginning  of  the  fourth  week,  the  time  of  the  separation  of  the 
sloughs.  Occasionally  it  results  simply  from  the  intense  hypersemia.  It  usu- 
ally comes  on  without  warning.  A  sensation  of  sinking  or  collapse  is  experi- 
enced by  the  patient,  the  temperature  falls,  and  may,  as  in  the  annexed  chart, 
drop  6°  or  7°  in  a  few  hours.  Fatal  collapse  may  supervene  before  the  blood 
appears  in  the  stool.  Haemorrhage  usually  occurs  in  cases  of  considerable 
severity.  Graves  and  Trousseau  held  that  it  was  not  a  very  dangerous  symp- 
tom, but  statistics  show  that  death  follows  in  from  30  to  50  per  cent  of 
the  cases. 

It  must  not  be  forgotten  that  melsna  may  also  be  part  of  a  general  heem- 
orrhagic  tendency  (to  be  referred  to  later),  in  which  case  it  is  associated  with 
petechias  and  h^ematuria.  There  may  be  a  special  family  predisposition  to 
intestinal  haemorrhages  in  typhoid  fever. 

Meteorism,  a  frequent  symptom,  is  not  serious  if  of  moderate  grade,  but 
when  excessive  is  usually  of  ill  omen.  Owing  to  defective  tone  in  the  walls, 
in  severe  cases  to  their  infiltration  with  serum,  gas  accumulates  in  the  small 
and  large  bowels,  particularly  in  the  latter.  Pushing  up  the  diaphragm,  it 
interferes  very  much  with  the  action  of  the  heart  and  lungs,  and  may  also 
favor  perforation.  Gurgling  in  the  right  iliac  fossa  exists  in  a  large  propor- 
tion of  all  the  cases,  and  indicates  simply  the  presence  of  gas  and  fluid  faeces 
in  the  colon  and  caecum. 

Atdominal  pain  and  tenderness  were  present  in  three-fifths  of  a  series 
of  500  cases  studied  with  special  reference  to  the  point  by  T.  McCrae.  In 
some  it  was  only  present  at  the  onset.  Pain  occurred  during  the  course  in 
about  one-third  of  the  cases.  This  is  due  in  some  instances  to  conditions' 
apart  from  the  bowel  lesions,  such  as  pleurisy,  distention  of  the  bladder,  and 
phlebitis.  It  may  be  associated  with  diarrhoea,  severe  constipation,  a  painful 
spleen,  or  acute  abdominal  complications.     Pain  occurs  with  some  cases  of 


TYPHOID  FEVER. 


81 


haemorrhage,  but  is  most  constantly  present  with  perforation.  In  a  large 
group  no  cause  could  be  found  for  the  pain,  and  if  other  symptoms  be  asso- 
ciated the  condition  may  lead  to  error  in  diagnosis.  Operation  for  appendi- 
citis has  been  performed  in  the  early  stage  of  typhoid  fever,  owino-  to  the 
combination  of  pain  in  the  right  iliac  fossa,  fever  and  constipation.  This 
has  happened  twice  at  the  Johns  Hopkins  Hospital, 


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Peepoeation. — From  one-fourth  to  one-third  of  the  deaths  are  due  to 
perforation,  and  as  there  were  35,379  deaths  from  typhoid  fever  in  the  United 
States  in  the  year  1900,  this  gives  between  9,000  and  13,000  deaths  from 
this  cause.  Watchful  care  on  the  part  of  the  physician  should  result  in  a 
saving  of  at  least  one-third  of  the  cases.     While  it  may  occur  as  early  as  the 


82  SPECIFIC  INFECTIOUS  DISEASES. 

first  week,  in  the  great  majority  it  is  at  the  height  of  the  disease  in  the  third 
week,  and  much  more  frequently  in  the  severe  cases,  particularly  those  asso- 
ciated with  tympanites  and  haemorrhage.  It  may  occur,  however,  in  very- 
mild  cases  and  with  great  suddenness,  when  the  patient  is  apparently  pro- 
gressing favorably. 

Symptoms  of  Perforation. — By  far  the  most  important  single  indication  is 
a  sudden,  sharp  pain  of  increasing  severity,  often  paroxysmal  in  character.  It 
is  rarely  absent,  except  in  the  small  group  of  cases  with  profound  toxaemia. 
The  situation  is  most  frequent  in  the  hypogastric  region  and  to  the  right  of 
the  middle  line.  Tenderness  on  pressure  is  present  in  the  great  majority  of 
cases,  usually  in  the  hypogastric  and  right  iliac  regions,  sometimes  diffuse; 
it  may  only  be  brought  out  on  deep  pressure.  As  LeConte  points  out,  when 
the  perforation  happens  to  be  in  contact  with  the  parietal  peritonaeum  the 
local  features  on  palpation  are  much  more  marked  than  when  the  perforated 
Tilcer  is  next  to  a  coil  or  to  the  mesentery.  There  may  be  early  irritability 
of  the  bladder,  with  frequent  micturition,  and  pain  extending  toward  the 
penis.  A  third  important  sign  is  muscle  rigidity,  increased  tension,  and 
spasm  on  any  attempt  to  palpate.  "With  the  onset  of  these  features  the 
patient  may  have  signs  of  shock — a  fall  in  temperature,  an  increase  in  the 
rapidity  of  the  pulse  and  respirations,  and  slight  sweating.  Following  these 
features  in  a  few  hours  there  is  usually  a  reaction,  and  then  the  features  of 
general  peritonitis  become  manifest  to  a  more  or  less  marked  degree.  Among 
the  general  features,  the  fades  of  the  patient  shows  changes;  there  is  in- 
creased pallor,  a  pinched  expression  of  the  face,  and  as  the  symptoms  pro- 
gress and  toward  the  end  a  marked  Hippocratic  f acies,  a  dusky  sufEusion, 
and  the  forehead  bathed  in  a  clammy  perspiration.  The  temperature,  which 
often  drops  at  the  onset  of  a  perforation,  rises  with  the  increase  of  the  peri- 
tonitis. The  pulse  quickens,  is  running  and  thready,  the  heart's  action 
becomes  progressively  more  feeble,  and  there  is  an  increase  in  the  frequency 
of  the  respiration.  Vomiting  is  a  variable  feature;  it  is  present  in  a  major- 
ity of  the  cases.  Hiccough  is  common  and  may  occur  earl}-,  but  more  fre- 
quently late. 

The  local  abdominal  features  are  often  more  important  than  the  gen- 
eral, as  it  is  surprising  to  notice  how  excellent  the  condition  of  a  patient 
may  be  with  perforative  peritonitis.  Limitation  of  the  respiratory  move- 
ments is  usually  present,  perhaps  confined  to  the  hypogastric  area.  In- 
creasing distention  is  the  rule,  but  perforation  and  peritonitis  may  occur, 
it  is  to  be  remembered,  with  an  abdomen  flat  or  even  scaphoid.  Increasing 
pain  on  pressure,  increasing  muscle  spasm  and  tension  of  the  wall  are  im- 
portant signs.  Percussion  ma)^  reveal  a  flat  note  in  the  flanks,  due  to  exu- 
date. Auscultation  may  show  absence  of  peristalsis,  and  auscultatory  percus- 
sion may  possibly  show  the  presence  of  air  free  in  the  peritonaeum.  A  friction 
may  be  present  within  a  few  hours  of  the  onset  of  the  perforation.  Obliter- 
ation of  the  liver  flatness  in  the  nipple  line  may  be  caused  by  excessive 
tympany.  Eapid  obliteration  of  liver  flatness  in  a  flat,  or  a  not  much  dis- 
tended abdomen,  is  a  valuable  sign.  Examination  of  the  rectum  may  show 
fullness  in  the  pelvis,  or  tenderness. 

In  a  majority  of  all  cases  th^re  is  a  rise  in  the  leucocytes,  and  when  pres- 
ent may  be  a  valuable  help,  but  it  is  not  constant. 


TYPHOID  FEVER.  83 

General  peritonitis,  without  perforation  of  the  howel,  may  occur  by  exten- 
sion from  an  ulcer,  or  by  rupture  of  a  softened  mesenteric  gland,  or,  as  in 
one  recent  case  in  my  series,  from  inflammation  of  the  Fallopian  tubes.  It 
was  present  in  2.2  per  cent  of  the  Munich  autopsies. 

Perforation  is  almost  invariably  fatal.  In  a  few  cases  healing  takes  place 
spontaneously,  as  is  beautifully  shown  in  one  of  the  Pennsylvania  Hospital 
specimens,  or  the  orifice  may  be  closed  by  a  tag  of  omentum,  as  in  a  remark- 
able case  reported  by  J.  Milton  Miller. 

There  is  a  group  of  cases  in  which  haemorrhage  complicates  the  perfora- 
tion and  adds  to  the  difficulty  in  diagnosis.  In  7  of  our  43  cases  haemorrhage 
accompanied  the  perforation ;  in  3  others  the  haemorrhage  had  occurred  some 
days  before. 

The  diagnosis  of  perforation,  easy  enough  at  times,  is  not  without  serious 
difficulties.  The  conditions  for  which  it  has  been  mistaken  in  my  wards  have 
been :  appendicitis,  occurring  during  the  course  of  the  typhoid  fever,  phlebitis 
of  the  iliac  vein  with  great  pain,  haemorrhage,  and  in  one  case  a  local  perito- 
nitis without  perforation,  for  which  no  cause  was  found.  Eecovery  followed 
the  exploratory  operation,  which  was  made  in  all  but  one  (haemorrhage  case) 
of  these  cases. 

The  SPLEEN  is  usually  enlarged,  and  the  edge  was  felt  below  the  costal 
margin  in  71.6  per  cent  of  my  cases.  Percussion  is  uncertain,  as,  owing  to 
distention  of  the  stomach  and  colon,  even  the  normal  area  of  dulness  may 
not  be  obtainable.  I  have  seen  a  very  large  spleen  post  mortem,  when  during 
life  the  increase  in  size  was  not  observable. 

LiVEE. — Symptoms  on  the  part  of  this  organ  are  rare. 

(a)  Jaundice  was  present  in  only  8  cases  of  my  series.  Catarrh  of 
the  ducts,  toxEemia,  abscess,  and  occasionally  gall-stones  are  the  usual 
causes. 

(h)  Abscess. — Solitary  abscess  is  exceedingly  rare  and  occurred  in  but  3 
cases  in  my  series.  It  may  follow  the  intestinal  lesion  or  more  commonly 
one  of  the  complications,  as  parotitis  or  necrosis  of  bone.  Suppurative  pyle- 
phlebitis, which  is  more  frequent  than  abscess,  may  follow  perforation  of 
the  appendix.     Suppurative  cholangitis  has  been  described. 

(c)  Cholecystitis  occurred  in  19  cases  of  the  series.  Camac  *  has  col- 
lected 115  cases,  in  21  of  which  perforation  occurred.  Pain  in  the  region 
of  the  gall-bladder  is  the  most  constant  symptom.  Tenderness,  muscle  spasm 
with  rigidity,  and  a  gall-bladder  tumor  are  present  in  a  majority  of  the  cases. 
Jaundice  is  inconstant.  With  perforation  there  may  be  a  marked  drop  in 
the  fever  and  the  onset  of  signs  of  peritonitis.  In  simple  cholecystitis  the 
urgency  of  the  symptoms  may  abate,  and  recovery  may  follow.  Suppura- 
tion may  occur  with  infection  of  the  bile  passages.  Months  or  years  after 
(eighteen  years  in  Hunner's  case)  the  bacilli  may  cause  cholecystitis  or  gall- 
stones. Typhoid  bacilli  have  been  found  by  Gushing  as  a  cause  of  cholecys- 
titis in  a  patient  who  had  never  had  typhoid  fever. 

(d)  Gall-Stones. — Bernheim  called  attention  to  the  frequency  of  chole- 
lithiasis after  typhoid  fever.  It  is  probably  associated  with  the  presence 
of  typhoid  bacilli  in  the  gall-bladder  (see  under  Gall-Stones). 

*  Studies  in  Typhoid  Fever,  Series  III,  Johns  Hopkins  Hospital  Reports,  vol.  viii. 


84  SPECIFIC  INFECTIOUS  DISEASES. 

Eespiratoey  System. — Epistaxis,  an  early  symptom,  precedes  typhoid 
fever  more  commonly  than  any  other  febrile  afEection.  It  is  occasionally 
profuse  and  serious. 

Laryngitis  is  not  very  common.  The  ulcers  and  the  perichondritis  have 
already  been  described.  Oedema,  apart  from  ulceration,  is  rare.  In  the 
United  States  the  laryngeal  complications  of  typhoid  fever  seem  much  less 
frequent  than  on  the  Continent.  I  have  twice  seen  severe  perichondritis; 
both  of  the  cases  recovered,  one  after  the  expectoration  of  large  portions  of  the 
thyroid  cartilage. 

Keen  and  Liining  have  collected  331  cases  of  serious  -surgical  complica- 
tions of  the  larynx.  General  emphysema  may  follow  the  perforation  of  an 
ulcer.     Stenosis  is  a  very  serious  sequence. 

From  some  recent  studies  it  would  appear  that  paralysis  of  the  laryn- 
geal muscles  is  much  more  common  than  we  have  supposed.  Przedborski 
(Volkmann's  Sammlung,  ISTo.  183)  has  systematically  examined  the  larynx 
in  100  consecutive  cases  and  found  85  with  paralysis.  The  condition  is 
nearly  always  due  to  neuritis,  sometimes  in  connection  with  affections  of 
other  nerves. 

Bronchitis  is  one  of  the  most  frequent  initial  symptoms.  It  is  indicated 
by  the  presence  of  sibilant  rales.  The  smaller  tubes  may  be  involved,  pro- 
ducing urgent  cough  and  even  slight  cyanosis.  Collapse  and  lobular  pneu- 
monia may  also  occur. 

Lobar  pneumonia  is  met  with  under  two  conditions : 

1.  At  the  outset  the  pneumo-typlius  of  the  Germans.  This  occurred  in 
three  of  our  cases.  After  an  indisposition  of  a  day  or  so,  the  patient  is  seized 
with  a  chill,  has  high  fever,  pain  in  the  side,  and  within  forty-eight  hours  there 
are  signs  of  consolidation  and  the  evidences  of  an  ordinary  lobar  pneumonia. 
The  intestinal  symptoms  may  not  occur  until  toward  the  end  of  the  first 
week  or  later;  the  pulmonary  symptoms  persist,  crisis  does  not  occur;  the 
aspect  of  the  patient  changes,  and  by  the  end  of  the  second  week  the  clinical 
picture  is  that  of  typhoid  fever.  Spots  may  then  be  present  and  doubts  as 
to  the  nature  of  the  case  are  solved.  In  other  instances,  in  the  absence  of 
a  characteristic  eruption,  the  case  remains  doubtful,  and  it  is  impossible  to 
say  whether  the  disease  has  been  pneumonia,  in  which  the  so-called  typhoid 
symptoms  have  developed,  or  whether  it  was  typhoid  fever  with  early  implica- 
tion of  the  lungs.  This  condition  may  depend  upon  an  early  localization  of 
the  typhoid  bacillus  in  the  lung. 

3.  Lobar  pneumonia  forms  a  serious  and  by  no  means  infrequent  com- 
plication of  the  second  or  third  week — in  19  of  our  cases.  It  was  present  in 
over  8  per  cent  of  the  Munich  cases.  The  symptoms  are  usually  not  marked. 
There  may  be  no  rusty  sputa,  and,  unless  sought  for,  the  condition  is  fre- 
quently overlooked.  The  etiological  agent  in  these  cases  is  still  in  dispute. 
T_yphoid  bacilli  have  been  isolated  from  the  sputum  by  Jehle,  Eau,  and  others. 
They  have  also  been  isolated  from  the  consolidated  lungs  at  autopsy,  but  in 
such  cases  the  pneumococci  may  have  been  originally  present,  and  the  typhoid 
bacilli  secondary  invaders.  In  all  cases  of  pneumonia  during  typhoid  fever 
occurring  in  the  Johns  Hopkins  Hospital  and  coming  to  autopsy,  the  pneu- 
mococci could  be  demonstrated  in  the  consolidated  lung.  Infarction,  abscess, 
and  gangrene  are  occasionally  pulmonary  complications. 


TYPHOID  FEVER.  85 

Hypostatic  congestion  of  the  lungs  and  oedema,  due  to  enfeebled  circu- 
lation in  the  later  periods  of  the  disease,  are  very  common.  The  physical 
signs  are  defective  resonance  at  the  bases,  feeble  breath-sounds,  and,  on  deep 
inspiration,  moist  rales. 

Hcemo'ptysis  may  occur.     Creagh  reports  a  case  in  which  it  caused  death. 

Pleurisy  was  present  in  about  8  per  cent  of  the  Munich  autopsies.  It 
may  occur  at  the  outset — pleuro-typhoid — or  slowly  during  convalescence, 
in  which  case  it  is  almost  always  purulent  and  due  to  the  typhoid  bacilli. 

Pneumothorax  is  rare.  Hale  White  has  reported  two  cases,  in  both  of 
which  pleurisy  existed.  After  death,  no  lesions  of  the  lungs  or  bronchi  were 
discovered.  The  condition  may  be  due  to  straining,  or  to  the  rupture  of  a 
small  pygemic  abscess.     It  may  occur  also  during  convalescence. 

Nervous  System. — Cereiro-spinal  Form. — As  already  noted,  the  disease 
may  set  in  with  intense  and  persisting  headache,  or  an  aggravated  form  of 
neuralgia.  There  are  cases  in  which  the  effect  of  the  poison  is  manifested 
on  the  nervous  system  early  and  with  the  greatest  intensity.  There  are  head- 
ache, photophobia,  retraction  of  the  neck,  marked  twitchings  of  the  muscles, 
rigidity,  and  even  convulsions.  In  such  cases  the  diagnosis  of  meningitis  is 
invariably  made.  The  cases  showing  marked  meningeal  features  during  the 
course  of  the  disease  may  be  divided  into  three  groups.  First,  those  with  symp- 
toms suggestive  of  meningitis,  but  without  localizing  features  and  without 
at  post  mortem  the  anatomical  lesions  of  meningitis.  In  every  series  of 
cases  numerous  such  examples  occur.  Secondly,  the  cases  of  so-called  serous 
meningitis.  There  is  a  localization  of  typhoid  bacilli  in  the  cerebro-spinal 
fluid  and  a  mild  inflammatory  reaction,  but  Avlthout  suppurative  meningitis. 
Cole  has  collected  thirteen  such  cases,  five  of  them  occurring  in  our  series. 
Probably  more  frequent  lumbar  punctures  will  show  that  this  occurs  not 
infrequently.  Thirdly,  true  typhoid  suppurative  meningitis  due  to  B.  typho- 
sus. Only  one  such  case  occurred  in  our  series,  and  Cole  has  collected  thir- 
teen from  the  literature.  Meningitis  in  typhoid  fever  is  occasionally  due  to 
other  organisms,  as  tubercle  bacilli,  and  the  micrococcus  intracellularis. 
Marked  convulsive  movements,  local  or  general,  with  coma  and  delirium,  are 
seen  also  in  thrombosis  of  the  cerebral  veins  and  sinuses. 

Delirium,  usually  present  in  very  severe  cases,  is  certainly  less  frequent 
under  a  rigid  plan  of  hydrotherapy.  It  may  exist  from  the  outset,  but  usu- 
ally does  not  occur  until  the  second  and  sometimes  not  until  the  third  week. 
It  may  be  slight  and  only  nocturnal.  It  is,  as  a  rule,  a  quiet  delirium,  thovigh 
there  are  cases  in  which  the  patient  is  very  noisy  and  constantly  tries  to  get 
out  of  bed,  and,  unless  carefully  watched,  may  escape.  The  patient  does 
not  often  become  maniacal.  In  heavy  drinkers  the  delirium  may  have  the 
character  of  delirium  tremens.  Even  in  cases  which  have  no  positive 
delirium,  the  mental  processes  are  usually  dulled  and  the  aspect  is  listless 
and  apathetic.  In  severe  cases  the  patient  passes  into  a  condition  of  uncon- 
sciousness. The  eyes  may  be  open,  but  he  is  oblivious  to  all  surrounding  cir- 
cumstances and  neither  knows  nor  can  indicate  his  wants.  The  urine  and 
faeces  are  passed  involuntarily.  In  this  pseudo-wakeful  state,  or  coma  vigil, 
as  it  is  called,  the  eyes  are  open  and  the  patient  is  constantly  muttering. 
The  lips  and  tongue  are  tremulous;  there  are  twitchings  of  the  fingers  and 
wrists — subsultus  tendinum  and  carphologia.     He  picks  at  the  bedclothes  or 


86  SPECIFIC  INFECTIOUS  DISEASES. 

grasps  at  invisible  objects.  These  are  among  the  most  serious  symptoms  of 
the  disease  and  always  indicate  danger. 

Convulsions  in  typhoid  fever  are  rare.  There  were  8  instances  in  sixteen 
years  among  between  fifteen  and  sixteen  hundred  cases.  They  occur:  first, 
at  the  onset  of  the  disease,  particularly  in  children;  secondly,  as  a  manifes- 
tation of  the  toxaemia;  and  thirdly,  as  a  result  of  severe  cerebral  complica- 
tions— thrombosis,  meningitis,  or  acute  encephalitis.  Occasionally  in  con- 
valescence convulsions  may  occur  from  unknown  causes.  Of  the  8  cases 
3  died. 

Neuritis,  which  is  not  uncommon — 11  cases  in  the  series — may  be  local,  or 
a  wide-spread  affection  of  the  nerves  of  the  legs  or  of  both  arms  and  legs. 

Local  Neuritis. — This  may  occur  during  the  height  of  the  fever  or  after 
convalescence  is  established.  It  may  set  in  with  agonizing  pain,  and  with 
sensitiveness  of  the  affected  nerve  trunks.  The  local  neuritis  may  affect 
the  nerves  of  an  arm  or  of  a  leg,  and  involve  chiefly  the  extensors,  so  that 
there  is  wrist-drop  or  foot-drop.  The  arm  or  leg  may  be  much  swollen 
and  the  skin  over  it  er}d:hematous.  Painful  muscles  are  not  uncommon,  par- 
ticularly in  the  calves.  I  have  reported  a  series  of  cases  (Studies  III). 
Painful  cramps  may  also  occur.  In  some  of  the  cases  of  painful  legs  the 
condition  is  a  myositis ;  in  others  the  swelling  and  pain  may  be  due  to  throm- 
bosis in  the  deeper  veins. 

A  curious  condition,  probably  a  local  neuritis,  is  that  which  was  first 
described  by  Handford  as  tender  toes,  and  which  appears  to  be  much  more 
common  after  the  cold-bath  treatment.  The  tips  and  pads  of  the  toes,  rarely 
the  pads  at  their  bases,  become  exquisitely  sensitive,  so  that  the  patient  can 
not  bear  the  weight  of  the  bedclothes.  There  is  no  discoloration  and  no 
swelling,  and  it  disappears  usually  within  a  week  or  ten  days. 

Multiple  neuritis  in  typhoid  fever  comes  on  usually  during  convalescence. 
The  legs  may  be  affected,  or  the  four  extremities.  The  cases  are  often  diffi- 
cult to  differentiate  from  those  with  subacute  poliomyelitis.  Recovery  is 
the  rule. 

Poliomyelitis  may  occur  with  the  s3^mptoms  of  acute  ascending  paral- 
ysis and  prove  fatal  in  a  few  days.  More  frequently  it  is  less  acute,  and 
causes  either  a  paraplegia  or  a  limited  atrophic  paralysis  of  one  arm  or  leg. 

Hemiplegia  is  a  rare  complication.  Francis  Hawkins  has  collected  17 
cases  from  the  literature;  aphasia  was  present  in  12.  The  lesion  is  usually 
thrombosis  of  the  arteries,  less  often  a  meningo-encephalitis.  The  aphasia 
usually  disappears. 

True  tetany  occurs  sometimes,  and  has  been  reported  in  connection  with 
certain  epidemics.     It  may  set  in  during  the  full  height  of  the  disease. 

Typhoid  Psychoses. — There  are  three  groups  of  cases :  first,  an  initial 
delirium,  which  may  be  serious,  and  cause  the  patient  to  wander  away  from 
his  home,  or  he  may  even  become  maniacal;  secondly,  the  psychosis  asso- 
ciated directly  vrith  the  p}Texia  and  the  toxaemia;  in  a  few  cases  this  outlasts 
the  disappearance  of  the  fever  for  months  or  even  years;  and,  lastly,  the 
asthenic  psychosis  of  convalescence,  more  common  after  typhoid  than  after 
any  other  fever.  The  prognosis  is  usually  good.  Edsal  has  recently  studied 
the  condition  in  children,  finding  69  cases  in  the  literature,  of  which  43 
recovered. 


TYPHOID  FEVER.  87 

There  is  a  distressing  post-typhoid  neurasthenia,  in  which  for  months  or 
even  for  years  the  patient  is  unable  to  get  into  harmony  with  his  sur- 
roundings. 

Special  Senses. — Eye. — Conjunctivitis,  simple  or  phlyctenular,  some- 
times with  keratitis  and  iritis,  may  develop.  Panophthalmitis  has  been 
reported  in  one  case  in  association  with  haemorrhage  (Finlay).  Loss  of  accom- 
modation may  occur,  usually  in  the  asthenia  of  convalescence.  Oculo-motor 
paralysis  has  been  seen,  due  probably  to  neuritis.  Eetinal  haemorrhages  may 
occur  alone  or  in  association  with  other  haemorrhagic  features.  Double  optic 
neuritis  has  been  described  in  the  course  of  the  fever.  It  may  be  independent 
of  meningitis.  Atrophy  may  follow,  but  these  complications  are  excessively 
rare.  Cataract  may  follow  inflammation  of  the  uveal  tract.  Other  rare  com- 
plications are  thrombosis  of  the  orbital  veins  and  orbital  haemorrhage.  (See 
De  Schweinitz  in  Keen's  monograph  for  full  consideration  of  the  subject.) 

Ear. — Otitis  media  is  not  infrequent,  2.5  per  cent  in  Hengst's  collected 
cases.  We  have  never  found  the  typhoid  bacillus  in  the  discharge.  Seri- 
ous results  are  rare;  only  one  case  of  mastoid  disease  occurred  in  our  series. 
The  otitis  may  set  in  with  a  chill  and  an  aggravation  of  the  fever. 

Eenal  System. — Retention  of  urine  is  an  early  symptom  and  may  be  the 
cause  of  abdominal  pain.  It  may  recur  throughout  the  attack.  Suppres- 
sion of  urine  is  rare.  The  urine  is  usually  diminished  at  first,  has  the  ordi- 
nary febrile  characters,  and  the  pigments  are  increased.  Later  in  the  disease 
it  is  more  abundant  and  lighter  in  color. 

Polyuria  is  not  very  uncommon.  The  amount  of  water  depends  very 
much  on  the  fluid  taken.  In  certain  cases  enormous  quantities  are  passed, 
up  to  seven  and  eight  quarts.  While  most  common  during  convalescence,  the 
increase  may  be  sudden  in  the  second  week  at  the  height  of  the  fever,  as  in 
a  case  reported  by  Fussell.  Patients  treated  by  what  is  known  as  the  wash- 
ing-out method,  in  which  large  quantities  of  water  are  taken,  may  pass  enor- 
mous amounts,  18  or  19  litres.  One  of  my  patients  passed  as  much  as  33 
litres  in  one  day ! 

The  Diazo-reaction  of  EhrUch. — Two  solutions  are  employed,  kept  in 
separate  bottles :  one  containing  a  saturated  solution  of  sulphanilic  acid  in 
a  solution  of  hydrochloric  acid  (50  cc.  to  1,000  cc.)  ;  the  other  a  half  per 
cent  solution  of  sodium  nitrite.  To  make  the  test,  a  few  cubic  centimetres 
of  urine  are  placed  in  a  small  test-tube  with  an  equal  quantity  of  a  mixture 
of  the  solution  of  the  sulphanilic  acid  (-10  cc.)  and  the  sodium  nitrite  (1  cc), 
the  whole  being  thoroughly  shaken.  One  cubic  centimetre  of  ammonia  is 
then  allowed  to  flow  carefully  down  the  side  of  the  tube,  forming  a  colorless 
zone  above  the  yellow  urine,  and  at  the  junction  of  the  two  a  deep  brownish- 
red  ring  will  be  seen  if  the  reaction  is  present.  With  normal  urine  a  lighter 
brownish  ring  is  produced,  without  a  shade  of  red.  The  color  of  the  foam  of 
the  mixed  urine  and  reagent,  and  the  tint  they  produce  when  largely  diluted 
with  water,  are  characteristic,  being  in  both  cases  of  a  delicate  rose-red  if  the 
diazo-reaction  be  present;  but  if  not,  brownish-yellow.  It  was  found  in  894 
of  1,467  cases.  It  may  be  present  previous  to  the  occurrence  of  the  rash,  and 
as  late  as  the  twenty-second  day.  The  value  of  the  test  is  lessened  by  its 
occurrence  in  cases  of  miliary  tuberculosis,  in  malarial  fever,  and  occasion- 
ally in  the  acute  diseases  associated  with  high  fever.    The  urotoxic  coefficient 


88  SPECIFIC  INFECTIOUS  DISEASES. 

in  typhoid  fever  is  high  and  is  said  to  be  increased  by  the  tubs.  In  cases 
passing  large  quantities  of  urine  the  diazo-reaction  is  very  feeble  or  even 
absent. 

BaciUuria  occurs  in  about  one-third  of  the  cases,  caused  by  the  typhoid 
bacilli.  The  urine  may  be  turbid  from  their  presence  and  in  the  test-tube 
give  a  peculiar  shimmer.  There  may  be  millions  of  bacilli  to  the  cubic  milli- 
metre without  pyuria  or  any  symptoms  of  renal  or  bladder  trouble.  The 
bacilli  may  be  present  in  the  urine  for  years  after  the  attack  (see  Gwyn, 
Studies  III).  Of  51  cases  during  the  session  of  1900-1901  in  my  clinic. 
Cole  found  typhoid  bacilli  in  the  urine  in  16. 

The  renal  complications  in  typhoid  fever  may  be  thus  grouped : 

(a)  Febrile  albuminuria  is  common  and  of  no  special  significance.  It 
was  present  in  999  of  1,500  cases,  66  per  cent.  Tube  casts  were  present  in 
568  cases,  37.8  per  cent.     Hamoglohinuria  occurred  in  one  case. 

(&)  Acute  nephritis  at  the  onset  or  during  the  height  of  the  disease — 
the  nephro-typlius  of  the  Germans,  the  fievre  typho'ide  a  forme  renale  of  the 
French — may  set  in,  with  all  the  symptoms  of  acute  Bright's  disease,  mask- 
ing in  many  instances  the  true  nature  of  the  malady.  After  an  indisposi- 
tion of  a  few  days  there  may  be  fever,  pain  in  the  back,  and  the  passage  of 
a  small  amount  of  bloody  urine. 

(c)  jSTephritis  during  convalescence  is  rare,  and  is  usually  associated  with 
anaemia  and  oedema.  Chronic  nephritis  is  a  most  exceptional  sequel  of  the 
disease. 

{d)  The  lymphomatous  nephritis,  described  by  E.  Wagner,  and  already 
referred  to  in  the  section  on  morbid  anatomy,  produces,  as  a  rule,  no 
symptoms. 

(e)  Pyuria,  a  not  uncommon  complication,  may  be  associated  with  the 
typhoid  or  the  colon  bacillus,  less  often  with  staphylococci.  It  disappears 
during  convalescence.  It  is  usually  due  to  a  simple  catarrh  of  the  bladder, 
rarely  to  an  intense  cystitis. 

(/)  Post-typhoid  Pyelitis. — One  or  both  kidneys  may  be  involved,  either 
at  the  height  of  the  disease  or  during  convalescence.  There  may  be  blood 
and  pus  at  first,  later  pus  alone,  varying  in  amount.  A  severe  pyelonephritis 
may  follow.     Perinephric  abscess  is  a  rare  sequel. 

Generative  System. — Orchitis  is  occasionally  met  with.  Kinnicutt  has 
collected  53  cases  in  the  literature.  It  is  usually  associated  with  a  catarrhal 
urethritis.  Induration  or  atrophy  may  occur,  and  more  rarely  suppuration. 
It  was  present  in  4  cases  in  my  series.  In  1  case  double  hydrocele  developed 
suddenly  on  the  nineteenth  day  (Dunlap). 

Acute  mastitis,  which  may  go  on  to  suppuration,  is  a  rare  complication. 
It  was  present  in  3  cases  of  my  series,  during  the  fever  and  in  one  late  in 
convalescence. 

Osseous  System. — Among  the  most  common  and  troublesome  of  the 
sequelae  of  the  disease  are  the  hone  lesions.  In  a  few  cases  the  bone  lesions 
occur  at  the  height  of  the  disease  or  even  earlier.  A  boy  was  admitted  in  the 
second  week  of  an  attack  of  typhoid  fever  with  acute  periostitis  of  the  frontal 
bone  and  of  one  rib.  Of  237  cases  collected  by  Keen  there  were  periostitis  in 
110,  necrosis  in  85,  and  caries  in  13.  They  are,  I  am  sure,  much  more  frequent 
than  the  figures  indicate.     Six  cases  came  under  my  notice  in  the  course  of  a 


TYPHOID  FEVER.  89 

year,  and  formed  the  basis  of  Parsons'  paper  (Studies  II).  The  legs  are  chiefly 
involved.  In  Keen's  series  the  tibia  was  affected  in  91  cases,  the  ribs  in  40. 
The  typhoid  bone  lesion  is  apt  to  form  what  the  old  writers  called  a  cold 
abscess.  Only  a  few  of  the  cases  are  acute.  Chronicity,  indolence,  and  a 
remarkable  tendency  to  recurrence  are  perhaps  the  three  most  striking 
features  of  the  typhoid  bone  lesions.  A  bony  node  may  be  left  by  the  typhoid 
periostitis. 

Arthritis  was  present  in  5  cases  of  my  series.  Eheumatic  and  septic  forms 
are  described,  as  well  as  a  typhoid  arthritis  proper.  The  complication  is  exceed- 
ingly rare,  and  yet  Keen  has  collected  from  the  literature  84  cases.  One  of  the 
most  important  points  relating  to  it  is  the  frequency  with  which  spontaneous 
dislocations  occur,  particularly  of  the  hip. 

Typhoid  Spine  (Gibney). — During  the  disease  in  protracted  cases,  more 
often  during  convalescence,  the  patient  complains  of  pain  in  the  lumbar  and 
sacral  regions,  perhaps  after  a  slight  jar  or  shock.  Stiffness  of  the  back,  pain 
on  movement,  and  tenderness  on  pressure  are  the  chief  features,  but  there  are 
in  addition  marked  nervous,  sometimes  hysterical  manifestations.  The  diag- 
nosis of  spondylitis.  Pott's  disease,  or  perinephritic  abscess,  etc.,  may  be  made. 
The  examination  is  negative.  The  patient  is  afebrile,  as  a  rule.  The  outlook 
is  good.  In  rare  instances  there  may  be  perispondylitis,  but  usually  the  condi- 
tion is  a  neurosis  (Studies  I). 

The  muscles  may  be  the  seat  of  the  degeneration  already  referred  to,  but  it 
rarely  causes  any  symptoms.  Hsemorrhage  occasionally  occurs  into  the  muscles, 
and  late  in  protracted  eases  abscesses  may  follow.  Eupture  of  a  muscle,  usually 
the  rectus  abdominis,  may  occur,  possibly  associated  with  acute  hasmorrhagic 
myositis. 

Post-typhoid  Septicaemia  and  Pyaemia. — In  very  protracted  cases  there  may 
recur  after  defervescence  a  slight  fever  (100°-101°),  with  sweats,  which  is  pos- 
sibly septic.  In  other  cases  for  two  or  three  weeks  there  are  recurring  chills, 
often  of  great  severity.  They  are  usually  of  no  moment  in  the  absence  of  signs 
of  complication.     (See  Studies  II  and  III.) 

Typhoid  pyaemia  is  not  very  uncommon,  (a)  Extensive  furunculosis  may 
be  associated  with  irregular  fever  and  leucocytosis.  (&)  Following  the  fever 
there  may  be  multiple  subcutaneous  "  cold  "  abscesses,  often  with  a  dark,  thin 
bloody  pus.  A  score  or  more  of  these  may  appear  in  different  parts.  Pratt 
has  isolated  the  bacillus  in  pure  culture  from  the  subcutaneous  abscesses,  (c)  A 
crural  thrombus  may  suppurate  and  cause  a  wide-spread  pyaemia,  (d)  In  rare 
instances  suppuration  of  the  mesenteric  glands,  of  a  splenic  infarct,  a  slough- 
ing parotid  bubo,  a  perinephric  or  perirectal  abscess,  acute  necrosis  of  the  bones, 
or  a  multiple  suppurative  arthritis  may  cause  pygemia.  In  other  cases  follow- 
ing bed-sores  or  a  furunculosis  there  occurs  a  general  infection  with  pyogenic 
organisms,  with  fatal  result.  In  three  such  cases  in  our  series  staphylococci 
were  cultivated  from  the  blood.  In  one  case  with  many  chills  late  in  the  dis- 
ease, and  the  general  condition  excellent,  typhoid  bacilli  were  cultivated  from 
the  blood. 

Association  of  other  Diseases. — Erysipelas  is  a  rare  complication,  most  com- 
monly met  with  during  convalescence.  In  1,420  cases  at  Basel  it  occurred  10 
times.  Griesinger  states  that  it  is  met  with  in  2  per  cent.  Measles  or  scarlet 
fever  may  develop  during  the  fever  or  in  convalescence.    Chicken-pox  and  noma 


90  SPECIFIC  INFECTIOUS  DISEASES. 

have  been  reported  in  children.  Pseudo-membranous  inflammations  may  occur 
in  the  pharynx,  larynx,  or  genitals. 

Malarial  and  typhoid  fevers  may  he  associated,  but  a  majority  of  the  cases 
of  so-called  typho-malarial  fever  are  either  remittent  malarial  fever  or  true 
typhoid.  It  is  interesting  to  note  that  among  the  829  cases  of  typhoid  fever 
Plasmodia  were  found  in  the  blood  during  the  course  of  the  disease  in  only  1 
case.  (See  Lyon,  Studies  III.)  Many  of  our  typhoid-fever  cases  came  from 
malarious  regions. 

The  s3'mptoms  of  influenza  may  precede  the  t3^phoid  fever,  or  the  two  dis- 
eases may  run  concurrently.  There  are  cases  of  chronic  influenza  which  simu- 
late typhoid  fever  very  closely. 

Typhoid  Fever  and  Tiiberculosis. —  (a)  The  diseases  may  coexist.  A  per- 
son with  chronic  tuberculosis  may  contract  the  fever.  Of  80  autopsies  in 
typhoid  fever,  4  presented  marked  tuberculous  lesions.  Miliary  tuberculosis 
and  tj'phoid  fever  may  occur  together,  (fe)  Cases  of  typhoid  fever  with  pulmo- 
nary and  pleuritic  symptoms  may  suggest  tuberculosis  at  the  onset,  (c)  There 
are  five  types  of  tuberculous  infection  which  may  simulate  typhoid  fever: 
the  acute  miliary  form  (page  298) ;  tuberculous  meningitis  (page  301)  ;  tuber- 
culous peritonitis  (page  310)  ;  the  acute  toxaemia  of  certain  local  lesions  (page 
306)  ;  and  forms  of  ordinary  pulmonary  tuberculosis.  And,  lastly,  pulmonary 
tuberculosis  may  follow  typhoid  fever.  In  a  large  majority  of  such  cases  the 
disease  has  been  tuberculosis  from  the  onset,  which  has  begun  with  a  low  fever 
and  features  suggestive  of  typhoid  fever. 

In  epilepsy  and  in  chronic  chorea  the  fits  and  movements  usually  cease  dur- 
ing an  attack,  and  in  typhoid  fever  in  a  diabetic  subject  the  sugar  may  be 
absent  during  the  height  of  the  disease. 

Varieties  of  Typhoid. — Typhoid  fever  presents  an  extremely  complex  symp- 
tomatolog}^  Many  forms  have  been  described,  some  of  which  present  exaggera- 
tion of  common  s3"mptoms,  others  modification  in  the  course,  others  again 
greater  intensity  of  action  of  the  poison  on  certain  organs.  As  we  have  seen, 
when  the  nervous  system  is  specially  involved,  it  has  been  called  the  cerebro- 
spinal form;  when  the  kidneys  are  early  and  severely  affected,  nephro-typhoid ; 
when  the  disease  begins  with  pulmonary  symptoms,  pneumo-typhoid ;  with 
pleurisy,  pleuro-typhoid ;  when  the  disease  is  characterized  throughout  by  pro- 
fuse sweats,  the  sudoral  form  of  the  disease.  It  is  enough  to  remember  that 
typhoid  has  no  fixed  and  constant  course,  that  it  may  set  in  occasionally  with 
symptoms  localized  in  certain  organs,  and  that  many  of  its  symptoms  are 
extremely  variable — in  one  epidemic  uniform  and  text-book-like,  in  another 
slight  or  not  met  with.  This  diversified  symptomatolog}^  has  led  to  many 
clinical  errors,  and  in  the  absence  of  the  salutary  lessons  of  morbid  anatomy 
it  is  not  surprising  that  practitioners  have  so  often  been  led  astray.  We  may 
recognize  with  Murchison  the  following  varieti':!S : 

1.  The  mild  and  abortive  forms.  Much  attention  has  been  paid  of  late  to 
the  milder  varieties  of  t3^phoid  fever — the  typhus  levissimus  of  Griesinger. 
Woodruff,  of  the  United  States  Arm3%  has  called  special  attention  to  the  great 
danger  of  neglecting  these  mild  forms,  which  are  often  spoken  of  as  mountain 
fever  and  malarial  fever,  "  acclimation,"  "  ground,"  and  "  miasmatic  "  fevers. 
During  the  prevalence  of  an  epidemic  there  ma3'  be  cases  of  fever  so  mild  that 
the  patient  does  not  go  to  bed.    The  onset  may  be  sudden,  particularly  in  chil- 


TYPHOID  FEVER.  91 

dren.  The  general  symptoms  are  slight,  the  pulse  rate  not  high,  the  fever 
rarely  above  102°.  Eose  spots  are  usually  present,  with  splenic  enlargement. 
Diarrhoea  is  rare.  The  Widal  reaction  is  present  in  a  majority  of  the  patients. 
There  may  be  a  marked  tendency  to  relapse.  While  infrequent,  characteristic 
complications  and  sequelae  may  give  the  first  positive  clue  to  the  nature  of  the 
trouble.  J.  B.  Briggs  has  studied  44  of  these  mild  cases  from  my  clinic,  in 
which  the  fever  lasted  14  days  or  less.  Eose  spots  were  present  in  24,  and  the 
Widal  reaction  in  26.  There  were  three  relapses.  It  can  not  be  too  forcibly 
impressed  upon  the  profession  that  it  is  just  by  these  mild  cases,  to  which  so 
little  attention  is  paid,  that  the  disease  may  be  kept  up  in  a  community. 

2.  The  grave  form  is  usually  characterized  by  high  fever  and  pronounced 
nervous  symptorns.  In  this  category,  too,  come  the  very  severe  cases,  setting  in 
with  pneumonia  and  Bright's  disease,  and  with  the  very  intense  gastro-intestinal 
or  cerebro-spinal  symptoms. 

3.  The  latent  or  ambulatory  form  of  typhoid  fever,  which  is  particularly 
common  in  hospital  practice.  The  symptoms  are  usually  slight,  and  the  patient 
scarcely  feels  ill  enough  to  go  to  bed.  He  has  languor,  perhaps  slight  diarrhoea, 
but  keeps  about  and  may  even  attend  to  his  work  throughout  the  entire  attack. 
In  other  instances  delirium  sets  in.  The  worst  cases  of  this  form  are  seen  in 
sailors,  who  keep  up  and  about,  though  feeling  ill  and  feverish.  When  brought 
to  the  hospital  they  often  have  symptoms  of  a  most  severe  type  of  the  disease. 
Hagmorrhage  or  perforation  may  be  the  first  marked  symptom  of  this  ambula- 
tory type.  Sir  W.  Jenner  has  called  attention  to  the  dangers  of  this  form,  and 
particularly  to  the  grave  prognosis  in  the  case  of  persons  who  have  travelled 
far  with  the  disease  in  progress. 

Hemorrhagic  Typhoid  Fever. — This  is  excessively  rare.  Among  Ouskow's 
6,513  cases  there  were  4  fatal  eases  with  general  hsemorrhagic  features.  Only 
three  instances  were  present  in  our  series.  Haemorrhages  may  be  marked  from 
the  outset,  but  more  commonly  they  come  on  during  the  course  of  the  disease. 
The  condition  is  not  necessarily  fatal.  Several  of  those  reported  by  Nicholls 
from  the  Eoyal  Victoria  Hospital,  Montreal,  recovered.  (See  Hamburger, 
Studies  III.) 

An  afebrile  typhoid  fever  is  recognized  by  authors.  Liebermeister  says  that 
the  cases  were  not  uncommon  at  Basel.  The  patients  presented  lassitude,  de- 
pression, headache,  furred  tongue,  loss  of  appetite,  slow  pulse,  and  even  the 
spots  and  enlarged  spleen.  I  have  seen  the  temperature  normal  on  the  sixteenth 
day,  while  the  spots  did  not  come  out  until  later. 

Typhoid  Fever  in  Children. — Griffith  collected  a  series  of  325  cases  in 
children  under  two  and  a  half  years;  111  of  these  were  in  the  first  year.  Out 
of  a  total  of  278  cases  in  which  the  result  was  recorded,  142  died.  The  cases 
are  not  very  uncommon.  The  high  mortality  in  Griffith's  paper  was  probably 
due  to  the  fact  that  only  the  more  serious  cases  are  reported.  The  abdominal 
symptoms  are  usually  mild;  fatal  haemorrhage  and  perforation  are  rare. 
Among  sequelae,  aphasia,  noma,  and  bone  lesions  are  stated  to  be  more  common 
in  children  than  in  adults.     Two  of  our  cases  were  under  one  year  of  age. 

Typhoid  Fever  in  the  Aged. — After  the  sixtieth  year  the  disease  runs 
a  less  favorable  course,  and  the  mortality  is  very  high.  The  fever  is  not  so 
high,  but  complications  are  more  common,  particularly  pneumonia  and  heart- 
failure. 


92  SPECIFIC  INFECTIOUS  DISEASES. 

Typhoid  Fever  in  Peegxaxct. — Pregnancy  affords  no  immunity  against 
typhoid.  In  1,500  of  our  cases  to  September  10,  190-i,  438  of  which  were 
females,  there  were  6  cases.  Goltdammer  noted  26  pregnancies  in  600  cases 
of  typhoid  fever  in  the  female.  It  is  more  commonly  seen  in  the  first  half  of 
pregnancy.  The  pregnancy  is  interrupted  in  about  65  per  cent  of  the  cases, 
iisually  in  the  second  week  of  the  disease.  In  the  obstetrical  department  of  the 
Johns  Hopkins  Hospital  (J.  W.  Williams)  there  have  been  (to  January, 
1905)  three  cases  of  puerperal  infection  with  bacillus  typhosus.  One  case 
showed  a  localized  lesion  of  the  chorion,  from  which  cultures  were  obtained 
(Little). 

Typhoid  Fever  ix  the  Fcetus. — From  the  recent  studies  of  Fordyce, 
J.  L.  Morse,  and  F.  W.  L3Tich,  we  may  conclude  that  the  typhoid  bacillus  may 
pass  through  the  jjlacenta  to  the  child,  causing  a  typhoid  septicasmia,  without 
intestinal  lesions.  Ljmch  has  recently  collected  16  such  cases.  Infection  of 
the  foetus  does  not  necessarily  follow,  but  when  infected  the  child  dies,  either 
in  utero  or  shortly  after  birth.  The  Widal  reaction  has  been  obtained  with 
foetal  blood.  Its  presence  does  not  indicate  that  the  child  has  survived  infec- 
tion in  utero,  as  the  agglutinating  substances  may  filter  through  the  placenta. 
They  may  also  be  transmitted  to  the  nursling  through  the  milk,  and  cause  a 
transient  reaction.  The  reaction  could  not  be  obtained  with  foetal  blood  from 
Avhich  typhoid  bacilli  were  cultivated  (Lynch). 

Eelapse. — Eelapses  vary  in  frequenc}^  in  different  epidemics,  and,  it  would 
appear,  in  different  places.  The  percentages  of  different  authors  range  from 
3  per  cent  (Murchison),  11  per  cent  (Baumler),  to  15  or  18  per  cent  (Immer- 
mann).     In  1,500  cases  there  were  172  relapses,  11.4  per  cent. 

We  may  recognize  the  ordinary,  the  intercurrent,  and  the  spurious  relapse. 

The  ordinary  relapse  sets  in  after  complete  defervescence.  The  average 
duration  of  the  interval  in  Irvine's  cases  was  a  little  over  five  days. 

In  one  of  my  cases  there  was  complete  apjTCxia  for  twenty-three  days,  fol- 
lowed b}'  a  relapse  of  forty-one  days'  duration;  then  apyrexia  for  forty-two 
days,  followed  by  a  second  relapse  of  two  weeks'  duration.  As  a  rule,  two  of 
the  three  important  symptoms — step-like  temperature  at  onset,  roseola,  an 
enlarged  spleen — should  be  present  to  justify  the  diagnosis  of  a  relapse.  The 
intestinal  symptoms  are  variable.  The  onset  may  be  abrupt  with  a  chill,  or 
the  temperature  may  have  a  typical  ascent,  as  shown  in  Chart  I.  The  number 
of  relapses  range  from  1  to  5.  In  a  case  at  the  Pennsylvania  Hospital  in  1904 
the  disease  lasted  eleven  months  and  four  days,  during  which  there  were  six 
relapses.  The  attack  is  usually  less  severe  and  of  shorter  duration.  Of 
Murchison's  53  cases,  the  mean  duration  of  the  -first  attack  was  about  twenty- 
six  days;  of  the  relapse,  fifteen  days.  The  mortality  of  relapse  cases  is  not 
high. 

The  intercurrent  relapse  is  common,  often  most  severe,  and  is  responsible 
for  a  great  man}^  of  the  most  protracted  cases.  The  temperature  drops  and 
the  patient  improves;  but  after  remaining  between  100°  and  102°  for  a 
few  days,  the  fever  again  rises  and  the  patient  enters  upon  another  attack, 
Avhich  may  be  even  more  protracted,  and  of  much  greater  intensity  than  the 
original  one. 

Spurious  relapses  are  very  common.  They  have  already  been  referred  to 
on  page  72,  under  post-t}^hoid  elevations  of  temperature.    They  are  recrudes- 


TYPHOID  FEVER.  93 

eenees  of  the  fever  due  to  a  number  of  causes.  It  is  not  always  easy  to  deter- 
mine whether  a  relapse  is  present,  particularly  in  cases  in  which  the  fever 
persists  for  only  five  or  seven  days  without  rose-spots  and  without  enlargement 
of  the  spleen. 

Undoubtedly  a  reinfection  from  within,  yet  of  the  conditions  favoring  the 
occurrence  of  relapse  we  as  yet  know  little.  Durham  has  advanced  an  interest- 
ing theory :  Every  typhoid  infection  is  a  complex  phenomenon  caused  by  groups 
of  bacilli  alike  in  species  but  not  identical,  as  shown  by  their  serum  reactions. 
The  antitoxin  formed  in  the  blood  during  the  primary  attack  neutralizes  only 
one  (or  several)  groups,  the  remaining  groups  still  preserving  their  pathogenic 
power.  Following  an  error  in  diet,  or  some  indiscretion,  these  latter  groups 
may  multiply  sufficiently  to  cause  a  reinfection.  Multiple  relapses  may  be- 
similarly  explained.  Bacteriological  proof  of  this  interesting  theory  has  not  yet 
been  given. 

Biagnosis. — There  are  several  points  to  note.  In  the  first  place,  typhoid 
fever  is  the  most  common  of  all  continued  fevers.  Secondly,  it  is  extraordi- 
narily variable  in  its  manifestations.  Thirdly,  there  is  no  such  hybrid  malady 
as  typho-malarial  fever.  Fourthly,  errors  in  diagnosis  are  inevitable,  even 
under  the  most  favorable  conditions. 

Data  for  Diagnosis. —  (a)  General. — IsTo  single  symptom  or  feature  is 
characteristic.  The  onset  is  often  suggestive,  particularly  the  occurrence  of 
epistaxis,  and  (if  seen  from  the  start)  the  ascending  fever.  The  steadiness  of 
the  fever  for  a  week  or  longer  after  reaching  the  fastigium  is  an  important 
point.  The  irregular  remittent  character  in  the  third  week,  and  the  intermit- 
tent features  with  chills,  are  common  sources  of  error.  While  there  is  nothing 
characteristic  in  the  pulse,  dicrotism  is  so  much  more  common  early  in  typhoid 
fever  that  its  presence  is  always  suggestive.  The  rash  is  the  most  valuable 
single  sign,  and  with  the  fever  usually  clinches  the  diagnosis.  The  enlarged 
spleen  is  of  less  importance,  since  it  occurs  in  all  febrile  conditions,  but  with 
the  fever  and  the  rash  it  completes  a  diagnostic  triad  of  the  disease.  The 
absence  of  leucocytosis  and  the  presence  of  Ehrlich's  reaction  are  valuable  acces- 
sory signs. 

(&)  Specific. —  (1)  Isolation  of  TypJioid  Bacilli  from  the  Blood. — New 
methods  have  given  better  results  in  this  procedure,  which  has  been  carried  out 
extensively  in  my  ward  by  Cole,  and  I  can  testify  to  its  great  value  in  doubtful 
cases  and  in  the  acute  septic  forms.  The  hypodermic  puncture  of  a  vein  for 
the  blood  causes  little  or  no  pain. 

(2)  Isolation  of  Typhoid  Bacilli  from  the  Stools. — Cultures  from  the  stools 
have  proved  of  diagnostic  value.  A  new  and  very  satisfactory  method  is  that 
of  von  Drigalski  and  Conradi  (Zeit.  f.  Hygiene,  Bd.  39),  largely  used  in  the 
campaign  against  typhoid  in  Germany,  with  which  those  familiar  with  bac- 
teriologic  methods  are  able  to  isolate  the  bacilli  in  a  majority  of  the  cases. 

(3)  Isolation  of  Typhoid  Bacilli  from  the  Urine. — Neumann,  Horton- 
Smith,  Eichardson,  and  Gwyn  have  shown  the  great  frequency  of  typhoid  bacilli 
in  the  urine.  In  some  cases  they  may  be  obtained  before  the  Widal  test  is  posi- 
tive. Eoutine  cultures  do  not  offer  great  difficulties,  and  may  frequently  be 
of  diagnostic  value. 

(4)  Isolation  of  Typhoid  Bacilli  from  the  Rose-spots. — Neufeld,  Cursch- 
mann,  and  Richardson  have  demonstrated  the  presence  of  the  bacilli  in  rose- 


94  SPECIFIC  INFECTIOUS  DISEASES. 

spots  in  32  of  40  cases  examined.     As  the  procedure  causes  considerable  dis- 
comfort it  can  not  be  used  as  a  routine  method. 

(5)  The  Agglutination  Test. — In  1894  Pfeiffer  showed  that  cholera  spirilla, 
when  introduced  into  the  peritonaeum  of  an  immunized  animal,  or  when  mixed 
with  the  serum  of  immimized  animals,  lose  their  motion  and  break  up.  This 
"  Pfeiffer's  phenomenon  "  of  agglutination  and  immobilization  was  thoroughly 
studied  by  Durham  and  also  by  A.  S.  Grlinbaum,  and  the  specificity  of  the 
reaction  demonstrated.  Widal  took  the  method,  and  made  it  available  in 
clinical  work. 

Methods. — (a)  Macroscopic  or  Slow  Method. — This  has  not  been  largely 
used  in  clinical  work,  but  on  the  whole  the  results  are  probably  more  satisfactory 
than  with  the  microscopic  method,  and  in  hospitals,  at  least,  the  difficulties  are 
no  greater.  Lately  the  use  of  cultures  of  dead  bacilli  has  received  quite  wide 
application.  This  method  is  very  satisfactory  when  the  living,  active  bacilli 
can  not  be  conveniently  employed., 

(6)  Microscopic  or  Rapid  Method. — The  serum  is  mixed  with  a  young 
bouillon  culture  of  the  tj^phoid  bacillus,  or  with  a  suspension  of  a  young  agar 
culture,  in  such  a  manner  as  to  dilute  the  serum  to  the  required  degree.  A 
hanging-drop  preparation  of  the  mixture  is  made,  and  if  the  reaction  is  posi- 
tive the  bacilli  will  within  a  given  time  lose  their  motility  and  collect  in  clumps. 
Wyatt  Johnston  introduced  the  use  of  dried  blood.  It  is  convenient,  but  does 
not  permit  accurate  dilutions.  The  use  of  glass  bulbs  to  obtain  the  serum,  and 
small  glass  pipettes  to  make  accurate  dilutions,  is  of  value.  As  Cabot  says, 
"  the  test  is  a  quantitative,  not  a  qualitative,  one."  Both  the  degree  of  dilu- 
tion and  the  time  limit  are  of  importance.  A  safe  standard,  and  the  one  in 
use  at  the  Johns  Hopkins  Hospital,  is  a  dilution  of  1-50  and  a  time  limit  of 
one  hour. 

Eesults. — Cabot's  collection  of  5,978  cases  gives  a  positive  reaction  in  97.2 
per  cent.  A  positive  reaction  was  obtained  in  93  per  cent  of  849  cases  tested 
before  the  eighth  day.  It  may  not  appear  until  the  relapse.  In  4  of  my  cases 
it  developed  on  the  twenty-second,  twenty-sixth,  thirty-fifth,  and  forty-second 
days,  respectively.  It  may  be  present  even  twenty  or  thirty  years  subsequent 
to  the  attack  of  fever. 

While  on  the  whole  the  serum  reaction  is  of  very  great  value,  there  are  cer- 
tain difficulties  and  objections  which  must  be  considered.  A  perfectly  charac- 
teristic case  with  hsemorrhages,  rose-spots,  etc.,  may  give  no  reaction  throughout. 
In  other  cases  the  reaction  is  much  delayed,  becoming  positive  only  during 
convalescence,  or  even  during  a  relapse.  It  must  be  borne  in  mind  that  occasion- 
ally the  reaction  is  not  obtained  with  low  dilutions,  while  with  higher  dilutions 
the  reaction  is  characteristic. 

Common  Sources  op  Eeeoe  in  Diagnosis. — An  early  and  intense  local- 
ization of  the  infection  in  certain  organs  may  give  rise  to  doubt  at  first. 

Cases  coming  on  with  severe  headache,  photophobia,  delirium,  twitching  of 
the  muscles  and  retraction  of  the  head  are  almost  invariably  regarded  as  cerebro- 
spinal meningitis.  Under  such  circumstances  it  may  for  a  few  days  be  impos- 
sible to  make  a  satisfactory  diagnosis.  I  have  thrice  performed  autopsies  on 
cases  of  this  kind  in  which  no  suspicion  of  typhoid  fever  had  been  present,  the 
intense  cerebro-spinal  manifestations  having  dominated  the  scene.  Until  the 
appearance  of  abdominal  symptoms,  or  the  rash,  it  may  be  quite  impossible  to 


TYPHOID  FEVER.  95 

determine  the  nature  of  the  case.  Cerebro-spinal  meningitis  is,  however,  a 
rare  disease;  typhoid  fever  a  very  common  one,  and  the  onset  with  severe 
nervous  symptoms  is  by  no  means  infrequent.  The  lumbar  puncture  is  now 
a  great  help. 

I  have  already  spoken  of  the  misleading  pulmonary  symptoms,  which  occa- 
sionally occur  at  the  very  outset  of  the  disease.  The  bronchitis  rarely  causes 
error,  though  it  may  be  intense  and  attract  the  chief  attention.  More  difficult 
are  the  cases  setting  in  with  chill  and  followed  rapidly  by  pneumonia.  I  have 
brought  such  a  case  before  the  class  one  week  as  typical  pneumonia,  and  a  fort- 
night later  shown  the  same  case  as  undoubtedly  one  of  typhoid  fever.  In 
another  case,  in  which  the  onset  was  with  definite  pneumonia,  no  spots  were 
present,  and,  though  there  were  diarrhoea,  meteorism,  and  the  most  pronounced 
nervous  symptoms,  the  doubt  still  remains  whether  it  was  a  case  of  typhoid 
fever  or  one  of  pneumonia  in  which  severe  secondary  symptoms  developed. 
There  is  less  danger  of  mistaking  the  pneumonia  which  occurs  at  the  height 
of  the  disease,  and  yet  this  is  possible,  as  in  a  case  admitted  a  few  years  ago 
to  my  wards — a  man  aged  seventy,  insensible,  with  a  dry  tongue,  tremor,  ecchy- 
moses  upon  the  wrists  and  ankles,  no  rose-spots,  enlargement  of  the  spleen,  and 
consolidation  of  his  right  lower  lobe.  It  was  very  natural,  particularly  since 
there  was  no  history,  to  regard  such  a  case  as  senile  pneumonia  with  profound 
constitutional  disturbance,  but  the  autopsy  showed  the  characteristic  lesions  of 
typhoid  fever.  Early  involvement  of  the  pleura  or  the  kidneys  may  for  a  time 
obscure  the  diagnosis. 

Of  diseases  with  which  typhoid  fever  may  be  confounded,  malaria,  certain 
forms  of  pyaemia,  acute  tuberculosis,  and  tuberculous  peritonitis  are  the  most 
important. 

From  malarial  fever,  typhoid  is,  as  a  rule,  readily  recognized.  There  is  no 
such  disease  as  typho-malarial  fever — that  is,  a  separate  and  distinct  malady. 
Typhoid  fever  and  malarial  fever  may  coexist  in  the  same  patient.  Of  1,500 
cases  of  typhoid  fever,  in  only  three  were  the  malarial  parasites  found  in  the 
blood  during  the  fever.  In  patients  returning  from  Cuba  and  Porto  Rico 
during  the  late  war  the  two  conditions  were  often  found  together,  but  in  this 
country  it  is  excessively  rare.  The  term  typho-malarial  fever  should  be  aban- 
doned. The  autumnal  type  of  malarial  fever  may  present  a  striking  simi- 
larity in  its  early  days  to  typhoid  fever.  Differentiation  may  be  made  only 
by  the  blood  examination.  There  ma}^  be  no  chills,  the  remissions  may  be 
extremely  slight,  there  is  a  history  perhaps  of  malaise,  weakness,  diarrhoea, 
and  sometimes  vomiting.  The  tongue  is  furred  and  white,  the  cheeks  flushed, 
the  spleen  slightly  enlarged,  and  the  temperature  continuous,  or  with  very 
slight  remissions.  The  gestivo-autumnal  variety  of  the  malarial  parasite  may 
not  be  present  in  the  circulating  blood  for  several  days.  Every  year  we  had 
one  or  two  cases  in  which  the  diagnosis  was  in  doubt  for  a  few  days. 

Pycemia. — The  long-continued  fever  of  obscure,  deep-seated  suppuration, 
without  chills  or  sweats,  may  simulate  typhoid.  The  more  chronic  cases  of 
ulcerative  endocarditis  are  usually  diagnosed  enteric  fever.  The  presence  or 
absence  of  leucocytosis  is  an  important  aid.  The  Widal  reaction  and  the  blood 
cultures  now  offer  additional  and  valuable  help. 

Acute  miliary  tuberculosis  is  not  infrequently  mistaken  for  typhoid  fever. 
The  points  in  differential  diagnosis  will  be  discussed  under  that  disease.    Tuber- 


96  SPECIFIC  INFECTIOUS  DISEASES. 

culous  peritonitis  in  certain  of  its  forms  may  closely  simiilate  typhoid  fever, 
and  "vrill  be  referred  to  in  another  section. 

The  early  abdominal  pain^  etc.,  may  lead  to  the  diagnosis  of  appendicitis. 
(See  Appendicitis.) 

Prognosis. —  (a)  Death-rate. — The  mortality  is  very  variable,  ranging  in 
private  practice  from  5  to  12  and  in  hospital  practice  from  T  to  20  per  cent. 
In  some  large  epidemics  the  death-rate  has  been  very  low.  In  the  Maidstone 
epidemic  it  was  between  7  and  8  per  cent.  In  recent  years  the  mortality  from 
tA'phoid  fever  has  certainly  diminished,  and,  nnder  the  influence  of  Brand,  the 
reintroduction  of  hydrotherapy  has  reduced  the  death-rate  in  institutions  in  a 
remarkable  manner,  even  as  low  as  5  or  6  per  cent.  Of  the  1,500  cases  treated 
in  my  wards,  9.1  per  cent  died.  The  mortality  in  the  Spanish- American  War 
was  very  low — T  per  cent — and  may  be  attributed  to  the  picked  set  of  men  and 
to  the  care  and  attention  which  the  patients  received.  In  South  Africa  the 
mortality-  was  20.9  per  cent  to  March  31,  1901. 

(&)  Special  Features  in  Prognosis. — ^Unfavorable  s^miptoms  are  high  fever, 
tosic  symptoms  with  delirium,  meteorism,  and  haemorrhage.  Fat  subjects 
stand  typhoid  fever  badly.  The  mortality  in  women  is  greater  than  in  men. 
The  complications  and  dangers  are  more  serious  in  the  ambulatory  form  in 
which  the  patient  has  kept  about  for  a  week  or  ten  days.  Early  involvement 
of  the  nervous  system  is  a  bad  indication;  and  the  low,  muttering  delirium 
with  tremor  means  a  close  fight  for  life.  Prognostic  signs  from  the  fever  alone 
are  deceptive.  A  temperature  above  10-1°  may  be  well  borne  for  many  days 
if  the  nervous  system  is  not  involved. 

(c)  Sudden  Death. — It  is  difficult  in  many  cases  to  explain  this  most 
lamentable  of  accidents  in  the  disease.  There  are  cases  in  which  neither  cere- 
bral, renal,  nor  cardiac  changes  have  been  found;  there  are  instances  too  in 
which  it  does  not  seem  likely  that  there  could  have  been  a  special  localization 
of  the  toxins  in  the  pneumogastric  centres.  McPhedran,  in  reporting  a  case 
of  the  kind,  in  which  the  post  mortem  showed  no  adequate  cause  of  death,  sug- 
gests that  the  experiments  of  McWilliam  on  sudden  cardiac  failure  probably 
explain  the  occurrence  of  death  in  certain  of  the  cases  in  which  neither  em- 
bolism nor  uraemia  is  present.  Under  conditions  of  abnormal  nutrition  there 
is  sometimes  induced  a  state  of  delirium  cordis,  which  may  occur  spontane- 
ously, or,  in  the  case  of  animals,  on  slight  irritation  of  the  heart,  with  the  result 
of  extreme  irregularity  and  finally  failure  of  action.  Sudden  death  occurs 
more  frequently  in  men  than  in  women,  according  to  Dewevre's  statistics,  in 
a  proportion  of  114  to  26.  It  may  occur  at  the  height  of  the  fever,  and,  as 
pointed  out  by  Graves,  may  also  happen  during  convalescence.  There  were 
four  cases  in  my  series. 

Prophylaxis. — In  cities  the  prevalence  of  typhoid  fever  is  directly  propor- 
tionate to  the  inefficiency  of  the  drainage  and  the  water-supply.  With  their 
improvement  the  mortality  has  been  reduced  one-half  or  even  more.  Fulton 
has  shown  that  in  the  United  States,  at  least,  the  disease  exists  to  a  propor- 
tionately greater  extent  in  the  country  than  it  does  in  the  city,  and  that  the 
propagation  of  this  disease  is  in  general  from  the  country  to  the  town.  In  the 
water-supply  of  the  latter  the  chances  for  dilution  of  the  contaminating  fluids 
are  so  much  greater  than  in  the  country,  where  the  privy  vault  is  often  in 
such  close  proximit}'  to  the  well. 


TYPHOID  FEVER.  97 

But  it  is  not  only  through  water  that  the  disease  is  transmitted.  Other 
methods  play  an  important  though  not  so  frequent  role.  The  bacilli  may  be 
carried  by  milk,  oysters,  uncooked  vegetables,  etc.  Flies  play  an  important 
role  in  the  spread  of  the  disease.  Many  cases  undoubtedly  arise  by  direct 
infection.  But  through  whatever  channel  the  infection  occurs,  for  new  cases 
to  arise  the  virus  must  be  obtained  from  another  patient.  It  has  been  dem- 
onstrated by  Jordan,  Eussell,  Zeit  and  others  that  under  ordinary  circum- 
stances the  bacilli  do  not  live  and  thrive  long  outside  the  body.  To  stamp  out 
typhoid  fever  requires  (1)  the  recognition  of  all  cases,  including  the  typhoid 
carriers,  and  (2)  the  destruction  of  all  typhoid  bacilli  as  they  leave  the  patient. 
It  is  as  much  a  part  of  the  physician's  duty  to  look  after  these  points  as  to 
take  care  of  the  patient.    Mild  cases  of  fever  are  to  be  regarded  with  suspicion. 

From  the  standpoint  of  prophylaxis,  the  question  practically  narrows  down 
to  disinfection  of  the  urine,  stools,  sputum .  ( in  the  few  cases  where  bacilli  are 
present),  and  of  objects  which  may  accidentally  be  contaminated  by  these 
excretions. 

The  nurse  or  attendant  should  be  taught  to  regard  every  specimen  of  urine 
as  a  pure  culture  of  typhoid  bacilli,  and  to  exercise  the  greatest  care  in  pre- 
venting the  scattering  of  drops  of  urine  over  the  patient,  bedding  or  floor,  or 
over  the  hands  of  the  attendant. 

To  disinfect  the  urine  the  best  solutions  are  carbolic  acid,  1-30,  _  in  an 
amount  equal  to  that  of  the  urine,  or  bichloride  of  mercury,  1-1,000,  in  an 
amount  one-fifteenth  that  of  the  fluid  to  be  sterilized.  These  mixtures  with 
the  urine  should  stand  at  least  two  hours. 

Urotropin  causes  disappearance  of  the  bacilli  from  the  urine  when  bacil- 
luria  is  present,  but  under  no  circumstances  should  its  administration  permit 
the  disinfection  of  the  urine  to  be  neglected. 

To  disinfect  stools  carbolic  acid  is  the  most  useful.  It  is  cheap,  and  efficient 
when  used  in  strong  solutions.  The  stool  should  be  mixed  with  at  least  twice 
its  volume  of  1-20  carbolic-acid  solution  and  allowed  to  stand  for  several  hours. 

With  hydrotherapy  the  disinfection  of  the  bath  water  after  use  offers  a  seri- 
ous and  somewhat  difficult  problem. 

E.  Babucke  has  sought  experimentally  the  best  method  for  the  disinfec- 
tion of  the  bath  water.  He  found  chloride  of  lime  the  best  substance  to  use, 
and- found  that  even  where  the  water  contains  coarse  fecal  matter,  '250  gm. 
(one-half  pound)  of  chloride  of  lime  will  render  the  ordinary  bath  of  200 
litres  sterile  in  one-half  hour. 

If  there  be  any  expectoration,  the  sputum  should  receive  the  same  care  as 
in  tuberculosis.    It  is  best  to  collect  it  in  small  cloths,  which  may  be  burned. 

All  the  linen  leaving  the  patient's  bed  or  person  should  be  soaked  for  two 
hours  in  1-20  carbolic-acid  solution,  and  then  sent  to  the  laundry,  where  it 
should  be  boiled.    All  dishes  should  be  boiled  before  leaving  the  patient's  room. 

The  nurse  should  wear  a  rubber  apron  when  giving  tubs  or  working  over 
a  typhoid  patient,  and  this  should  be  washed  frequently  with  a  carbolic  acid 
or  bichloride  of  mercury  solution.  The  nurse  should  wear  rubber  gloves  when 
giving  tubs,  or  else  soak  her  hands  thoroughly  in  1-1,000  bichloride  solution, 
after  she  has  finished. 

It  is  impossible  here  to  deal  with  all  the  possible  modes  of  spread  of 'the 
infection.     Keeping  in  mind  that  everything  leaving  the  patient  should  be 


98  SPECIFIC  INFECTIOUS  DISEASES. 

sterilized  whenever  there  is  a  chance  of  its  having  been  contaminated  by  the 
discharges,  a  nurse  of  ordinary  intelligence,  even  one  of  the  family,  can  carry 
-out  very  satisfactory  prophylaxis. 

Should  the  typhoid  fever  patient  be  isolated?  To  prevent  direct  infection 
of  other  members  of  the  family  a  moderate  degree  of  isolation  should  be  car^ 
ried  out,  though  this  need  not  be  absolute  as  in  the  exanthemata.  The  win- 
dows should  have  fly  screens  in  summer.  After  recovery  the  room  should  be 
disinfected. 

An  important  question  is  as  to  the  necessity  for  the  isolation  of  typhoid 
patients  in  special  wards  in  hospitals.  At  present  this  is  not  generally  done  in 
the  United  States.  When,  however,  in  a  hospital  with  as  good  sanitary  arrange- 
ments as  the  Johns  Hopkins  possesses,  and  in  vfhich  all  possible  precautions 
are  taken  to  prevent  the  infection  spreading  from  patient  to  patient,  1.81  per 
cent  of  all  the  cases  have  been  of  hospital  origin,  the  advisability  of  isolation 
of  typhoid  fever  patients  is  certainly  worth  considering.  On  the  other  hand, 
in  the  general  hospital,  with  students  in  the  wards,  the  cases  are  more  thor- 
oughly studied,  and  in  the  graver  complications,  as  perforation,  it  is  of  the 
greatest  advantage  to  have  the  early  co-operation  of  the  house  surgeon. 

During  the  past  few  years  an  active  campaign  has  been  started  in  Ger- 
many, under  the  leadership  of  Professor  Koch,  with  the  object  of  ultimately 
stamping  out  this  disease  by  means  of  early  diagnosis  and  the  institution  of 
rigid  measures  for  j)reventing  the  distribution  of  the  infecting  agent  from  the 
patients  so  diagnosed.  With  a  corps  of  assistants  he  fitted  up  a  laboratory  in 
Trier,  a  localit}'^  where  the  disease  had  a  firm  hold.  By  bacteriological  methods 
he  was  able  to  demonstrate  that  72  persons  were  suffering  from  typhoid  infec- 
tion. So  soon  as  the  nature  of  a  case  was  established,  isolation  and  vigorous 
disinfection  were  practiced.  The  result  was  that  within  three  months  no  more 
typhoid  bacilli  were  discoverable,  the  patients  were  cured,  no  fresh  cases  arose, 
and,  so  far  as  that  group  of  villages  was  concerned,  typhoid  was  exterminated. 
Since,  in  other  groups  of  villages  situated  under  strictly  comparable  conditions, 
but  where  these  methods  of  dealing  with  the  disease  were  not  practiced,  typhoid 
continues  to  be  prevalent,  it  may  reasonably  be  inferred  that  the  disappearance 
at  Trier  was  not  spontaneous,  but  due  to  the  methods  of  identification  and  dis- 
infection which  were  used. 

When  epidemics  are  prevalent  the  drinking-water  and  the  milk  used  in 
families  should  be  boiled.  Travellers  should  drink  light  wines  or  mineral 
water  rather  than  ordinary  water  or  milk.  Care  should  be  taken  to  thor- 
oughly cook  oysters  which  have  been  fattened  or  freshened  in  streams  con- 
taminated with  sewage. 

While  in  camps  it  is  easy  to  boil  and  filter  the  water;  with  troops  on 
the  march  it  is  a  very  different  matter,  and  it  is  impossible  to  restrain  men 
from  relieving  their  thirst  the  moment  they  reach,  water.  Various  chemical 
methods  have  been  recommended — the  use  of  bromine,  hypochlorite  of  lime, 
permanganate  of  potassium,  and  the  tablets  of  sodium  bisulphate,  none  of 
which  are  probably  very  satisfactory. 

Vaccination. — A.  E.  Wright  has  introduced  a  method  of  vaccination 
against  typhoid.  A  full  description  of  the  principles  involved,  as  well  as  of  the 
technique,  is  given  in  his  work,  A  Short  Treatise  on  Anti-Typhoid  Inoculation, 
London,  1901.     The  material  used  is  a  bouillon  culture  of  virulent  bacilli 


TYPHOID  FEVER.  99 

heated  to  60°  in  order  to  kill  them.  By  a  somewhat  complicated  procedure  the 
number  of  bacteria  in  this  culture  is  estimated,  and  for  the  first  inoculation 
a  quantity  of  the  vaccine  containing  750  to  1,000  millions  of  bacteria  is 
employed,  and  for  the  second  inoculation  a  quantity  containing  1,500  to 
2,000  millions  of  bacilli  is  employed.  Two  inoculations  are  given  at  an 
interval  of  about  two  weeks.  Following  inoculation  there  is  a  mild  local 
reaction  and  constitutional  symptoms  begin  within  two  or  three  hours.  As 
a  sequence  of  the  injection,  there  is  an  increase  in  both  the  bactericidal 
and  agglutinating  powers  of  the  blood.  Many  thousand  inoculations  have 
now  been  made  under  Wright's  direction,  mainly  on  the  British  troops  in 
India  and  South  Africa.  From  the  statistics  so  far  available  he  concludes 
that  the  incidence  of  typhoid  fever  was  diminished  by  at  least  one-half  in 
the  inoculated,  while  in  the  aggregate  the  proportion  of  deaths  to  cases  among 
the  inoculated  has  been  rather  less  than  half  that  among  the  uninoculated. 
The  evidence  so  far  points  to  a  persistence  of  the  protective  effect  for  at  least 
two  years  after  inoculation.  Wright's  conclusions  are  supported  by  the  evi- 
dence of  a  large  number  of  English  army  officers.  Wherever,  therefore,  large 
bodies  of  persons  are  likely  to  be  exposed  to  unusual  dangers  of  infection  the 
procedure  may  be  employed. 

Treatment. — {a)  Geneeal  Management. — The  profession  was  long  in 
learning  that  typhoid  fever  is  not  a  disease  to  be  treated  mainly  with  drugs. 
Careful  nursing  and  a  regulated  diet  are  the  essentials  in  a  majority  of  the 
cases.  The  patient  should  be  in  a  well-ventilated  room  (or  in  summer  out 
of  doors  during  the  day),  strictly  confined  to  bed  from  the  outset,  and  there 
remain  until  convalescence  is  well  established.  The  bed  should  be  single,  not 
too  high,  and  the  mattress  should  not  be  too  hard.  The  woven  wire  bed,  with 
soft  hair  mattress,  upon  which  are  two  folds  of  blanket,  combines  the  two 
great  qualities  of  a  sick-bed,  smoothness  and  elasticity.  A  rubber  cloth  should 
be  placed  under  the  sheet.  An  intelligent  nurse  should  be  in  charge.  When 
this  is  impossible,  the  attending  physician  should  write  out  specific  instruc- 
tions regarding  diet,  treatment  of  the  discharges,  and  the  bed-linen, 

(&)  Diet. — Milk,  eggs,  and  water  are  the  essential  foods  during  the 
febrile  period.  An  adult  receives  four  ounces  of  milk,  diluted  with  two  ounces 
of  lime-water  or  soda-water,  every  four  hours ;  and  four  ounces  of  albumen- 
water,  made  from  the  white  of  one  or  two  eggs,  every  four  hours.  In  this 
way  he  is  fed  every  two  hours.  The  juice  of  half  a  lemon  or  an  ounce  of 
fresh  orange  juice  is  added  to  the  albumen-water,  which  may  be  sweetened 
with  a  little  sugar.  The  great  majority  of  our  patients  have  this  diet  alone 
during  the  fever.  Whey  is  substituted  for  the  milk  i"f  there  are  curds  in 
the  stools  or  if  there  is  much  distention  or  if  the  plain  milk  disagrees  in 
any  way.  If  necessary,  milk  is  cut  off  altogether  and  the  albumen-water 
increased.  Buttermilk,  boiled  milk,  koumiss,  or  peptonized  milk  may  be 
used.  The  beef  extracts,  meat  juices,  and  artificially  prepared  foods  are 
unnecessary,  and  in  private  practice  among  people  in  moderate  circumstances 
add  greatly  to  the  expense  of  the  illness.  Such  a  diet  is  simple,  reduces  the 
work  of  feeding  to  a  minimum,  and  agrees  with  a  great  majority  of  all 
patients.  Water  is  given  at  fixed  intervals.  A  good  plan  is  to  have  a  jug 
of  water  beside  the  patient  and  a  tubing  with  a  glass  mouth-piece,  so  that  he 
can  drink  as  much  as  he  wishes.    A  washing-out  plan  of  treatment  is  advised 


100  SPECIFIC  INFECTIOUS  DISEASES. 

by  E.  W.  Gushing  and  T.  W.  Clarke,  of  the  Lake-side  Hospital,  Cleveland. 
A  gallon  or  more  may  be  taken  in  the  day.  The  water  causes  polyuria,  and  is 
a  sort  of  internal  hydrotherapy  by  which  the  toxins  may  be  washed  out. 
Barley  water,  lemonade,  or  iced-tea  may  be  used.  A  small  cup  of  coffee  in  the 
morning  is  very  grateful.  Bouillon  or  strained  vegetable  soup  may  serve  as  a 
change.  Ice  cream  ma}'  be  taken  at  any  time,  and  is  an  agreeable  variation, 
particularly  for  children. 

It  is  possible  that  we  give  too  much  food.  Of  late  years  the  disease  has 
been  treated  by  what  has  been  called  therapeutic  fasting — ^little  or  no  food, 
only  water. 

Alcohol  is  unnecessary  in  a  great  majority  of  the  cases.  Of  late  years 
I  have  used  it  much  less  freely;  but  when  the  heart  is  feeble  and  the  toxic 
symptoms  are  severe,  eight  to  twelve  ounces  of  whisky  may  be  given  in  the 
twenty- four  hours. 

(c)  Htdeotherapy. — The  use  of  water,  inside  and  outside,  was  no  new 
treatment  in  fevers  at  the  end  of  the  eighteenth  century,  when  James  Currie 
(a  friend  of  Burns  and  the  editor  of  his  poems)  wrote  his  Medical  Reports 
on  the  Effects  of  Water,  Cold  and  Warm,  as  a  Eemedy  in  Fevers  and  other 
Diseases.  In  this  country  it  was  used  with  great  effect  and  recommended 
strongly  by  Xathan  Smith,  of  Yale.  Since  1861  the  value  of  bathing  in 
fevers  has  been  specially  emphasized  by  the  late  Dr.  Brand,  of  Stettin. 

Hydrotherapy  may  be  carried  out  in  several  different  ways,  of  which, 
in  typhoid  fever,  the  most  satisfactorv  are  sponging,  the  wet  pack,  and  the 
full  bath. 

(a)  Cold  Sponging. — The  water  may  be  tepid,  cold,  or  ice-cold,  according 
to  the  height  of  the  fever.  A  thorough  sponge-bath  should  take  from  fifteen 
to  twenty  minutes.  The  ice-cold  sponging  is  not  quite  as  formidable  as  the 
full  cold  bath,  for  which,  when  there  is  an  insuperable  objection  in  private 
practice,  it  is  an  excellent  alternative.  But  frequently  it  is  difficult  to  get 
the  friends  to  appreciate  the  advantages  of  the  sponging.  When  such  is  the 
case,  and  in  children  and  delicate  persons,  it  can  be  made  a  little  less  for- 
midable by  sponging  limb  by  limb  and  then  the  back  and  abdomen. 

(&)  The  cold  pacTv  is  not  so  generall}^  useful  in  typhoid  fever,  but  in 
eases  with  very  pronounced  nervous  symptoms,  if  the  tub  is  not  available, 
the  patient  may  be  wrapped  in  a  sheet  wrung  out  of  water  at  60°  or  65°,  and 
then  cold  water  sprinkled  over  him  with  an  ordinary  watering-pot. 

(c)  The  Bath. — The  tub  should  be  long  enough  so  that  the  patient  can 
be  completely  covered  except  his  head.  Our  rule  for  some  years  has  been 
to  give  a  bath  at  70°  every  third  hour  when  the  temperature  was  above  103.5°. 
The  patient  remains  in  the  tub  for  fifteen  or  twenty  minutes,  is  taken  out, 
wrapped  in  a  dry  sheet,  and  covered  with  a  blanket.  Wliile  in  the  tub  the 
limbs  and  trunk  are  rubbed  thoroughly,  either  with  the  hand  or  with  a  suit- 
able rubber.  It  is  well  to  give  the  first  one  or  two  baths  at  a  temperature 
of  80°  or  85°.  There  is  no  routine  temperature.  If  the  bath  at  70°  is  not 
well  taken,  raise  the  temperature  to  75°  or  80°.  It  is  important  to  see  that 
the  canvas  supports  are  properly  arranged,  and  that  the  rubber  pillow  is  com- 
fortable for  the  patient's  head.  The  first  bath  should  not  be  given  at  night, 
and  it  should  be  superintended  by  the  house-physician.  The  amount  of  com- 
plaint made  by  the  patient  is  largely  dependent  upon  the  skill  and  care  with 


TYPHOID  FEVER. 


101 


which  the  baths  are  given.  Food  is  usually  given,  sometimes  a  stimulant, 
after  the  bath.  The  blueness  and  shivering,  which  often  follow  the  bath, 
are  not  serious  features.  The  rectal  temperature  is  taken  immediately  after 
the  bath,  and  again  three-quarters  of  an  hour  later.  Contra-indications  are 
peritonitis,  hasmorrhage,  phlebitis,  severe  abdominal  pain,  and  great  pros- 
tration.    The  accompanying  chart   (Chart  V)   shows  the  number  of  baths 


June  li 
Temp 
109 

108 

107 

IOC 

lOS 

m 

103 
102 
101 

100 

99 

08 

97 

96 
Temp 

Pulse 

Resp 

Stoois 


Day  of    yj 
Disease. 


M  G  H 


,  n         20  ■!,  28  24         24  „    1  3  j  S      M 


I  I 


Chart  V. 


and  the  influence  on  the  fever  during  two  days  of  treatment.  The  good 
effects  of  the  baths  are :  (1)  The  effect  on  the  nervous  system.  The  delirium 
lessens,  the  tremor  diminishes,  and  the  toxic  features  are  less  marked.  The 
excretion  of  the  toxins  by  the  kidneys  is  stimulated.  (2)  The  fever  is  re- 
duced, though  this  is  not  the  chief  effect  of  the  tubs ;  indeed  at  the  height  of 
the  disease  there  may  be  very  little  reduction.  (3)  The  heart  rate  usually 
falls,  the  pulse  becomes  smaller  and  harder,  and  the  blood  pressure  rises  15 
or  20  mm.  of  Hg.  (4)  With  hydrotherapy  the  initial  bronchitis  is  bene- 
fited, and  there  is  less  chance  of  passive  congestion  of  the  bases  of  the  lungs. 
(5)  The  liability  to  bed-sores  is  diminished  and  the  frequent  cleansing  of  the 
skin  is  beneficial.  Should  boils  occur,  one  bath-tub  should  be  used  for  that 
patient  alone.  (6)  The  mortality  is  reduced.  In  general  hospitals  from 
six  to  eight  patients  in  every  hundred  are  saved  by  this  plan  of  treatment. 
At  the  Brisbane  Hospital,  where  F.  E.  Hare  used  it  so  thoroughly,  the  mortal- 
ity was  reduced  from  14.8  per  cent  to  7.5.  There  is  a  remarkable  uniformity 
in  the  death-rate  of  institutions  using  the  method — usually  from  6  to  8  per 


102  SPECIFIC  INFECTIOUS  DISEASES. 

cent.  At  the  Eoyal  Victoria  Hospital,  Montreal,  the  rate  for  the  six  years 
was  5.4  per  cent.  At  the  Johns  Hopkins  Hospital  the  mortality  among  1,500 
cases  was  137,  or  9.1  per  cent. 

(d)  Medicinal  Treatment. — In  hospital  practice  medicines  are  not 
often  needed.  A  great  majority  of  my  cases  do  not  receive  a  dose.  In  private 
practice  it  may  be  safer,  for  the  young  practitioner  especially,  to  order  a 
mild  fever  mixture.  The  question  of  medicinal  antipyretics  is  important: 
they  are  used  far  too  often  and  too  rashly  in  typhoid  fever.  An  occasional 
dose  of  antifebrin  or  antipyrin  may  do  no  harm,  but  the  daily  use  of  these 
drugs  is  most  injurious.  Quinine  in  moderate  doses  is  still  much  employed. 
The  local  use  of  guaiacol  on  the  skin,  3ss.  painted  on  the  flank,  causes  a  prompt 
fall  in  the  temperature. 

In  the  various  antiseptic  drugs  which  have  been  advised  I  have  no  faith. 
Most  of  them  do  no  harm,  except  that  in  private  practice  their  use  has  too 
often  diverted  the  practitioner  from  more  rational  and  safer  courses. 

(e)  Serum  Therapy. — Numerous  attempts  have  been  made  to  obtain 
specific  sera,  which  have  been  of  two  varieties,  bactericidal  and  antitoxic. 
As  Wasserman  has  shown,  the  probable  reason  why  the  former  have  failed 
is  owing  to  the  lack  of  sufficient  complement  in  the  patient's  blood,  and  at 
present  no  available  method  has  been  found  to  increase  this  complement. 
As  the  isolation  of  a  soluble  typhoid  toxin  has  presented  insuperable  difficul- 
ties so  far,  it  is  questionable  whether  an  antitoxin  of  any  value  has  yet  been 
obtained.  With  the  reported  isolation  of  typhoid  toxins  of  considerable 
strength  by  Conradi,  and  also  by  Macfadyen,  it  is  possible  that  in  the  near 
future  an  antitoxin  serum  of  great  value  may  be  produced.  One  of  the  most 
important  problems  in  connection  with  this  disease  is  the  isolation  of  a  strong 
soluble  toxin,  the  results  of  which  would  probably  be  very  far-reaching. 
Chantemesse  (Presse  Med.,  1904,  jSTo.  86)  has  published  the  results  obtained 
in  several  of  the  Paris  hospitals  with  an  antitoxic  serum.  The  toxin  is 
obtained  in  the  filtered  cultures  of  typhoid  bacilli  grown  on  a  medium  con- 
taining splenic  pulp  and  human  defibrinated  blood.  By  injection  of  this  into 
horses  a  serum  has  been  produced,  which,  during  a  period  of  three  and  a  half 
years,  has  been  employed  in  the  treatment  of  765  cases,  545  by  Chantemesse 
himself,  and  220  cases  in  children  by  Josias  and  Brunon.  Of  these  765  cases 
only  30  died,  a  mortality  of  about  4  per  cent,  while  in  the  other  Paris  hos- 
pitals during  the  same  period  there  occurred  a  mortality  of  18  per  cent,  in 
none  of  them  under  12  per  cent. 

A  third  method  is  by  means  of  the  so-called  extract  of  Jez,  by  the  use  of 
which  good  results  have  been  reported  by  Eichhorst  and  others,  though  so 
far  on  a  relatively  small  number  of  cases.  This  extract  is  obtained  from 
the  bone-marrow,  spleen,  thymus,  brain,  and  spinal  cord  of  animals  highly 
immunized  to  typhoid  bacilli.  Large  amounts  must  be  used.  Eemember- 
ing  the  considerable  period  of  time  after  the  discovery  of  the  diphtheria  anti- 
toxin before  a  serum  of  high  value  was  obtained,  it  is  not  too  much  to  hope 
that  some  of  these  experiments  may  lead  to  important  results. 

(/)  Treatment  of  the  Special  Symptoms. — The  abdominal  pain  and 
tympanites  are  best  treated  with  fomentations  or  turpentine  stupes.  The 
latter,  if  well  applied,  give  great  relief.  Sir  William  Jenner  used  to  lay 
great    stress    on   the    advantages    of   a   well-applied  turpentine    stupe.     He 


TYPHOID  FEVER.  103 

directed  it  to  be  applied  as  follows:  A  flannel  roller  was  placed  beneath  the 
patient,  and  then  a  double  layer  of  thin  flannel,  wrung  out  of  very  hot  water, 
with  a  drachm  of  turpentine  mixed  with  the  water,  was  applied  to  the  abdo- 
men and  covered  with  the  ends  of  the  roller.  When  the  gas  is  in  the  large 
bowel,  a  tube  may  be  passed  or  a  turpentine  enema  given.  For  tympanites, 
with  a  dry  tongue,  turpentine  may  be  given,  or  the  oil  of  cinnamon,  T(l  iii-v, 
every  two  hours  (Caiger).  If  whey  and  albumen-water  are  substituted  for 
milk,  the  distention  lessens.  Charcoal,  bismuth,  )8-naphthol,  and  eserine, 
•^  gr.  hypodermically,  may  be  tried.    Opium  should  not  be  given. 

For  the  diarrhoea,  if  severe — that  is,  if  there  are  more  than  three  or  four 
stools  daily — a  starch  and  opium  enema  may  be  given;  or,  by  the  mouth,  a 
combination  of  bismuth,  in  large  doses,  with  Dover's  powder;  or  the  acid 
diarrhoea  mixture,  acetate  of  lead  (gr.  ii),  dilute  acetic  acid  (tti,  xv-xx)^ 
and  acetate  of  morphia  (gr.  ^— |).  The  amount  of  food  should  be  reduced, 
and  whey  and  albumen-water  in  small  amounts  be  substituted  for  the  milk. 
An  ice-bag  or  cold  compresses  relieve  the  soreness  which  sometimes  accom- 
panies the  diarrhoea. 

Constipation  is  present  in  many  cases,  and  though  I  have  never  seen  it 
do  harm,  yet  it  is  well  every  third  or  fourth  day  to  give  an  Ordinary  enema. 
If  a  laxative  is  needed  during  the  course  of  the  disease,  the  Hunyadi-janos 
or  Friedrichshall  water  may  be  given. 

Hcemorrhage. — As  absolute  rest  is  essential,  the  greatest  care  should  be 
taken  in  the  use  of  the  bed-pan.  It  is  perhaps  better  to  allow  the  patient  to 
pass  the  motions  into  the  draw-sheet.  Ice  may  be  given,  and  a  light  ice-bag 
placed  on  the  abdomen.  The  amount  of  food  should  be  restricted  for  eight 
or  ten  hours.  If  there  is  a  tendency  to  collapse,  stimulants  should  be  given, 
and,  if  necessary,  hypodermic  injections  of  ether.  Injection  of  salt  solu- 
tion beneath  the  skin  or  directly  into  a  vein  may  revive  a  failing  heart.  Tur- 
pentine is  warmly  recommended  by  certain  authors.  Should  opium  be  given  ? 
One-fifth  of  the  cases  of  perforation  occur  with  haemorrhage,  and  the  opium 
may  obscure  the  features  upon  which  alone  the  diagnosis  of  perforation  may 
be  made.  Of  late  we  have  abandoned  the  use  of  opium  and  have  given  the 
calcium  chloride  or  lactate  in  doses  of  gr.  xv  every  four  hours.  Gelatine  we 
have  also  used  a  good  deal,  but  it  seems  of  doubtful  value. 

Perforation  and  Peritonitis. — Early  diagnosis  and  early  operation  mean 
the  saving  of  one-third  of  the  cases  of  this  heretofore  uniformly  fatal  com- 
plication. The  aim  should  be  to  operate  for  the  perforation,  and  not  to  wait 
until  a  general  peritonitis  diminishes  by  one-half  the  chances  of  recovery. 
An  incessant,  intelligent  watchfulness  on  the  part  of  the  medical  attendant 
and  the  early  co-operation  of  the  surgeon  are  essentials.  Every  case  of  more 
than  ordinary  severity  should  be  watched  with  special  reference  to  this  com- 
plication. Thorough  preparation  by  early  observation,  careful  notes,  and 
knowledge  of  the  conditions  will  help  to  prevent  needless  exploration.  No 
case  is  too  desperate;  we  have  had  one  recovery  after  three  operations. 
Twenty  cases  of  perforation  in  my  series  were  operated  upon  with  seven 
recoveries;  in  an  eighth  case  the  patient  died  of  the  toxaemia  on  the  eighth 
day  after  the  laparotomy.  The  figures  now  published  give  from  25  to  33  per 
cent  of  recoveries.  In  doubtful  cases  it  is  best  to  operate,  as  experience 
shows  that  patients  stand  an  exploration  very  well. 


104  SPECIFIC  INFECTIOUS  DISEASES. 

Cholecystitis. — A  majority  of  the  cases  recover,  but  if  the  symptoms  are 
very  severe  and  progressive,  operation  should  be  advised. 

Bone  Lesions. — The  typhoid  periostitis  of  the  ribs  or  of  the  tibia  does 
not  always  go  on  to  suppuration,  though,  as  a  rule,  it  requires  operation. 
Unless  the  practitioner  is  accustomed  to  do  very  thorough  surgical  work, 
he  should  hand  over  the  patient  to  a  competent  surgeon,  who  vidll  clear  out 
the  diseased  parts  with  the  greatest  thoroughness.  Eecurrence  is  inevitable 
unless  the  operation  is  complete. 

For  the  progressive  Jieart-wealcness,  alcohol,  strychnine  and  ether  hypo- 
dermically  in  full  doses,  digitalis,  and  the  saline  infusions  may  be  tried. 

The  nervous  symptoms  of  typhoid  fever  are  best  treated  by  hydrother- 
apy. Special  advantages  of  this  plan  are  that  the  restlessness  is  allayed, 
the  delirium  quieted,  and  sedatives  are  rarely  needed.  In  the  cases  which 
set  in  early  with  severe  headache,  meningeal  symptoms,  and  high  fever,  the 
cold  bath,  or  in  private  practice  the  cold  pack,  should  be  employed.  An 
ice-cap  may  be  placed  on  the  head,  and  if  necessary  morphia  administered 
hypodermically.  For  the  nocturnal  restlessness,  so  distressing  in  some  cases, 
Dover's  powder  should  be  given.  As  a  rule,  if  a  hypnotic  is  indicated,  it  is 
best  to  give  opium  in  some  form.  Pulmonary  complications  should,  if  severe, 
receive  appropriate  treatment. 

Bacilluria. — When  bacilli  are  present,  as  demonstrated  by  cultures  or 
shown  by  the  microscope,  urotropin  may  be  given  in  ten-grain  doses  and  kept 
lip,  if  necessary,  for  several  weeks.  A  patient  should  not  be  discharged  with 
bacilli  in  his  urine. 

In  protracted  cases  very  special  care  should  be  taken  to  guard  against  hed- 
■  sores.  Absolute  cleanliness  and  careful  drjdng  of  the  parts  after  an  evacua- 
tion should  be  enjoined.  The  patient  should  be  turned  from  side  to  side  and 
propped  with  pillows,  and  the  back  can  then  be  sponged  with  spirits.  On  the 
first  appearance  of  a  sore,  the  water-  or  air-bed  should  be  used. 

{(j)  The  Management  of  Convalescence. — Convalescents  from  typhoid 
fever  frequently  cause  greater  anxiety  than  patients  in  the  attack.  The  ques- 
tion of  food  has  to  be  met  at  once,  as  the  patient  acquires  a  ravenous  appetite 
and  clamors  for  a  fuller  diet.  My  custom  has  been  not  to  allow  solid  food 
until  the  temperature  has  been  normal  for  ten  days.  This  is,  I  think,  a  safe 
rule,  leaning  perhaps  to  the  side  of  extreme  caution ;  but,  after  all,  with  eggs, 
milk  toast,  milk  puddings,  and  jellies,  the  j)atient  can  take  a  fairly  varied 
diet.  Many  leading  practitioners  allow  solid  food  to  a  patient  so  soon  as  he 
desires  it.  Peabody  gives  it  on  the  disappearance  of  the  fever ;  the  late  Austin 
Flint  was  also  in  favor  of  giving  solid  food  early.  I  had  a  lesson  in  this 
matter  which  I  have  never  forgotten.  A  young  lad  in  the  Montreal  General 
Hospital,  in  whose  case  I  was  much  interested,  passed  through  a  tolerably 
sharp  attack  of  typhoid  fever.  Two  weeks  after  the  evening  temperature  had 
been  normal,  and  only  a  day  or  two  before  his  intended  discharge,  he  ate 
several  mutton  chops,  and  within  twenty-four  hours  was  in  a  state  of  col- 
lapse from  perforation.  A  small  transverse  rent  was  found  at  the  bottom 
of  an  ulcer  which  was  in  process  of  healing.  It  is  not  easy  to  say  why  solid 
food,  particularly  meats,  should  disagree,  but  in  so  many  instances  an  indis- 
cretion in  diet  is  followed  by  slight  fever,  the  so-called  fehris  carnis,  that  it 
is  in  the  best  interests  of  the  patient  to  restrict  the  diet  for  some  time  after 


TYPHUS  FEVER.  105 

the  fever  has  fallen.  Whether  an  error  in  diet  may  cause  relapse  is  doiibt- 
ful.  The  patient  may  be  allowed  to  sit  up  for  a  short  time  about  the  end  of 
the  first  week  of  convalescence,  and  the  period  may  be  prolonged  with  a 
gradual  return  of  strength.  He  should  move  about  slowly,  and  when  the 
weather  is  favorable  should  be  in  the  open  air  as  much  as  possible.  He 
should  be  guarded  at  this  period  against  all  unnecessary  excitement.  Emo- 
tional disturbance  not  infrequently  is  the  cause  of  recrudescence  of  the  fever. 
Constipation  is  not  uncommon  in  convalescence  and  is  best  treated  by 
enemata.  A  protracted  diarrhoea,  which  is  usually  due  to  iilceration  in  the 
colon,  may  retard  recovery.  In  such  cases  the  diet  should  be  restricted  to 
milk,  and  the  patient  should  be  confined  to  bed;  large  doses  of  bismuth  and 
astringent  injections  will  prove  useful.  The  recrudescence  of  the  fever  does 
not  require  special  measures.  The  treatment  of  the  relapse  is  essentially  that 
of  the  original  attack. 

Post-typhoid  insanity  requires  the  judicious  care  of  an  expert.  The 
cases  usually  recover.  The  swollen  leg  after  phlebitis  is  a  source  of  great 
worry.  A  bandage  should  be  worn  during  the  day  or  a  well-fitting  elastic 
stocking.  The  outlook  depends  on  the  completeness  with  which  the  col- 
lateral circulation  is  established.  In  a  good  many  cases  there  is  permanent 
disability. 

The  post-typJioid  neuritis,  a  cause  of  much  alarm  and  distress,  usually 
gets  well,  though  it  may  take  months,  or  even  a  couple  of  years,  before  the 
paralysis  disappears.  After  the  subsidence  of  the  acute  symptoms  systematic 
massage  of  the  paralyzed  and  atrophic  muscles  is  the  most  satisfactory 
treatment. 

The  condition  spoken  of  as  the  typhoid  spine  may  drag  on  for  months 
and  prove  very  obstinate.  The  neurotic  state  has  to  be  treated.  Separa- 
tion from  solicitous  and  sympathetic  friends,  hydrotherapy  in  the  form  of 
the  wet  pack,  and  the  Paquelin  cautery  are  the  most  efficacious  means  of 
cure.     An  encouraging  prognosis  may  be  followed  by  rapid  improvement. 


II.     TYPHUS    FEVER. 

Definition. — An  acute  infectious  disease  of  unknown  origin,  highly  con- 
tagious, characterized  by  sudden  onset,  maculated  r^sh,  marked  nervous  symp- 
toms, and  a  cyclical  course  terminating  by  crisis,  usually  about  the  end  of  the 
second  week.  Post  mortem  there  are  no  special  lesions  other  than  those  asso- 
ciated with  fever. 

The  disease  is  known  by  the  names  of  hospital  fever,  spotted  fever,  jail 
fever,  camp  fever,  and  ship  fever,  and  in  Germany  is  called  exanthematic 
typhus,  in  contradistinction  to  abdominal  typhus. 

Etiology. — Typhus  fever  has  been  one  of  the  great  epidemics  of  the  world. 
Until  the  middle  of  the  nineteenth  century  it  prevailed  extensively  in  all  the 
larger  cities  of  Europe,  and  at  times  extended  to  wide-spread  outbreaks.  As 
Hirsch  has  remarked,  "  The  history  of  typhus  is  written  in  those  dark  pages 
of  the  world's  story  which  tell  of  the  grievous  visitations  of  mankind  by  war, 
famine,  and  misery  of  every  kind."  Few  countries  have  suffered  more  than 
Ireland,  particularly  between  the  years  1817  and  1819  and  in  1846.    In  Eng- 


106  SPECIFIC  INFECTIOUS  DISEASES. 

land  the  disease  has  progressively  diminished  in  intensity.  In  1875  there  were 
1,499  deaths,  in  1895  only  58  deaths.  In  1897  there  were  only  3  cases  of  typhus 
fever  in  the  London  Fever  Hospitals.  In  England  and  Wales  the  disease  has 
steadily  diminished.  In  1883  there  were  877  deaths;  in  1903,  61  deaths.  Of 
late  years  the  name  typhus  has  not  appeared  in  the  Registrar-G-eneral  Report 
for  England  and  Wales.  The  last  really  great  epidemic  was  in  the  Turko- 
Eussian  War  in  1877-'78. 

The  gradual  disappearance  of  typhus  fever  is  one  of  the  great  triumphs  of 
modern  medicine.  At  present  the  disease  lurks  in  only  a  few  centres  in  Great 
Britain  and  on  the  Continent,  and  every  few  years  slight  outbreaks  occur  in 
larger  cities,  and  sporadic  cases  appear  from  time  to  time.  In  the  United 
States  typhus  fever  has  not  prevailed  as  an  extensive  epidemic  for  many  years. 
There  were  small  epidemics  in  New  York  in  1881-'82  and  in  1892-'93,  and  in 
1883  in  Philadelphia.  A  remarkable  feature  is  the  occurrence  of  a  few  cases 
at  long  intervals  of  time  from  any  other  outbreaks,  and  at  great  distances  from 
any  known  foci  of  the  disease.  This  was  one  of  the  points  which  led  Murchi- 
son  to  the  belief  that  under  favorable  conditions  it  might  originate  spontane- 
ously. Two  small  groups  of  cases  of  this  nature  have  come  under  my  observa- 
tion. In  1877  there  occurred  a  local  outbreak  at  the  House  of  Refuge,  in 
Montreal,  a  city  in  which  the  disease  had  not  existed  for  many  years.  The 
overcrowding  was  so  great  in  the  basement  rooms  of  the  refuge  that  at  night 
there  were  not  more  than  88  cubic  feet  of  space  to  each  person.  Eleven  indi- 
viduals were  affected.     It  was  not  possible  to  trace  the  source  of  infection. 

In  the  spring  of  1901  from  one  house  three  cases  of  fever  were  admitted 
to  my  wards,  which  were  regarded  at  first  as  typhoid  fever,  but  the  features  were 
so  anomalous  that  our  suspicions  were  aroused.  The  rash  was  perfectly  char- 
acteristic of  typhus,  the  Widal  reaction  was  negative,  blood  cultures  were  nega- 
tive, and  a  post-mortem  on  one  fatal  case  showed  no  typhoid  lesions,  and  no 
cultures  were  obtained  from  the  spleen  or  the  blood  post-mortem.  The  other 
two  cases  terminated  by  crisis,  so  that  I  think  there  can  be  no  question  that 
the  cases  were  typhus  fever.  The  disease  has  not  prevailed  in  Baltimore  for  more 
than  a  quarter  of  a  century.  The  patients  were  Lithuanians,  they  lived  under 
most  unsanitary  conditions,  and  were  workers  at  a  suburb  frequented  by  a  great 
many  foreigners  from  the  eastern  parts  of  Europe.  The  origin  of  the  outbreak 
could  not  be  traced,  nor  did  any  other  cases  occur. 

Typhus  is  one  of  the  most  highly  contagious  of  febrile  affections.  In  epi- 
demics, nurses  and  doctors  in  attendance  are  almost  invariably  attacked.  There 
is  no  disease  which  has  had  so  many  victims  in  the  profession.  It  is  stated 
that  in  a  period  of  twenty-five  years,  among  1,230  physicians  attached  to  institu- 
tions in  Ireland,  550  succumbed  to  this  disease.  Casual  attendance  upon  cases 
in  limited  epidemics  does  not  appear  to  be  very  risky,  but  when  the  sick  are 
aggregated  in  wards  the  poison  appears  concentrated  and  the  danger  of  infec- 
tion is  much  enhanced.  Bedding  and  clothes  retain  the  poison  for  a  long  time. 
Murchison  thought  that  the  virus  was  thrown  off  from  the  lungs  and  from  the 
skin.  It  attaches  itself  particularly  to  the  clothing  and  linen  and  to  the  furni- 
ture of  the  room,  and  appears  to  retain  its  activity  for  a  remarkably  long  time. 
To  catch  the  disease  there  apparently  must  be  fairly  intimate  contact  with  the 
patient,  more  particularly  contact  with  a  large  number  of  patients.  Thus  in 
mild  outbreaks  of  only  a  few  cases  physicians  and  nurses  are  rarely  affected. 


TYPHUS  FEVER.  107 

while  in  severe  epidemics  all  in  attendance  may  be  attacked.  Nothing  has  yet 
been  determined  as  to  the  nature  of  the  specific  virus. 

Morbid  Anatomy. — The  anatomical  changes  are  those  which  result  from 
intense  fever.  The  blood  is  dark  and  fluid ;  the  muscles  are  of  a  deep  red  color, 
and  often  show  a  granular  degeneration,  particularly  in  the  heart ;  the  liver  is 
enlarged  and  soft  and  may  have  a  dull  clay-like  lustre ;  the  kidneys  are  swollen ; 
there  is  moderate  enlargement  of  the  spleen,  and  a  general  hyperplasia  of  the 
lymph-follicles.  Peyer's  glands  are  not  ulcerated.  Bronchial  catarrh  is  usu- 
ally, and  hypostatic  congestion  of  the  lungs  often,  present.  The  skin  shows 
the  petechial  rash. 

Symptoms. — Incubation. — This  is  placed  at  about  twelve  days,  but  it  may 
be  less.  There  may  be  ill-defined  feelings  of  discomfort.  As  a  rule,  however, 
the  invasion  is  abrupt  and  marked  by  chills  or  a  single  rigor,  followed  by  fever. 
The  chills  may  recur  during  the  first  few  days,  and  there  is  headache  with  pains 
in  the  back  and  legs.  There  is  early  prostration,  and  the  patient  is  glad  to 
take  to  his  bed  at  once.  The  temperature  is  high  at  first,  and  may  attain  its 
maximum  on  the  second  or  third  day.  The  pulse  is  full,  rapid,  and  not  so 
frequently  dicrotic  as  in  typhoid.  The  tongue  is  furred  and  white,  and  there 
is  an  early  tendency  to  dryness.  The  face  is  flushed,  the  eyes  congested,  and 
the  expression  dull  and  stupid.  Vomiting  may  be  a  distressing  symptom.  In 
severe  cases  mental  symptoms  are  present  from  the  outset,  either  a  mild  febrile 
delirium  or  an  excited,  active,  almost  maniacal  condition.  Bronchial  catarrh 
is  common. 

Stage  of  Eruption. — From  the  third  to  the  fifth  day  the  eruption  appears 
— first  upon  the  abdomen  and  upper  part  of  the  chest,  and  then  upon  the 
extremities  and  face;  occurring  so  rapidly  that  in  two  or  three  days  it  is  all 
out.  There  are  two  elements  in  the  eruption :  a  subcuticular  mottling,  "  a 
fine,  irregular,  dusky  red  mottling,  as  if  below  the  surface  of  the  skin  some 
little  distance,  and  seen  through  a  semi-opaque  medium"  (Buchanan)  ;  and 
distinct  papular  rose-spots  which  change  to  petechise.  In  some  instances  the 
petechial  rash  comes  out  with  the  rose-spots.  Collie  describes  the  rash  as  con- 
sisting of  three  parts:  rose-colored  spots  which  disappear  on  pressure,  dark- 
red  spots  which  are  modified  by  pressure,  and  petechias  upon  which  pressure 
produces  no  effect.  In  children  the  rash  at  first  may  present  a  striking  resem- 
blance to  that  of  measles,  and  give  as  a  whole  a  curiously  mottled  appearance  to 
the  skin.  The  term  mulberry  rash  is  sometimes  applied  to  it.  In  mild  cases  the 
eruption  is  slight,  but  even  then  is  largely  petechial  in  character.  As  the  rash  is 
hasmorrhagic,  it  does  not  disappear  after  death.  Usually  the  skin  is  dry,  so  that 
sudaminal  vesicles  are  not  common.  It  is  stated  by  some  authors  that  a  distinc- 
tive odor  is  present.  During  the  second  week  the  general  symptoms  are  much 
aggravated.  The  prostration  becomes  more  marked,  the  delirium  more  intense, 
and  the  fever  rises.  The  patient  lies  on  his  back  with  a  dull  expressionless  face, 
flushed  cheeks,  injected  conjunctivae,  and  contracted  pupils.  The  pulse  increases 
in  frequency  and  is  feebler;  the  face  is  dusky,  and  the  condition  becomes  more 
serious.  Eetention  of  urine  is  common.  Coma-vigil  is  frequent,  a  condition 
in  which  the  patient  lies  with  open  eyes,  but  quite  unconscious ;  with  it  there 
may  be  subsultus  tendinum  and  picking  at  the  bedclothes.  The  tongue  is  dry, 
brown,  and  cracked,  and  there  are  sordes  on  the  teeth.  Kespiration  is  accel- 
erated, the  heart's  action  becomes  more  and  more  enfeebled,  and  death  takes 


108  SPECIFIC  INFECTIOUS  DISEASES. 

place  from  eshaiisTion.  In  favorable  cases,  about  the  end  of  the  second  week 
occurs  the  crisis,  in  "n'hich,  often  after  a  deep  sleep,  the  patient  awakes  feeling 
much  better  and  with  a  clear  mind.  The  temperature  falls,  and  although  the 
prostration  may  be  extreme,  convalescence  is  rapid  and  relapse  very  rare.  This 
abrupt  termination  by  crisis  is  in  striking  contrast  to  the  mode  of  termination 
in  typhoid  fever. 

Fever. — The  temperature  rises  steadily  during  the  first  four  or  five  days, 
and  the  morning  remissions  are  not  marked.  The  maximum  is  usually  attained 
by  the  fifth  day,  when  the  temperature  may  be  105°,  106'',  or  107°.  In  mild 
cases  it  seldom  rises  above  103°.  After  reaching  its  maximum  the  fever  gen- 
erally continues  with  slight  morning  remissions  until  the  twelfth  or  fourteenth 
day,  when  the  crisis  occurs,  during  which  the  temperature  may  fall  below  nor- 
mal within  twelve  or  twentv^-four  hours.  Preceding  a  fatal  termination,  there 
is  usually  a  rapid  rise  in  the  fever  to  108°  or  even  109°. 

The  heart  may  early  show  signs  of  weakness.  The  first  sound  becomes 
feeble  and  almost  inaudible,  and  a  systolic  murmur  at  the  apex  is  not  infre- 
quent. Hypostatic  congestion  of  the  lungs  occurs  in  all  severe  cases.  The 
brain  symjjtoms  are  usually  more  pronounced  than  in  typhoid,  and  the  delirium 
is  more  constant.     A  slight  leucocytosis  is  more  common  than  in  typhoid. 

The  urine  in  typhus  shows  the  usual  febrile  increase  of  urea  and  uric  acid. 
The  chlorides  diminish  or  disappear.  Albumin  i^  present  in  a  large  proportion 
of  the  cases,  but  nephritis  seldom  occurs. 

Variations  in  the  course  of  the  disease  are  naturally  common.  There  are 
malignant  cases  which  rapidly  prove  fatal  within  two  or  three  days;  the 
so-called  typhus  siderans.  On  the  other  hand,  during  epidemics  there  are 
extremely  mild  cases  in  which  the  fever  is  slight,  the  delirium  absent,  and  con- 
valescence is  established  by  the  tenth  day. 

CoMPLiCATioxs  AXD  SEQUELS. — Bronclio-pneumonia  is  perhaps  the  most 
common  complication.  It  may  pass  on  to  gangrene.  In  certain  epidemics 
gangrene  of  the  toes,  the  hands,  or  the  nose,  and  in  children  noma  or  cancrum 
oris,  have  occurred.  Meningitis  is  rare.  Paralyses,  which  are  probably  due 
to  a  post-febrile  neuritis,  are  not  very  uncommon.  Septic  processes,  such  as 
parotitis  and  abscesses  in  the  subcutaneous  tissues  and  in  the  joints,  are  occa- 
sionally met  with.     Xephritis  is  rare.    Htematemesis  may  occur. 

Prognosis. — The  mortality  ranges  in  difEerent  epidemics  from  12  to  20  per 
cent.  It  is  very  slight  in  the  young.  Children,  who  are  quite  as  frequently 
attacked  as  adults,  rarely  die.  After  middle  age  the  mortality  is  high,  in  some 
epidemics  50  per  cent.  Death  usually  occurs  toward  the  close  of  the  second 
week  and  is  due  to  the  toxemia.  In  the  third  week  it  more  commonly  results 
from  pneumonia. 

Diagnosis. — During  an  epidemic  there  is  rarely  any  doubt,  for  the  disease 
presents  distinctive  general  characters.  Isolated  cases  may  be  very  difficult  to 
distinguish  from  typhoid  fever.  "While  in  typical  instances  the  eruption  in 
the  two  affections  is  very  difEerent,  yet  taken  alone  it  may  be  deceptive,  since 
in  typhoid  fever  a  roseolous  rash  may  be  abundant  and  there  may  be  occasion- 
ally a  subcuticular  mottling  and  even  petechiEe.  The  difference  in  the  onset, 
particularly  in  the  temperature,  is  marked;  but  cases  in  which  it  is  important 
to  make  an  accurate  diagnosis  are  not  usually  seen  until  the  fourth  or  fifth 
day.     The  suddenness  of  the  onset,  the  greater  frequency  of  the  chill,  and  the 


RELAPSING  FEVER.  109 

early  prostration  are  the  distinctive  features  in  typhus.  The  brain  symptoms 
too  are  earlier.  It  is  easy  to  put  down  on  paper  elaborate  differential  distinc- 
tions, which  are  practically  useless  at  the  bedside.  The  Widal  reaction  and 
blood  cultures  are  important  aids,  but  in  sporadic  cases  the  diagnosis  is  some- 
times extremely  difficult.  I  have  seen  Murehison  himself  in  doubt,  and  more 
than  once  I  have  known  the  diagnosis  to  be  deferred  until  the  sectio  cadaveris. 
Severe  cerebro-spinal  fever  may  closely  simulate  typhus  at  the  outset,  but  the 
diagnosis  is  usually  clear  within  a  few  days.  Malignant  variola  also  has  cer- 
tain features  in  common  with  severe  typhus,  but  the  greater  extent  of  the 
haemorrhages  and  the  bleeding  from  the  mucous  membranes  make  the  diagnosis 
clear  within  a  short  time.  The  rash  at  first  resembles  that  of  measles,  but  in 
the  latter  the  eruption  is  brighter  red  in  color,  often  crescentic  or  irregular  in 
arrangement,  and  appears  first  on  the  face. 

The  frequency  with  which  other  diseases  are  mistaken  for  typhus  is  shown 
by  the  fact  that  during  and  following  the  epidemic  of  1881  in  New  York  108 
cases  were  wrongly  diagnosed — one-eighth  of  the  entire  number — and  sent  to 
the  Eiverside  Hospital  (F.  W.  Chapin). 

Treatment. — The  general  management  of  the  disease  is  like  that  of 
typhoid  fever.  Hydrotherapy  should  be  thoroughly  and  systematically  em- 
ployed. Judging  from  the  good  results  which  we  have  obtained  by  this 
method  in  typhoid  cases  with  nervous  symptoms  much  may  be  expected 
from  it.  Certain  authorities  have  spoken  against  it,  but  it  should  be  given 
a  more  extended  trial.  Medicinal  antipyretics  are  even  less  suitable  than  in 
typhoid,  as  the  tendency  to  heart-weakness  is  often  more  pronounced.  As 
a  rule,  the  patients  require  from  the  outset  a  supporting  treatment;  water 
should  be  freely  given^  and  alcohol  in  suitable  doses,  according  to  the  condi- 
tion of  the  pulse. 

The  bowels  may  be  kept  open  by  mild  aperients.  The  so-called  specific 
medication,  by  sulphocarbolates,  the  sulphides,  carbolic  acid,  etc.,  is  not 
commended  by  those  who  have  had  the  largest  experience.  The  special  nerv- 
ous symptoms  and  the  pulmonary  symptoms  should  be  dealt  with  as  in  typhoid 
fever.  In  epidemics,  when  the  conditions  of  the  climate  are  suitable,  the 
cases  are  best  treated  in  tents  in  the  open  air. 


III.    RELAPSING   FEVER    (Febris  recurrens). 

Definition. — A  specific  infectious  disease  caused  by  the  spirochaete  (spi- 
rillum) of  Obermeier,  characterized  by  a  definite  febrile  paroxysm  which  usu- 
ally lasts  six  days  and  is  followed  by  a  remission  of  about  the  same  length 
of  time,  then  by  a  second  paroxysm,  which  may  be  repeated  three  or  even 
four  times,  whence  the  name  relapsing  fever. 

Etiology. — This  disease,  which  has  also  the  names  "  famine  fever  "  and 
*'  seven-day  fever,"  has  been  known  since  the  early  part  of  the  eighteenth 
century,  and  has  from  time  to  time  extensively  prevailed  in  Europe,  espe- 
cially in  Ireland.  It  is  common  in  India,  where  the  conditions  for  its  devel- 
opment seem  always  to  be  present,  and  where  it  was  specially  studied  by 
Vandyke  Carter,  of  Bombay.  It  appeared  in  the  United  States  in  1844, 
when  cases  were  admitted  to  the  Philadelphia  Hospital,  which  are  described 


110  SPECIFIC  INFECTIOUS  DISEASES. 

by  Meredith  Clymer  in  his  work  on  Fevers.  Flint  saw  cases  in  1850-51.  In 
1869  it  prevailed  extensively  in  epidemic  form  in  New  York  and  Philadel- 
phia; since  when  it  has  not  reappeared.  Only  an  occasional  case  has  occurred 
in  England  and  Wales  during  the  past  twenty  years.  In  the  Philippines  there 
have  been  several  severe  outbreaks. 

The  special  conditions  under  which  it  occurs  are  similar  to  those  of 
typhus  fever.  Overcrowding  and  deficient  food  are  the  conditions  which 
seem  to  promote  the  rapid  spread  of  the  virus.  Neither  age,  sex,  nor  season 
seems  to  have  any  special  influence.  It  is  a  contagious  disease  and  may 
be  communicated  from  person  to  person,  but  is  not  so  contagious  as  typhus. 
Murchison  thinks  it  may  be  transported  by  fomites.  One  attack  does  not 
confer  immunity  from  subsequent  attacks.  In  1873  Obermeier  described  an 
organism  in  the  blood  which  is  now  recognized  as  the  specific  agent.  This 
spirillum,  or  more  correctly  spirochete,  is  from  3  to  6  times  the  length  of 
the  diameter  of  a  red  blood-corpuscle,  and  forms  a  narrow  spiral  filament 
which  is  readily  seen  moving  among  the  red  corpuscles  during  a  paroxysm. 
They  are  present  in  the  blood  only  during  the  fever.  Shortly  before  the 
crisis  and  in  the  intervals  they  are  not  found,  though  small  glistening  bodies, 
which  are  stated  to  be  their  spores,  appear  in  the  blood.  The  disease  has 
been  produced  in  human  beings  by  inoculation  with  blood  taken  during  the 
paroxysm.  It  has  also  been  produced  in  monkeys.  Bed-bugs  may  suck  out 
the  spirilla,  and  Tictin  reproduced  the  disease  by  injecting  into  a  healthy 
monkey  blood  sucked  by  a  bug  from  an  infected  monkey.  Nothing  is  yet 
known  with  reference  to  the  life  history  of  the  spirochgete.  It  has  not  been 
found  in  the  secretions  or  excretions. 

Morbid  Anatomy. — There  are  no  characteristic  anatomical  appearances 
in  relapsing  fever.  If  death  takes  place  during  the  paroxysm  th,e  spleen  is 
large  and  soft,  and  the  liver,  kidneys,  and  heart  show  cloudy  swelling.  There 
may  be  infarcts  in  the  kidneys  and  spleen.  The  bone-marrow  has  been  found 
in  a  condition  of  h3-perplasia.     Ecchymoses  are  not  uncommon. 

Symptoms. — The  incubation  appears  to  be  short,  and  in  some  instances 
the  attack  occurs  promptly  after  exposure;  more  frequently,  however,  from 
five  to  seven  days  elapse. 

The  invasion  is  abrupt,  with  chill,  fever,  and  intense  pain  in  the  back 
and  limbs.  In  young  persons  there  may  be  nausea,  vomiting,  and  convul- 
sions. The  temperature  rises  rapidly  and  may  reach  104°  on  the  evening 
of  the  first  da3\  Sweats  are  common.  The  pulse  is  rapid,  ranging  from 
110  to  130.  There  may  be  delirium  if  the  fever  is  high.  Swelling  of  the 
spleen  can  be  detected  early.  Jaundice  is  common  in  some  epidemics.  The 
gastric  symptoms  may  be  severe.  There  are  seldom  intestinal  s}Tnptoms. 
Cough  may  be  present.  Occasionally  herpes  is  noted,  and  there  may  be 
miliary  vesicles  and  petechias.  During  the  paroxysm  the  blood  invariably 
shows  the  spirochgete,  and  there  is  usually  a  leucoc}i;osis  (Ouskow).  After 
the  fever  has  persisted  with  severity  or  even  with  an  increasing  intensity 
for  five  or  six  days  the  crisis  occurs.  In  the  course  of  a  few  hours,  accom- 
panied by  profuse  sweating,  sometimes  by  diarrhoea,  the  temperature  falls 
to  normal  or  even  subnormal,  and  the  period  of  apyrexia  begins. 

The  crisis  may  occur  as  early  as  the  third  day,  or  it  may  be  delayed  to 
the  tenth;  it  usually  comes,  however,  about  the  end  of  the  first  week.     In 


RELAPSING  FEVER. 


Ill 


delicate  and  elderly  persons  there  may  be  collapse.  The  convalescence  is 
rapid,  and  in  a  few  days  the  patient  is  up  and  abont.  Then  in  a  week, 
usually  on  the  fourteenth  day,  he  again  has  a  rigor,  or  a  series  of  chills; 
the  fever  returns  and  the  attack  is  repeated.  A  second  crisis  occurs  from 
the  twentieth  to  the  twenty-third  day,  and  again  the  patient  recovers  rap- 
idly. As  a  rule,  the  relapse  is  shorter  than  the  original  attack.  A  second 
and  a  third  may  occur,  and  there  are  instances  on  record  of  even  a  fourth 
and  a  fifth.  In  epidemics  there  are  cases  which  terminate  by  crisis  on  the 
seventh  or  eighth  day  without  the  occurrence  of  relapse.  In  protracted  cases 
the  convalescence  is  very  tedious,  as  the  patient  is  much  exhausted. 

Eelapsing  fever  is  not  a  very  fatal  disease.  Murchison  states  that  the 
mortality  is  about  4  per  cent.  In  the  enfeebled  and  old,  death  may  occur 
at  the  height  of  the  first  paroxysm. 

Complications  are  not  frequent.  In  some  epidemics  hsematemesis  and 
hsematuria  have  occurred.  Pneumonia  is  not  infrequent.  The  acute  enlarge- 
ment of  the  spleen  may  end  in  rupture.     Post-febrile  paralyses  may  occur. 

1      2      3      4      5      6      7      8      9    10    11    12    13    14    15    IB    17  1R     19    20    51     9'J    23    94 


RIsSiiSilSBBSSSSHBBBSSifflSafiSBB 


'/■■■MSSBBBSSSBBBSSBnHHMHHiBinBSI 


IHWWVHI' 


■■BBSBmBBBSSmJBBBSBBBSbkiBBBSSBSBSBmiiwBBBSBSS 

■awBBSB,SSSByMyAMBigkw^MWi?giJiraMww  ■■■■■■■■!■■■■  ■'ATJgw^ 


107.6° 
105.8° 
104.0° 
102.2° 
100.4° 

98.6° 

96.8° 

95.0" 

Chart  VI.— Relapsing  Fever  (Murchison). 

Ophthalmia  has  followed  in  certain  epidemics,  and  may  prove  a  very  tedious 
and  serious  complication.  Jaundice  has  already  been  mentioned.  In  pregnant 
women  abortion  usually  takes  places.  Convulsions  occasionally  follow.  But- 
ton, the  well-known  worker  on  tropical  diseases,  died  in  status  epilepticus 
some  weeks  after  the  attack. 

Diag:nosis. — The  onset  and  general  symptoms  may  not  at  first  be  dis- 
tinctive. At  the  beginning  of  an  epidemic  the  cases  are  usually  regarded  as 
anomalous  typhoid;  but  once  the  typical  course  is  followed  in  a  case  the 
diagnosis  is  clear.    The  blood  examination  is  distinctive. 

Treatment. — The  paroxysm  can  neither  be  cut  short  nor  can  its  recur- 
rence be  prevented.  It  might  be  thought  that  quinine,  with  its  powerful 
action,  would  certainly  meet  the  indications,  but  it  does  not  seem  to  have  the 
slightest  influence.  The  disease  must  be  treated  like  any  other  continued 
fever,  by  careful  nursing,  a  regular  diet,  and  ordinary  hygienic  measures. 
Of  special  symptoms,  pain  in  the  back  and  in  the  limbs  and  joints  demand 


112  SPECIFIC  INFECTIOUS  DISEASES. 

opium.     In  enfeebled  persons  the  collapse  at  the  crisis  may  be  serious,  and 
stimulants  with  ammonia  and  digitalis  should  be  given  freely. 

IV.     SMALL-POX    (Variola). 

Definition. — An  acute  infectious  disease  characterized  by  a  cutaneous 
eruption  which  passes  through  the  stages  of  papule,  vesicle,  pustule,  and 
crust.  ^ 

History. — The  disease  existed  in  China  many  centuries  before  Christ.  1 
The  pesta  magna  described  by  Galen  (of  which  Marcus  Aurelius  died)  is 
believed  to  have  been  small-pox.  In  the  sixth  century  it  prevailed,  and  sub- 
sequently, at  the  time  of  the  Crusades,  became  wide-spread.  It  was  brought 
to  America  by  the  Spaniards  early  in  the  sixteenth  century.  The  first  accu- 
rate account  was  given  by  Ehazes,  an  Arabian  physician  who  lived  in  the 
ninth  century,  and  whose  admirable  description  is  available  in  Greenhill's 
translation  for  the  Sydenham  Society.  In  the  seventeenth  century  the  illus- 
trious Sydenham  differentiated  measles  from  small-pox.  Special  events  in 
the  history  of  the  disease  are  the  introduction  of  inoculation  into  Europe, 
by  Lady  Mary  Wortley  Montagu,  in  1718,  and  the  discovery  of  vaccination 
by  Jenner,  in  1796.  I 

Etiology. — Small-pox  is  one  of  the  most  virulent  of  contagious  diseases, 
and  persons  exposed,  if  unprotected  by  vaccination,  are  almost  invariably 
attacked.  Instances  of  natural  immunity  are  rare.  It  is  said  that  Diemer- 
broeck,  a  celebrated  Utrecht  professor  in  the  seventeenth  century,  was  not 
only  himself  exempt,  but  likewise  many  members  of  his  family.  One  of 
the  nurses  in  the  small-pox  department  of  the  Montreal  General  Hospital 
stated  that  she  had  never  been  successfully  vaccinated,  and  she  certainly 
had  no  mark.  An  attack  may  not  protect  for  life.  There  are  undoubted 
cases  of  a  second,  reputed  instances,  indeed,  of  a  third  attack. 

Age. — Small-pox  is  common  at  all  ages,  but  is  particularly  fatal  to  young 
children.  Of  3,164  deaths  in  the  Montreal  epidemic  of  1885-'86,  2,717  were 
of  children  under  ten  years  of  age.  The  foetus  in  utero  may  be  attacked,  but 
only  if  the  mother  herself  is  the  subject  of  the  disease.  The  child  may  be 
born  with  the  rash  out  or  with  the  scars.  In  the  case  of  twins,  only  one 
may  be  attacked;  Kaltenbach  records  an  instance  of  triplets,  only  two  of 
which  were  affected  (Comby).  Children  born  in  a  small-pox  hospital,  if 
vaccinated  immediately,  may  escape  the  disease;  usually,  however,  they  die  , 
early.     (See  Hunter's  works,  iv,  p.  74.)  I 

Sex. — Males  and  females  are  equally  affected. 

Race. — Among  aboriginal  races  small-pox  is  terribly  fatal.  When  the 
disease  was  first  introduced  into  America  the  Mexicans  died  by  thousands, 
and  the  North  American  Indians  have  also  been  frequently  decimated  by 
this  plague.  It  is  stated  that  the  negro  is  especially  susceptible,  and  the 
mortality  is  greater — about  43  per  cent  in  the  black,  against  39  per  cent  in 
the  white  (W.  M.  Welch). 

It  is  claimed  that  isolation  hospitals  increase  the  incidence  of  the  disease 
in  a  locality.  J.  Glaister,  who  has  considered  the  whole  question  very  care- 
fully, concludes  that  as  a  centre  of  traffic  such  an.  institution,  through  the 
channels  of  unavoidable  human  intercourse,  naturally  favors  the  spread  of 


i 


SMALL-POX.  113 

ihe  disease  locally,  but  decides  against  the  aerial  conveyance  of  the  disease, 
in  spite  of  the  very  strong  evidence  (mentioned  in  the  last  edition  in  the 
case  of  the  hospital  ship  on  the  Thames). 

The  disease  smoulders  here  and  there  in  different  localities,  and  when 
conditions  are  favorable  becomes  epidemic.  This  was  well  illustrated  by  the 
celebrated  Montreal  outbreak  of  1885.  For  several  years  there  had  been  no 
small-pox  in  the  city,  and  a  large  unprotected  population  grew  up  among 
the  French-Canadians,  many  of  whom  were  opposed  to  vaccination.  On 
February  28,  a  Pullman-ear  conductor,  who  had  travelled  from  Chicago, 
where  the  disease  had  been  slightly  prevalent,  was  admitted  into  the  Hotel- 
Dieu,  the  civic  small-pox  hospital  being  at  the  time  closed.  Isolation  was 
not  carried  out,  and  on  the  1st  of  April  a  servant  in  the  hospital  died  of 
small-pox.  Following  her  decease,  with  a  negligence  absolutely  criminal,  the 
authorities  of  the  hospital  dismissed  all  patients  presenting  no  symptoms  of 
contagion,  who  could  go  home.  The  disease  spread  like  fire  in  dry  grass, 
and  within  nine  months  there  died  in  the  city  o'f  small-pox  3,164  persons. 

Variations  in  the  Virulence  of  Epidemics. — Sydenham  states  that 
"  small-pox  also  has  its  peculiar  kinds,  which  take  one  form  during  one  series 
of  years,  and  another  during  another " ;  and  not  only  does  what  he  called 
the  epidemic  constitution  vary  greatly,  but  one  sometimes  sees  the  most 
extraordinary  variations  in  the  intensity  of  the  disease  in  members  of  a  fam- 
ily all  exposed  to  the  same  infection,  A  striking  illustration  of  this  variabil- 
ity has  been  given  in  the  recent  epidemics,  which  have  been  of  so  mild  a 
character  that  in  many  localities  it  has  been  mistaken  for  chicken-pox;  in 
others,  particularly  in  the  United  States,  the  belief  prevailed  that  a  new 
disease  had  arisen,  to  which  the  name  "  Cuban  itch  "  or  "  Philippine  itch  " 
has  been  given.  Very  often  a  correct  diagnosis  has  not  been  reached  until 
a  fatal  case  has  occurred.  As  will  be  mentioned,  a  small  outbreak  occurred 
in  one  of  my  wards  for  colored  patients,  which  we  mistook  at  first  for 
chicken-pox.  The  same  peculiarities  have  been  observed  in  the  Leicester, 
N"ottingham,  and  Cambridge  outbreaks.  Even  in  unvaccinated  children  the 
disease  has  been  exceedingly  mild.  Some  of  the  Leicester  cases  had  only 
a  few  pocks  (Allan  Warner)  ;  but  this  is  an  old  story  in  the  history  of  the 
disease.  John  Mason  Good,  in  commenting  on  this  very  point,  refers  to  the' 
great  variability  in  the  epidemics,  and  states  that  he  himself  as  a  child  of 
six  (1770)  passed  through  small-pox  with  "scarcely  any  disturbance  and 
not  more  than  twenty  scattered  pustules  " ! 

Recent  Prevalence. — In  the  United  States,  according  to  Dr.  Wyman's 
last  report  for  the  fiscal  year  1904,  there  had  been  a  steady  decrease.  The 
figures  for  1903  were  43,590  cases  and  1,643  deaths;  for  1904,  35,106  cases 
and  1,118  deaths.  In  England  and  Wales  there  were  760  deaths  in  1903, 
a  rate  of  33  per  million  living ;  the  rates  in  the  previous  four  years  having 
been  5,  3,  7,  and  75  severally  (John  W.  Tatham). 

Nature  of  Contagion. — Protozoon-like  bodies  were  first  described  in  the 
'skin  lesions  by  Guarnieri — the  cytoryctes  variolce.  Cou.ncilman  and  his  col- 
leagues describe  a  protozoon  with  a  double  cycle  and  cytoplasmic  stage,  with 
small  structureless  bodies  in  the  lower  layer  of  the  epithelial  cells.  Increas- 
ing in  size,  they  become  reticulated  and  segment  into  small  rounded  bodies. 
In  the  intranuclear  stage  these  small  round  bodies  or  granules  invade  the 
9 


114  SPECIFIC  INFECTIOUS  DISEASES. 

nuclei  of  the  epithelial  cells,  increase  in  size,  and  form  a  series  of  vacuoles 
around  a  central  vacuole.  Calkins,  an  acknowledged  expert  in  the  protozoa, 
has  confirmed  the  main  facts  in  the  life  history  of  this  organism.  Howard 
and  Perkins,  of  Cleveland,  describe  identical  changes.  So  definite  is  the 
relation  of  the  parasites  to  the  skin  lesions  that  it  seems  highly  probable  they 
may  be  the  cause  of  the  disease.  The  dried  scales  constitute  by  far  the 
most  important  element,  and  as  a  dust-like  powder  are  distributed  ever}'^- 
where  in  the  room  during  convalescence,  becoming  attached  to  clothing  and 
various  articles  of  furniture.  The  disease  is  probably  contagious  from  a  very 
early  stage,  though  I  think  it  has  not  yet  been  determined  whether  the  con- 
tagion is  active  before  the  eruption  develops.  The  poison  is  of  unusual 
tenacity  and  clings  to  infected  localities.  It  is  conveyed  by  persons  who  have 
been  in  contact  with  the  sick  and  by  fomites.  During  epidemics  it  is  no  doubt 
widely  spread  in  street-cars  and  public  conveyances.  It  must  not  be  forgotten 
that  an  unprotected  person  may  contract  a  very  virulent  form  of  the  disease 
from  the  mild  varioloid. 

Morbid  Anatomy. — The  pustules  may  be  seen  upon  the  tongue  and  the 
buccal  mucosa,  and  on  the  palate;  sometimes  also  in  the  pharjmx  and  the 
upper  part  of  the  oesophagus.  In  exceptionally  rare  cases  the  rash  extends 
down  the  oesophagus  and  even  into  the  stomach.  Swelling  of  the  Peyer's 
follicles  is  not  uncommon;  the  pustules  have  been  seen  in  the  rectum. 

In  the  larynx  the  eruption  may  be  associated  with  a  fibrinous  exudate  and 
sometimes  with  oedema.  Occasionally  the  inflammation  penetrates  deeply 
and  involves  the  cartilages.  In  the  trachea  and  bronchi  there  may  be  ulcera- 
tive erosions,  but  true  pocks,  such  as  are  seen  on  the  skin,  do  not  occur. 

The  heart  occasionally  shows  myocardial  changes,  parenchymatous  and 
fatty;  endocarditis  and  pericarditis  are  uncommon.  French  writers  have 
described  an  endarteritis  of  the  coronary  vessels  in  connection  with  small- 
pox. The  spleen  is  markedly  enlarged.  Apart  from  the  cloudy  swelling  and 
areas  of  coagulation-necrosis,  lesions  of  the  kidneys  are  not  common.  jSTephri- 
tis  -may  occur  during  convalescence. 

In  the  hsemorrhagic  form  extravasations  are  found  on  the  serous  and 
mucous  surfaces,  in  the  parenchyma  of  organs,  in  the  connective  tissues, 
and  about  the  nerve-sheaths.  In  one  instance  I  found  the  entire  retro- 
peritoneal tissue  infiltrated  with  a  large  coagulum,  and  there  were  also 
extensive  extravasations  in  the  course  of  the  thoracic  aorta.  Haemorrhages 
in  the  bone-marrow  have  also  been  described  by  Golgi.  There  may  be  heem- 
orrhages  into  the  muscles.  Ponfick  has  described  the  spleen  as  very  firm 
and  hard  in  hsemorrhagic  small-pox,  and  such  was  the  case  in  seven  instances 
I  examined.  In  these  rapidly  fatal  forms  the  liver  has  been  described  as  fatty, 
but  in  5  of  my  7  cases  it  was  of  normal  size,  dense,  and  firm. 

The  following  description  of  the  finer  changes  is  taken  largely  from  the 
recent  exhaustive  study  by  Councilman,  McGrath,  and  Brinkerhoff  (1904). 
The  specific  lesion  is  "  a  focal  degeneration  of  the  stratified  epithelium,  vacu- 
olar in  character,  and  accompanied  by  serous  exudation  and  the  formation 
of  a  reticulum."  The  specific  lesions  are  limited  to  the  skin,  the  mucous 
membranes  of  the  soft  palate,  the  phar}Tix,  and  the  oesophagus.  The  factors 
in  the  formation  of  the  pustule  are  degeneration  of  the  epithelial  cells,  asso- 
ciated with  fluid  and  cellular  exudate.     The  cells  of  the  lower  layers  of  the 


SMALL-POX.  115 

epidermis  are  first  involved.  They  become  swollen,  the  nuclei  are  shrunken 
and  formless,  the  exudate  increases  in  amount,  enlarging  the  spaces  of  the 
reticulum,  and  the  cells  represent  the  different  varieties  of  leucocytes,  poly- 
nuclear  neutrophiles  being  most  numerous.  The  umbilication  and  central 
depression  usually  correspond,  as  Weigert  suggests,  to  the  area  of  primary 
necrosis.  The  hair  follicle  and  the  sweat  gland  may  play  some  part.  The  para- 
sites described  occur  chiefly  in  the  cells  of  the  rete  ■  mueosum.  Associated 
lesions  are  numerous,  particularly  proliferation  in  the  haematopoietic  organs. 
Cellular  infiltrations  occur  constantly  in  the  testicle,  usually  in  the  kidney, 
the  liver,  and  the  adrenal  glands.  The  anaemic  focal  necroses  in  the  testicles 
seem  almost  specific  in  the  disease,  and  in  the  bone-marrow  there  are  foci  of 
necrosis  and  of  hemorrhage  with  hyperplasia  of  the  myelocytes,  and  a  marked 
reduction  or  even  complete  absence  of  the  polynuclear  leucocytes.  This  was 
the  change  described  originally  by  Chiari  as  osteomyelitis  variolosa.  Asso- 
ciated bacterial  lesions  are  common,  due  to  the  pyogenic  bacteria  which  are 
always  present  in  severe  cases. 

Symptoms. — Three  forms  of  small-pox  are  described: 

1.  Variola  vera;  (a)   Discrete,    (&)    Confluent. 

2.  Variola  licemorrliagica ;  (a)  Purpura  variolosa  or  black  small-pox; 
(h)  Hsemorrhagic  pustular  form,  variola  hsemorrhagica  pustulosa. 

3.  Varioloid,  or  small-pox  modified  by  vaccination. 

1.  Vaeiola  Vera. — The  affection  may  be  conveniently  described  under 
various  stages :  Incubation. — "  From  nine  to  fifteen  days ;  oftenest  twelve." 
I  have  seen  it  as  early  as  the  eighth  day  after  exposure,  and  there  are  well- 
authenticated  instances  in  which  this  stage  has  been  prolonged  to  twenty  days. 
It  is  unusual  for  patients  to  complain  of  any  symptoms. 

Invasion. — In  adults  a  chill  and  in  children  a  convulsion  are  common 
initial  symptoms.  There  may  be  repeated  chills  within  the  first  twenty- 
four  hours.  Intense  frontal  headache,  severe  lumbar  pains,  and  vomiting 
are  very  constant  features.  The  pains  in  the  back  and  in  the  limbs  are  more 
severe  in  the  initial  stage  of  this  than  of  any  other  eruptive  fever,  and  their 
combination  with  headache  and  vomiting  is  so  suggestive  that  precautionary 
measures  may  often  be  taken  several  days  before  the  eruption  appears.  The 
temperature  rises  quickly,  and  may  on  the  first  day  be  103°  or  104°.  The 
pulse  is  rapid  and  full,  not  often  dicrotic.  In  severe  cases  there  may  be 
marked  delirium,  particularly  if  the  fever  is  high.  The  patient  is  restless 
and  distressed,  the  face  is  flushed,  and  the  eyes  are  bright  and  clear.  The 
skin  is  usually  dry,  though  occasionally  there  are  profuse  sweats.  One 
can  not  Judge  from  the  initial  symptoms  whether  a  case  is  likely  to  be  dis- 
crete or  confluent,  as  convulsions,  severe  backache,  and  high  fever  may  pre- 
cede a  very  mild  attack. 

Initial  Rashes. — Two  forms  can  be  distinguished:  the  diffuse,  scarlatinal, 
and  the  macular  or  measly  form;  either  of  which  may  be  associated  with 
petechise  and  occupy  a  variable  extent  of  surface.  In  some  instances  they  are 
general,  but  as  a  rule,  as  pointed  out  by  Simon,  they  are  limited  either  to 
the  lower  abdominal  areas,  to  the  inner  surfaces  of  the  thighs,  and  to  the  lat- 
eral thoracic  region,  or  to  the  axillse.  Occasionally  they  are  found  over  the 
extensor  surfaces,  particularly  in  the  neighborhood  of  the  knees  and  elbows. 
These  rashes,  usually  purpuric,  are  often  associated  with  an  erythematous 


116 


SPECIFIC  INFECTIOUS  DISEASES. 


or  er^'sipelatous  blush.  The  scarlatinal  rash  may  come  out  as  early  as  the 
second  day,  and  be  as  diffuse  and  vivid  as  in  a  true  scarlatina.  The  measly 
rash  may  also  be  diffuse  and  resemble  closely  that  of  measles.     Urticaria 


2        3        4        5         6        7 


10       11       12       13       14       15       16       ir       18 


104°  F.-40.0° 


102.2°  F.— 39.0° 


100.4°  F.— 38.0" 


i.6°  F.— 37.0= 


■■■■■■■■■■■■■■■■■■■■■■■' 

■iiuiiiiiilldli 
HHiiiiiiiiim 

IM—W liiBHMI 


Initial  Fever  Eruption. 


Suppurative  Fever. 


Chart  YII, — True  Small-pox  (Striimpell). 

is  only  occasionally  seen.  It  was  present  once  in  my  Montreal  cases.  The 
initial  rashes  are  more  abundant  in  some  epidemics  than  in  others.  They 
occur  in  from  10  to  16  per  cent  of  cases. 

Eruption. —  (1)  In  the  discrete  form,  usually  on  the  fourth  day,  mac- 
ules appear  on  the  forehead,  preceded  sometimes  by  an  erythematous  flush, 
and  on  the  anterior  surfaces  of  the  wrists.  Within  the  first  twenty-four 
hours  from  their  appearance  they  occur  on  other  parts  of  the  face  and  on  the 
extremities,  and  a  few  are  seen  on  the  trunk.  The  spots  are  from  3—3 
millimetres  in  diameter,  of  a  bright  red  color,  and  disappear  completely 
on  pressure.  As  the  rash  comes  out  the  temperature  falls,  the  general 
s}Tnptoms  subside,  and  the  patient  feels  comfortable.  On  the  fifth  or  sixth 
day  the  papules  change  into  vesicles  with  clear  summits.  Each  one  is  ele- 
vated, circular,  and  presents  a  little  depression  or  umbilication  in  the 
centre.  About  the  eighth  day  the  vesicles  change  into  pustules,  the  umbil- 
ication disappears,  the  flat  top  assumes  a  globular  form  and  becomes  grayish- 
yellow  in  color,  owing  to  the  contained  pus.  There  is  an  areola  of  injec- 
tion about  the  pustules  and  the  skin  between  them  is  swollen.  This 
maturation  first  takes  place  on  the  face,  and  follows  the  order  of  the  appear- 
ance of  the  eruption.  The  temperature  now  rises — secondary  fever — and  the 
general  symptoms  return.  The  swelling  about  the  pustules  is  attended  with 
a  good  deal  of  tension  and  pain  in  the  face;  the  eyelids  become  swollen  and 
closed.  In  the  discrete  form  the  temperature  of  maturation  does  not  usually 
remain  high  for  more  than  twenty-four  or  twentj^-six  hours,  so  that  on  the 
tenth  or  eleventh  day  the  fever  disappears  and  the  stage  of  convalescence 
begins.  The  pustules  rapidly  dry,  first  on  the  face  and  then  on  the  other 
parts,  and  by  the  fourteenth  or  fifteenth  day  desquamation  may  be  far 
advanced  on  the  face.  The  march  and  distribution  of  the  rash  are  often  most 
characteristic.  The  abdomen  and  groins  and  the  legs  are  the  parts  least 
affected.  The  rash  is  often  copious  on  the  upper  part  of  the  back,  scanty'  on 
the  lower.     Vesicles  in  the  mouth,  phar^-nx,  and  larynx,  cause  soreness  and 


SMALL-POX.  117 

swelling  in  these  parts,  with  loss  of  voice.  Whether  pitting  takes  place  de- 
pends a  good  deal  upon  the  severity  of,  the  disease.  In  a  majority  of  cases 
Sydenham's  statement  holds  good,  that  "  it  is  very  rarely  the  case  that  the 
distinct  small-pox  leaves  its  mark."  The  odor  of  a  small-pox  patient  is  very 
distinctive  even  in  the  early  stages,  and  I  have  known  it  to  be  a  help  in  the 
diagnosis  of  a  doubtful  case. 

(3)  The  Confluent  Form. — With  the  same  initial  symptoms,  though  usu- 
ally of  greater  severity,  the  rash  appears  on  the  fourth,  or,  according  to 
Sydenham,  on  the  third  day.  The  more  the  eruption  shows  itself  before  the 
fourth  day,  the  more  sure  it  is  to  become  confluent  (Sydenham).  The  pap- 
ules at  first  may  be  isolated,  and  it  is  only  later  in  the  stage  of  maturation 
that  the  eruption  is  confluent.  But  in  severer  cases  the  skin  is  swollen  and 
hyperaemic  and  the  papules  are  very  close  together.  On  the  feet  and  hands, 
too,  the  papules  are  thickly  set;  more  scattered  on  the  limbs;  and  quite  dis- 
crete on  the  trunk.  With  the  appearance  of  the  eruption  the  symptoms  sub- 
side and  the  fever  remits,  but  not  to  the  same  extent  as  in  the  discrete  form. 
Occasionally  the  temperature  falls  to  normal  and  the  patient  may  be  very 
comfortable.  Then,  usually  on  the  eighth  day,  the  fever  again  rises,  the 
vesicles  change  to  pustules,  the  hypersemia  becomes  intense,  the  swelling  of 
the  face  and  hands  increases,  and  by  the  tenth  day  the  pustules  have  fully 
maturated,  many  of  them  have  coalesced,  and  the  entire  skin  of  the  head  and 
extremities  is  a  superficial  abscess.  The  fever  rises  to  103°  or  105°,  the  pulse 
is,  from  110  to  120,  and  there  is  often  delirium.  As  pointed  out  by  Syden- 
ham, salivation  in  adults  and  diarrhoea  in  children  are  common  symptoms 
of  this  stage.  There  is  usually  much  thirst.  The  eruption  may  also  be  pres- 
ent in  the  mouth,  and  usually  the  pharynx  and  larynx  are  involved  and  the 
voice  is  husky.  Great  swelling  of  the  cervical  lymphatic  glands  occurs.  At 
this  stage  the  patient  presents  a  terrible  picture,  unequalled  in  any  other 
disease;  one  which  fully  justifies  the  horror  and  fright  with,  which  small-pox 
is  associated  in  the  public  mind.  Even  when  the  rash  is  confluent  "on  the 
face,  hands,  and  feet,  the  pustules  remain  discrete  on  the  trunk.  The  danger, 
as  pointed  out  by  Sydenham,  is  in  proportion  to  the  number  upon  the  face. 
"  If  upon  the  face  they  are  as  thick  as  sand,  it  is  no  advantage  to  have  them 
few  and  far  between  on  the  rest  of  the  body."  In  fatal  cases,  by  the  tenth 
or  eleventh  day  the  pulse  gets  feebler  and  more  rapid,  the  delirium  is  marked, 
there  is  subsultus,  sometimes  diarrhoea,  and  with  these  symptoms  the  patient 
dies.  In  other  instances  between  the  eighth  and  eleventh  day  hsemorrhagic 
features  occur.  When  recovery  takes  place,  the  patient  enters  on  the  eleventh 
or  twelfth  day  the  period  of  desiccation. 

Desiccation. — The  pustules  break  and  the  pus  exudes  or  they  dry 
and  form  crusts.  Throughout  the  third  week  the  desiccation  proceeds  and 
in  cases  of  moderate  severity  the  secondary  fever  subsides;  but  in  others  it 
may  persist  until  the  fourth  week.  The  crusts  in  confluent  small-pox  adhere 
for  a  long  time  and  the  process  of  scarring  may  take  three  or  four  weeks. 
On  the  face  they  fall  off  singly,  but  the  tough  epidermis  of  the  hands  and 
feet  may  be  shed  entire. 

2.  HEMORRHAGIC  SMALL-POX  occurs  in  two  forms.  In  one,  the  petechial 
or  black  small-pox — purpura  variolosa — the  special  symptoms  appear  early 
and  death  follows  in  from  two  to  six  days.     In  the  other  form  the  case  pro- 


118  SPECIFIC  IXFECTIOUS  DISEASES. 

gresses  as  one  of  ordinary  variola,  and  in  the  resicular  or  pustular  stage 
hsemorrliages  take  place  into  the  pocks  or  from  the  mucous  membranes — 
variola  liCEmorrhagica  pustulosa. 

Yariola  haemorrhagica  is  more  common  in  some  epidemics  than  in  others. 
It  is  less  frequent  in  children  than  in  adults.  Of  27  cases  admitted  to  the 
small-pos  department  of  the  Montreal  General  Hospital  there  vrere  3  under 
ten  years,  -1  between  fifteen  and  twenty,  9  between  twenty  and  twenty-five, 
7  between  twent3'-five  and  thirty-five,  3  between  thirty-five  and  fortj^-five,  and 
1  above  fifty.  Young  and  vigorous  persons  seem  more  liable  to  this  form. 
Several  of  my  cases  were  above  the  average  in  muscular  development.  Men 
are  more  frequently  affected  than  women;  thus  in  my  list  there  were  21  males 
and  only  6  females.  The  influence  of  vaccination  is  shown  in  the  fact  that 
of  the  eases  14  were  un vaccinated,  while  not  one  of  the  13  who  had  scars  had 
been  revaccinated. 

In  purpura  variolosa  the  illness  starts  with  the  usual  s3'mptoms,  but  with 
more  intense  constitutional  disturbance.  On  the  evening  of  the  second  or  on 
the  third  day  there  is  a  diffuse  hypersemic  rash,  particularly  in  the  groins, 
with  small  punctiform  hsemorrliages.  The  rash  extends,  becomes  more  dis- 
tinctly ha?morrhagic,  and  the  spots  increase  in  size.  Ecchymoses  appear  on 
the  conjunctiva,  and  as  early  as  the  third  day  there  may  be  hsemorrliages 
from  the  mucous  membranes.  Death  may  take  place  before  the  papules 
appear.  In  this  truly  terrible  affection  the  patient  may  present  a  frightful 
appearance.  The  skin  may  have  a  uniformly  purplish  hue  and  the  unfortu- 
nate victim  may  even  look  plum-colored.  The  face  is  swollen  and  large  con- 
junctival haemorrhages  ^vith  the  deeply  sunken  comeae  gives  a  ghastly  appear- 
ance to  the  features.  The  mind  may  remain  clear  to  the  end.  Death  occurs 
from  the  third  to  the  sixth  day;  thus  in  thirteen  of  my  cases  it  took  place 
between  these  dates.  The  earliest  death  was  on  the  third  day  and  there  were 
no  traces  of  papules.  There  may  be  no  mucous  haemorrhages;  thus  in  one 
case  of  a  most  virulent  character  death  occurred  without  bleeding  early  on 
the  fourth  day.  Hsematuria  is  perhaps  most  common,  next  haematemesis,  and 
melsena  was  noticed  in  a  third  of  the  cases.  Metrorrhagia  was  present  in  one 
only  of  the  six  females  on  my  list.  Haemoptysis  occurred  in  five  cases.  The 
pulse  in  this  form  of  small-pox  is  rapid  and  often  hard  and  small.  The 
respirations  are  greatly  increased  in  frequency  and  out  of  all  proportion  to 
the  intensity  of  the  fever. 

In  variola  pustulosa  li(Binorrliagica  the  disease  progresses  as  a  severe  case, 
and  the  hsemorrhages  do  not  occur  until  the  vesicular  or  pustular  stage.  The 
first  indication  is  haemorrhage  into  the  areolse  of  the  pocks,  and  later  the  matu- 
rated pustules  fill  with  blood.  The  earlier  the  hemorrhage  the  greater  is  the 
danger.  Bleeding  from  the  mucous  membranes  is  also  common  in  this  form, 
and  the  great  majority  of  the  cases  prove  fatal,  usually  on  the  seventh,  eighth, 
or  ninth  day,  but  a  few  cases  recover.  In  patients  with  the  discrete  form,  if 
allowed  to  get  up  early,  haemorrhage  may  take  place  into  the  pocks  on  the  legs. 

Leucocyte  Reaction. — In  variola  vera  there  is  a  marked  leucocytosis,  12- 
16  thousand,  about  the  eighth  day,  then  a  slight  decline  and  a  rise  again 
about  the  twelfth  or  fourteenth  day,  sometimes  to  18,000  or  20,000.  There 
is  an  increase  in  the  mononuclear  elements,  which  may  be  the  only  marked 
feature  of  the  mild  cases    (Magrath,   Brinkerhoff,  and  Bancroft). 


SMALL-POX.  119 

3.  Varioloid. — This  term  is  applied  to  the  modified  form  which  affects 
persons  who  have  been  vaccinated.  It  may  set  in  with  abruptness  and  sever- 
ity, the  temperature  reaching  103°.  More  commonly  it  is  in  every  respect 
milder  in  its  initial  symptoms,  though  the  headache  and  backache  may  be 
very  distressing.  The  papules  appear  on  the  evening  of  the  third  or  on  the 
fourth  day.  They  are  few  in  number  and  may  be  confined  to  the  face  and 
hands.  The  fever  drops  at  once  and  the  patient  feels  perfectly  comfortable. 
The  vesiculation  and  maturation  of  the  pocks  take  place  rapidly,  and  there 
is  no  secondary  fever.  There  is  rarely  any  scarring.  As  a  rule,  when  small-- 
pox  attacks  a  person  who  has  been  vaccinated  within  five  or  six  years  the 
disease  is  mild,  but  it  may  prove  severe,  even  fatal. 

Abortive  Types. — As  already  mentioned,  recent  epidemics  have  been  char- 
acterized by  the  large  number  of  mild  cases.  Even  in  unvaccinated  children, 
only  a  few  pustules  may  appear,  and  the  disease  is  over  in  a  few  days.  Even 
with  a  thickly  set  eruption  the  vesicles  at  the  fifth  or  sixth  day,  instead  of  fill- 
ing, dry  and  abort,  forming  the  so-called  horn-,  crystalline-,  or  wart-pox.  Vari- 
ola sine  eruptione  is  described.  I  saw  no  cases  of  the  kind  in  Montreal.  They 
seem  to  have  been  not  uncommon  in  the  recent  epidemics.  Bancroft  observed 
twelve  cases  in  the  Boston  outbreak,  all  among  physicians  and  attendants. 
The  symptoms  are  headache,  pain  in  the  back,  fever,  and  vomiting.  As  already 
mentioned,  the- pocks  may  be  very  scanty  and  easily  overlooked,  even  in  unvac- 
cinated persons.  One  of  Bancroft's  cases  was  of  special  interest — a  pregnant 
woman  who  had  slight  symptoms  after  exposure,  but  no  rash.  Her  child 
showed  a  typical  eruption  when  two  days  old. 

Complications. — Considering  the  severity  of  many  of  the  cases  and  the 
general  character  of  the  disease,  associated  with  multiple  foci  of  suppuration, 
the  complications  in  small-pox  are  remarkably  few. 

Laryngitis  is  serious  in  three  ways :  it  may  produce  a  fatal  oedema  of  the 
glottis;  it  is  liable  to  extend  and  involve  the  cartilages,  producing  necrosis; 
and  by  diminishing  the  sensibility  of  the  larynx,  it  may  allow  irritating  par- 
ticles to  reach  the  lower  air-passages,  where  they  excite  bronchitis  or  broncho- 
pneumonia. 

Broncho-pneumonia  is  almost  invariably  present  in  fatal  cases.  Lobar  pneu- 
monia is  rare.    Pleurisy  is  common  in  some  epidemics. 

The  cardiac  complications  are  also  rare.  In  the  height  of  the  fever  a 
systolic  murmur  at  the  apex  is  not  uncommon;  but  endocarditis,  either  simple 
or  malignant,  is  rarely  met  with.  Pericarditis,  too,  is  very  uncommon.  Myo- 
carditis seems  to  be  more  frequent,  and  may  be  associated  with  endarteritis  of 
the  coronary  vessels. 

Of  complications  in  the  digestive  system,  parotitis  is  rare.  In  severe  cases 
there  is  extensive  pseudo-diphtheritic  angina.  Vomiting,  which  is  so  marked 
a  symptom  in  the  early  stage,  is  rarely  persistent.  Diarrhoea  is  not  uncom- 
mon, as  noted  by  Sydenham,  and  is  very  constantly  present  in  children. 

Albuminuria  is  frequent,  but  true  nephritis  is  rare.  Inflammation  of  the 
testes  and  of  the  ovaries  may  occur. 

Among  the  most  interesting  and  serious  complications  are  those  pertaining 
to  the  nervous  system.  In  children  convulsions  are  common.  In  adults  the 
delirium  of  the  early  stage  may  persist  and  become  violent,  and  finally  sub- 
side into  a  fatal  coma.    Post-febrile  insanity  is  occasionally  met  with  during 


120  SPECIFIC  INFECTIOUS  DISEASES. 

convalescence,  and  very  rarely  epilepsy.  Many  of  the  old  writers  spoke  of 
paraplegia  in  connection  with  the  intense  backache  of  the  early  stage,  but  it  is 
probably  associated  with  the  severe  agonizing  lumbar  and  crural  pains  and  is 
not  a  true  paraplegia.  It  must  be  distinguished  from  the  form  occurring  in 
convalescence,  which  may  be  due  to  peripheral  neuritis  or  to  a  diffuse  myelitis 
(Westphal).  The  neuritis  may,  as  in  diphtheria,  involve  the  phar}Tix  alone, 
or  it  may  be  multiple.  Of  this  nature,  in  all  probability,  is  the  so-called  pseudo- 
tabes, or  ataxie  variolique.  Hemiplegia  and  aphasia  have  been  met  with  in  a 
few  instances,  the  result  of  encephalitis. 

Among  the  most  constant  and  troublesome  complications  of  small-pox  are 
those  involving  the  skin.  During  convalescence  boils  are  very  frequent  and 
may  be  severe.  Acne  and  ecthyma  are  also  met  with.  Local  gangrene  in 
various  parts  may  occur. 

Arthritis  may  occur,  usually  in  the  period  of  desquamation,  and  may  pass 
on  to  suppuration.    Acute  necrosis  of  the  bone  is  sometimes  met  with. 

A  remarkable  secondary  eruption  (recurrent  small-pox)  occasionally  occurs 
after  desquamation. 

Special  Senses. — The  eye  affections  which  were  formerly  so  common  and 
serious  are  not  now  so  frequent,  owing  to  the  care  which  is  given  to  keeping 
the  conjunctivEe  clean.  A  catarrhal  and  purulent  conjunctivitis  is  common  in 
severe  cases.  The  secretions  cause  adhesions  of  the  eyelids,  and  unless  great 
care  is  taken  a  diffuse  keratitis  is  excited,  which  may  go  on  to  ulceration  and 
perforation.  Iritis  is  not  very  uncommon.  Otitis  media  is  an  occasional  com- 
plication, and  usually  results  from  an  extension  of  the  disease  through  the 
Eustachian  tubes. 

Prognosis. — In  unprotected  persons  small-pox  is  a  ver}^  fatal  disease,  the 
death-rate  ranging  from  25  to  35  per  cent.  In  William  M.  Welch's  report  from 
the  Municipal  Hospital,  Philadelphia,  of  2,831  eases  of  variola,  1,534 — i.  e., 
54.18  per  cent — died,  while  of  2,169  cases  of  varioloid  only  28 — i.  e.,  1.29  per 
cent — died.  Purpura  variolosa  is  invariably  fatal,  and  a  majority  of  those 
attacked  with  the  severer  confluent  forms  die.  The  intemperate  and  debilitated 
succumb  more  readilj'  to  the  disease.  As  Sydenham  observed,  the  danger  is 
directly  proportionate  to  the  intensity  of  the  disease  on  the  face  and  hands. 
"When  the  fever  increases  after  the  appearance  of  the  pustules,  it  is  a  bad 
sign;  but  if  it  is  lessened  on  their  appearance,  that  is  a  good  sign"  (Ehazes). 
Very  high  fever,  with  delirium  and  subsultus,  are  symptoms  of  ill  omen.  The 
disease  is  particularly  fatal  in  pregnant  women  and  abortion  usually  takes 
place.  It  is  not,  however,  uniformly  so,  and  I  have  twice  known  severe  cases 
to  recover  after  miscarriage.  Moreover,  abortion  is  not  inevitable.  Very  severe 
phar3mgitis  and  larjugitis  are  fatal  complications. 

Death  results  in  the  early  stage  from  the  action  of  the  poison  upon  the 
nervous  system.  In  the  later  stages  it  usually  occurs  about  the  eleventh  or 
twelfth  day,  at  the  height  of  the  eruption.  In  children,  and  occasionally  in 
adults,  the  lar^Tigeal  and  pulmonary  complications  prove  fatal. 

Diagnosis. — During  an  epidemic  the  initial  chill,  the  headache  and  back- 
ache, and  the  vomiting  at  once  put  the  physician  on  his  guard. 

The  initial  rashes  may  lead  to  error.  The  scarlatinal  rash  has  rarely  the 
extent  and  never  the  persistence  of  the  rash  in  true  scarlet  fever.  I  have  known 
the  rash  of  measles  to  be  mistaken  for  the  initial  rash  of  small-pox.    The  gen- 


SMALL-POX.  121 

eral  condition  of  the  patient,  and  the  presence  of  coryza  and  conjunctivitis  and 
Koplik's  sign,  may  be  better  guides  than  the  rash  itself. 

Malignant  hgemorrhagic  small-pox  may  prove  fatal  before  the  characteristic 
rash  appears.  Of  27  cases  of  hgemorrhagic  small-pox,  in  only  one,  in  which 
death  occurred  on  the  third  day,  did  inspection  fail  to  show  the  papules.  I^n 
3  cases  dying  on  the  fourth  day  the  characteristic  papular  rash  was  noticed. 
It  may  be  difficult  or  impossible  to  recognize  this  form  of  hgemorrhagic  small- 
pox from  hcEmorrhagic  scarlet  fever  or  JicBmorrhagic  measles,  though  in  the 
latter  there  is  rarely  so  constant  involvement  of  the  mucous  membranes.  Natu- 
rally enough,  as  they  are  allied  affections,  varicella  is  the  disease  which  most 
frequently  leads  to  error.  Particularly  has  this  been  the  case  in  the  mild 
epidemic  which  has  prevailed  throughout  the  country  during  the  past  three 
years.  A  negro  patient  was  admitted  to  my  wards  on  the  fourth  day  of  the 
disease.  Small-pox  was  not  prevalent  at  the  time,  and  the  case  was  regarded 
as  one  of  varicella.  Subsequently  eight  eases  appeared,  several  of  exceeding 
mildness,  but  our  mistake  was  forcibly  brought  home  to  us  by  the  occurrence, 
in  a  man  who  had  been  exposed  in  the  ward,  of  a  case  of  confluent  small-pox 
of  great  severity.  The  following  points  are  to  be  borne  in  mind:  first,  the 
experience  of  the  past  few  years  has  shown  that  very  mild  epidemics  of  true 
small-pox  may  occur ;  secondly,  any  large  number  of  cases  of  a  contagious  dis- 
ease with  a  pustular  eruption  occurring  in  adults  is  strongly  in  favor  of  small- 
pox. The  characters  of  the  rash  are  of  less  value.  Its  abundance  on  the  trunk 
in  varicella  is  important.  At  the  outset  the  papules  have  rarely  the  shotty, 
hard  feel  of  small-pox.  The  vesicles  are  more  superficial,  the  infiltrated  areola 
is  not  so  intense  nor  so  constant,  and  as  a  rule  the  pocks  may  be  seen  in  the 
same  patient  in  all  stages  of  development.  The  longer  period  of  invasion,  the 
prodromal  rashes,  the  greater  intensity  of  the  onset,  are  also  important  points 
in  small-pox.  But,  as  I  have  said,  there  are  mild  epidemics  in  which  it  must 
be  confessed  that  the  recognition  of  the  nature  of  the  outbreak  is  sometimes 
only  confirmed  by  the  appearance  of  a  severe  case  of  the  confluent  or  of  the 
hgemorrhagic  form. 

The  disease  may  be  mistaken  for  cerehro-spinal  fever,  in  which  purpuric 
symptoms  are  not  uncommon.  A  four-year-old  child  was  taken  suddenly  ill 
with  fever,  pains  in  the  back  and  head,  and  on  the  second  or  third  day  petechige 
appeared  on  the  skin.  There  were  retraction  of  the  head,  and  marked  rigidity 
of  the  limbs.  The  hgemorrhages  became  more  abundant;  and  finally  hgema- 
temesis  occurred  and  the  child  died  on  the  sixth  day.  At  the  post  mortem 
there  were  no  lesions  of  cerebro-spinal  fever,  and  in  the  deeply  hemor- 
rhagic skin  the  papules  could  be  readily  seen.  The  post-mortem  diagnosis 
of  small-pox  was  unhappily  confirmed  by  the  mother  taking  the  disease  and 
dying  of  it. 

Pustular  Sypliilides. — A  very  copious  pustular  rash  in  syphilis  may  resem- 
ble variola,  particularly  if  accompanied  by  fever,  but  the  history  and  the  dis- 
tribution, particularly  the  slight  amount  on  the  face,  leaves  no  question  as  to 
the  diagnosis. 

Pustular  glanders  has  been  mistaken  for  small-pox.     In  a  remarkable  in- 
stance of  the  kind  in  Montreal  there  was  a  wide-spread  pustular  eruption, 
which  we  thought  at  first  was  small-pox,  but  the  subsequent  course  and  the 
fact  that  there  was  glanders  among  the  horses  in  the  stable  led  to  the  correct 
10 


122  SPECIFIC  INFECTIOUS  DISEASES. 

diagnosis.  TPie  eruption  resembled  exactly  that  described  in  Bayer's  mono- 
graph (De  la  Morve,  1837). 

Impetigo  contagiosa  is  stated  to  have  been  mistaken  for  variola. 

Treatment. — General  Considerations. — Segregation  in  special  hospitals 
is  imperative.  In  the  case  of  local  outbreaks  temporary  barracks  or  tents  may 
be  constructed.  In  the  larger  cities^  considering  the  frequency  with  which 
epidemics  recur,  it  is  worth  while  to  have  a  special  small-pox  hospital. 
If  the  grounds  are  ample  and  all  necessary  precautions  taken,  there  is 
no  reason  why  this  should  not  be  part  of  the  general  hospital  for  infectious 
diseases. 

The  criticism,  already  referred  to,  of  the  danger  of  aerial  conveyance  in 
small-pox  is,  I  think,  correct. 

In  the  early  stages  two  symptoms  call  for  treatment :  the  pain  in  the  back, 
which  requires  opium  in  some  form,  as  advised  by  Sydenham;  and  the  vomit- 
ing, which  is  very  difficult  to  check  and  may  be  uncontrollable.  No  food  should 
be  given  except  a  little  ice  and  champagne,  and  it  usually  stops  with  the 
appearance  of  the  eruption. 

The  diet  is  that  usually  given  in  fevers,  with  plenty  of  cold  water,  or  barley 
water  or  the  Scotch  borse — oatmeal  and  water,  to  which  lemon-juice  may  be 
added. 

For  the  fever,  cold  sponging  or  the  cold  bath  may  be  used;  when  there  is 
much  delirium  with  high  fever  the  latter  is  preferable,  or  the  cold  pack. 

The  treatment  of  the  eruption  is  important.  After  trying  all  sorts  of 
remedies,  such  as  puncturing  the  pustules  with  nitrate  of  silver,  or  treating 
them  with  iodine  and  various  ointments,  I  came  to  Sydenham's  conclusion  that 
in  guarding  the  face  against  being  disfigured  by  the  sears  "  the  only  effect  of 
oils,  liniments,  and  the  like,  was  to  make  the  white  scurfs  slower  in  coming 
off."  The  constant  application  on  the  face  and  hands  of  lint  soaked  in  cold 
water,  to  which  antiseptics  such  as  carbolic  acid  or  bichloride  may  be  added, 
is  perhaps  the  most  suitable  local  treatment.  It  is  very  pleasant  to  the  patient, 
and  for  the  face  it  is  well  to  make  a  mask  of  lint,  which  can  then  be  covered 
with  oiled  silk.  When  the  crusts  begin  to  form,  the  chief  point  is  to  keep  them 
thoroughly  moist,  which  may  be  done  with  oil  or  glycerin.  This  prevents  the 
desiccation  and  diffusion  of  the  flakes  of  epidermis.  Vaseline  is  particularly 
useful,  and  at  this  stage  may  be  freely  used  upon  the  face.  It  also  relieves  the 
itching.  For  the  odor,  which  is  sometimes  so  characteristic  and  disagreeable, 
the  dilute  carbolic  solutions  are  probably  best.  If  the  eruption  is  abundant  on 
the  scalp,  the  hair  should  be  cut  short  to  prevent  matting  and  decomposition 
of  the  crusts. 

The  papules  do  not  maturate  so  well  when  protected  from  the  light,  and 
for  centuries  attempts  have  been  made  to  modify  the  course  of  the  pustules,  by 
either  excluding  the  light,  or  by  changing  its  character.  In  the  Middle  Ages 
Gilbertus  Magnus  and  John  of  Gaddesden  recommended  wrapping  the  patient 
in  red  flannel,  and  the  latter  treated  in  this  way  the  son  of  Edward  I.  It  was 
an  old  practice  of  the  Egyptians  and  Arabians  to  cover  the  exposed  parts  of 
small-pox  patients  with  gold-leaf.  Lutzenberg,  a  distinguished  New  Orleans 
physician,  in  1832  treated  patients  by  exclusion  of  the  sunlight.  Eecently  the 
red-light  treatment  of  the  disease  has  been  advocated  by  Finzen.  The  state- 
ments do  not  agree  as  to  its  value.    Nash  states  that  the  course  of  the  rash  may 


VACCINIA— VACCINATION.  123 

be  modified  by  the  treatment,  but  Eicketts  and  Byles  could  see  no  influence 
whatever,  even  in  cases  taken  at  the  earliest  possible  date. 

Complications. — If  the  diarrhoea  is  severe  in  children,  paregoric  may  be 
given.  When  the  pulse  becomes  feeble  and  rapid,  stimulants  may  be  freely 
given.  The  maniacal  delirium  may  require  chloroform  or  morphia,  but  for  less 
intense  nervous  symptoms  the  bath  or  cold  pack  is  the  best.  For  the  severe 
haemorrhages  of  the  malignant  cases  nothing  can  be  done,  and  it  is  only  cruel 
to  drench  the  unfortunate  patient  with  iron,  ergot,  and  other  drugs.  Symp- 
toms of  obstruction  in  the  larynx,  usually  from  oedema,  may  call  for  tracheot- 
omy. In  the  late  stages  of  the  disease,  should  the  patient  be  extremely  debili- 
tated and  the  subject  of  abscesses  and  bed-sores,  he  may  be  placed  on  a  water- 
bed  or  treated  in  the  continuous  warm  bath. 

The  care  of  the  eyes  is  most  important.  The  lids  should  be  thoroughly 
cleansed  and  the  conjunctivae  washed  with  a  warm  solution  of  salt  or  boracic 
acid.  In  the  confluent  cases  the  eyelids  are  much  swollen  and  glued  together, 
and  it  is  only  constant  watchfulness  which  prevents  keratitis.  The  mouth  and 
throat  should  be  kept  clean  and  the  treatment  of  the  nose  with  glycerin  or 
sweet  oil  should  be  begun  early,  as  it  prevents  the  formation  of  hard  crusts. 

The  treatment  in  the  stage  of  convalescence  is  important.  Frequent  bath- 
ing helps  to  soften  the  crusts,  and  the  skin  may  be  oiled  daily.  Convalescence 
should  not  be  considered  established  until  the  skin  is  perfectly  smooth  and 
clean  and  free  from  any  trace  of  scabs. 


V.    VACCINIA   (Cow-pox)— VACCINATION. 

Definition. — An  eruptive  disease  of  the  cow,  the  virus  of  which,  inoculated 
into  man  (vaccination),  produces  a  local  pock  with  constitutional  disturbance, 
which  affords  protection,  more  or  less  permanent,  against  small-pox. 

The  vaccine  is  got  either  directly  from  the  calf — animal  lymph — in  which 
the  disease  is  propagated  at  regular  stations,  or  is  obtained  from  persons  vac- 
cinated (humanized  lymph). 

History. — For  centuries  it  had  been  a  popular  belief  among  farmer  folk 
that  cow-pox  protected  against  small-pox.  The  notorious  Duchess  of  Cleve- 
land, replying  to  some  joker  who  suggested  that  she  would  lose  her  occupation 
if  she  was  disfigured  with  small-pox,  said  that  she  was  not  afraid  of  the  dis- 
ease, as  she  had  had  a  disease  that  protected  her  against  small-pox.  Jesty,  a 
Dorsetshire  farmer,  had  had  cow-pox,  and  in  1774  vaccinated  successfully  his 
wife  and  two  sons.  Plett,  in  Holstein,  in  1791,  also  successfully  vaccinated 
three  children.  When  Jenner  was  a  student  at  Sodbury,  a  young  girl,  who 
came  for  advice,  when  small-pox  was  mentioned,  exclaimed,  "  I  can  not  take 
that  disease,  for  I  have  had  cow-pox."  Jenner  subsequently  mentioned  the 
subject  to  Hunter,  who  in  reply  gave  the  famous  advice :  "  Do  not  think,  but 
try;  be  patient,  be  accurate."  As  early  as  1780  the  idea  of  the  protective  power 
of  vaccination  was  firmly  impressed  on  Jenner's  min,d.  The  problem  which 
occupied  his  attention  for  many  years  was  brought  to  a  practical  issue  when, 
on  May  14,  1796,  he  took  matter  from  the  hand  of  a  dairy-maid,  Sarah  Nelmes, 
who  had  cow-pox,  and  inoculated  a  boy  named  James  Phipps,  aged  eight  years. 
On  July  1st  matter  was  taken  from  a  small-pox  pustule  and  inserted  into 


124  SPECIFIC  INFECTIOUS  DISEASES. 

the  bo}^,  but  no  disease  followed.  In  1798  ajDpeared  An  Inquiry  into  the  Causes 
and  Effects  of  the  Variola  Vaccinae,  a  Disease  discovered  in  some  of  the  West- 
ern Counties  of  England,  particularly  Gloucestershire,  and  known  by  the  jSTame 
of  Cow-pox  (pp.  iv,  To,  four  plates,  4to.    London,  1798). 

In  the  United  States  cow-pox  was  introduced  by  Benjamin  Waterhouse, 
Professor  of  Physic  at  Harvard,  who  on  July  8,  1800,  vaccinated  seven  of  his 
children.  In  Boston  on  August  16,  1802,  nineteen  boys  were  inoculated  with 
the  cow-pox.  On  Xovember  9th  twelve  of  them  were  inoculated  with  small- 
pox; nothing  followed.  A  control  experiment  was  made  by  inoculating  two 
unvaccinated  boys  with  the  same  small-pox  virus ;  both  took  the  disease.  The 
nineteen  children  of  August  16th  were  again  unsuccessfully  inoculated  with 
fresh  virus  from  these  two  boys.  This  is  one  of  the  most  crucial  experiments 
in  the  history  of  vaccination,  and  fully  justified  the  conclusion  of  the  Board 
of  Health — cow-pox  is  a  complete  security  against  the  small-pox. 

Practitioners  should  familiarize  themselves  with  the  literature  on  vaccina- 
tion. The  centenary  number  of  the  British  Medical  Journal  is  particularly 
valuable  (1896).  The  report  of  the  Eoyal  Commission  on  vaccination  (1897), 
the  exhaustive  article  in  Allbutt's  System  by  T.  D.  Acland  and  Copeman,  and 
Cory's  recent  monograph  on  the  subject  afford  a  large  body  of  material.  To 
the  public  health  officials,  who  wish  for  distribution  in  handy  shape  Facts 
about  Small-pox  and  Vaccination,  leaflets  issued  by  the  British  Medical 
Association  (British  Medical  Journal,  1898,  vol.  i,  p.  632)  will  be  of 
the  greatest  value.  The  Vaccination  Law  of  the  German  Empire,  printed 
in  English  (Berlin,  B.  Paul,  1904),  contains  important  information  and 
statistics. 

Nature  of  Vaccinia. — Is  cow-pox  a  separate  independent  disease,  or  is  it 
only  small-pox  modified  by  passing  through  the  cow?  In  spite  of  a  host  of 
observations,  this  question  is  not  yet  settled,  as  may  be  seen  in  the  diametrically 
opposed  views  expressed  by  Copeman  in  Allbutt's  System  and  by  Brouardel  in 
the  Twentieth  Century  Practice.  The  experiments  may  be  divided  into  two 
groups.  First,  those  in  which  the  inoculation  of  the  small-pox  matter  in  the 
heifer  produced  pocks  corresponding  in  all  respects  to  the  vaccine  vesicles. 
Lymph  from  the  first  calf  inoculated  into  a  second  or  third  produced  the  char- 
acteristic lesions  of  cow-pox,  and  from  the  first,  second,  or  third  animal  lymph 
used  to  vaccinate  a  child  produced  a  typical  localized  vaccine  vesicle  without 
any  of  the  generalized  features  of  small-pox.  The  experiments  of  Ceely,  of 
Babcock,  and  many  other  more  recent  workers  seem  to  leave  no  question  what- 
ever that  t3'pical  vaccinia  may  be  produced  in  the  calf  by  the  inoculation  of 
variolous  matter.  A  great  deal  of  the  vaccine  material  at  one  time  in  use  in 
England  was  obtained  in  this  way.  Secondly,  against  this  is  urged  Chauveau's 
Lyons  experiments.  Seventeen  young  animals  were  inoculated  with  the  virus 
of  small-pox.  Small  reddish  papules  occurred  which  disappeared  rapidly,  but 
the  animals  did  not  acquire  cow-pox.  Fifteen  of  the  seventeen  animals  were 
also  vaccinated.  Of  these  only  one  showed  a  typical  cow-pox  eruption.  To 
determine  the  nature  of  the  original  papules  one  was  excised  and  inoculated 
into  a  non-vaccinated  child,  which  developed  as  a  result  generalized  confluent 
small-pox.  A  second  child  inoculated  from  the  primary  pustule  of  the  first 
child  developed  discrete  small-pox.  The  French  still  hold  to  the  Lyons  experi- 
ments as  demonstrating  the  duality  of  the  diseases. 


VACCINIA— VACCINATION.  125 

The  weight  of  evidence  favors  the  view  that  cow-pox  and  horse-pox  are 
variola  modified  by  transmission;  or,  as  has  been  suggested,  "small-pox  and 
vaccinia  are  both  of  them  descended  from  a  common  stock — from  an  ancestor, 
for  instance — which  resembled  vaccinia  far  more  than  it  resembled  small-pox  " 
(Copeman). 

The  bodies  described  by  Guarnieri  have  been  very  thoroughly  studied  by 
Councilman  and  his  colleagues,  who  regard  them  as  forms  of  a  protozoon — 
Cytoryctes  vaccinice — with  a  well  characterized  developmental  cycle,  increasing 
in  size  until  they  undergo  segmentation. 

Normal  Vaccination. — Period  of  Incubation. — At  first  there  may  be  a  little 
irritation  at  the  site  of  inoculation,  which  subsides.  Period  of  Eruption. — On 
the  third  day,  as  a  rule,  a  papule  is  seen  surrounded  by  a  reddish  zone.  This 
gradually  increases,  and  on  the  fifth  or  sixth  day  shows  a  definite  vesicle,  the 
margins  of  which  are  raised  while  the  centre  is  depressed.  By  the  eighth  day 
the  vesicle  has  attained  its  maximum  size.  It  is  round  and  distended  with  a 
limpid  fluid,  the  margin  hard  and  prominent,  and  the  umbilication  is  more 
distinct.  By  the  tenth  day  the  vesicle  is  still  large  and  is  surrounded  by  an 
extensive  areola.  The  contents  have  now  become  purulent.  The  skin  is  also 
swollen,  indurated,  and  often  painful.  On  the  eleventh  or  twelfth  day  the 
hypersemia  diminishes,  the  lymph  becomes  more  opaque  and  begins  to  dry.  By 
the  end  of  the  second  week  the  vesicle  is  converted  into  a  brownish  scab,  which 
gradually  becomes  dry  and  hard,  and  in  about  a  week  (that  is,  about  the 
twenty-first  or  twenty-fifth  day  from  the  vaccination)  separates  and  leaves  a 
circular  pitted  scar.  If  the  points  of  inoculation  have  been  close  together,  the 
vesicles  fuse  and  may  form  a  large  combined  vesicle.  Constitutional  symptoms 
of  a  more  or  less  marked  degree  follow  the  vaccination.  Usually  on  the  third 
or  fourth  day  the  temperature  rises,  and  may  persist,  increasing  until  the 
eighth  or  ninth  day.  There  is  a  marked  leucocytosis.  In  children  it  is  common 
to  have  with  the  fever  restlessness,  particularly  at  night,  and  irritability;  but 
as  a  rule  these  symptoms  are  trivial.  If  the  inoculation  is  made  on  the  arm, 
the  axillary  glands  become  large  and  sore;  if  on  the  leg,  the  inguinal  glands. 
The  duration  of  the  immunity  is  extremely  variable,  differing  in  different  indi- 
viduals. In  some  instances  it  is  permanent,  but  a  majority  of  persons  within 
ten  or  twelve  years  again  become  susceptible. 

Pevaccination  should  be  performed  between  the  tenth  and  fifteenth  year, 
and  whenever  small-pox  is  epidemic.  The  susceptibility  to  revaecination  is 
very  general.  In  1891-^92  vaccination  pustules  developed  in  88.7  per  cent  of 
the  newly  enrolled  troops  of  the  German  army,  most  of  whom  had  been  vac- 
cinated twice  in  their  lives  before.  The  vesicle  in  revaecination  is  usually 
smaller,  has  less  induration  and  hypersemia,  and  the  resulting  sear  is  less  per- 
fect. Particular  care  should  be  taken  to  watch  the  vesicle  of  revaecination,  as 
it  not  infrequently  happens  that  a  spurious  pock  is  formed,  which  reaches  its 
height  early  and  dries  to  a  scab  by  the  eighth  or  ninth  day. 

Irregular  Vaccination. — {a)  Local  Variations. — We  occasionally  meet 
with  instances  in  which  the  vesicle  develops  rapidly  with  much  itching,  has 
not  the  characteristic  flattened  appearance,  the  lymph  early  becomes  opaque, 
and  the  crust  forms  by  the  seventh  or  eighth  day.  The  evolu-tion  of  the  pocks 
may  be  abnormally  slow.  In  such  cases  the  operation  should  again  be  per- 
formed with  fresh  lymph.     The  contents  of  the  vesicles  may  be  watery  and 


126  SPECIFIC  INFECTIOUS  DISEASES. 

blood}'.  In  the  involution  the  bruising  or  irritation  of  the  pocks  may  lead  to 
ulceration  and  infiamniatioai.  A  very  rare  event  is  the  recurrence  of  the  pock 
in  the  same  place.     Sutton  reports  four  such  recurrences  within  six  months. 

(5)  Gexeralized  Yaccinia. — It  is  not  uncommon  to  see  vesicles  in  the 
vicinity  of  the  primary  sore.  Less  common  is  a  true  generalized  pustular  rash, 
developing  in  different  parts  of  the  body,  often  beginning  about  the  wrists  and 
on  the  back.  The  secondary  pocks  may  continue  to  make  their  appearance  for 
five  or  six  weeks  after  vaccination.  In  children  the  disease  may  prove  fatal. 
They  may  be  most  abundant  on  the  vaccinated  limb,  and  occur  usually  about 
the  eighth  to  the  tenth  day. 

(c)  CoMPLiCATioxs. — In  unhealthy  subjects,  or  as  a  result  of  uncleanli- 
ness,  or  sometimes  injury,  the  vesicles  inflame  and  deep  excavated  ulcers  result. 
Sloughing  and  deep  cellulitis  may  follow.  In  debilitated  children  there  may 
be  with  this  a  purpuric  rash.  Acland  thus  arranges  the  dates  at  which  the 
possible  eruptions  and  complications  may  be  looked  for : 

1.  During  the  first  three  days:  Erythema;  urticaria;  vesicular  and  bullous 
eruptions ;  invaccinated  erysipelas. 

2.  After  the  third  day  and  until  the  pock  reaches  maturity:  Urticaria; 
lichen  urticatus,  erythema  multiforme ;  accidental  erysipelas. 

3.  About  the  end  of  the  first  week:  Generalized  vaccinia;  impetigo;  vac- 
cinal ulceration;  glandular  abscess;  septic  infections;  gangrene. 

4.  After  the  involution  of  the  pocks :  Invaccinated  diseases — for  example, 
S}^hilis. 

(d)  Teaxsmissiox  of  Disease  by  Vaccixatiox. — S3^hilis  has  undoubt- 
edly been  transmitted  by  vaccination,  but  such  instances  are  very  rare.  A  large 
number  of  the  cases  of  alleged  vaccino-syphilis  must  be  thrown  out.  The  ques- 
tion has  now  become  really  of  minor  importance  since  the  wide-spread  use  of 
animal  lymph.  Dr.  Cory's  sad  experiment  may  here  be  referred  to.  He  vac- 
cinated himself  four  times  from  sj^hilitic  children.  The  first  vaccination 
followed,  but  no  syphilis.  Two  other  attempts  (negative)  were  made.  The 
fourth  time  he  was  vaccinated  from  a  child  the  subject  of  congenital  s}^hilis. 
The  lymph  was  taken  from  the  child's  arm  with  care,  avoiding  any  contamina- 
tion with  blood.  At  two  of  the  points  of  insertion  red  papules  aj)peared  on 
the  twenty-first  day.  On  the  thirty-eighth  day  a  little  ulcer  was  found,  which 
Mr.  Hutchinson  decided  was  syphilitic.  The  diseased  parts  were  then  removed. 
By  the  fiftieth  day  the  constitutional  s3'mptoms  were  well  marked.  Among 
the  differences  between  vaccino-syphilis  and  vaccination  ulcers  the  most  im- 
portant is  perhaps  that  the  chancre  never  appears  before  the  fifteenth  day, 
usually  not  until  from  three  to  five  weeks,  whereas  the  ulceration  of  ordinary 
vaccination  is  present  by  the  twelfth  or  fifteenth  day.  The  loss  of  substance 
in  the  chancre  is  usually  quite  superficial  and  the  induration  very  parchment- 
like and  specific,  with  but  a  slight  inflammatory  areola.  The  glandular  swell- 
ing, too,  is  constant  and  indolent,  while  in  the  vaccination  ulcer  it  is  often 
absent,  or,  when  present,  chiefly  inflammatory. 

Tuberculosis. — "  Xo  undoubted  case  of  invaccinated  tubercle  was  brought 
before  the  Eoyal  Commission  on  Vaccination"  (Acland).  The  risk  of  trans- 
mitting tuberculosis  from  the  calf  is  so  slight  that  it  need  not  be  considered. 
The  transmission  of  leprosy  by  vaccination  is  doubtful. 

The  observations  on  the  presence  of  actinomyces  in  vaccine  virus  have  been 


VACCINIA— VACCINATION.  127 

confirmed  by  W.  T.  Howard,  Jr.,  who  found  it  34  times  in  95  cultures  from 
the  virus  of  five  producers  in  the  United  States. 

Tetanus. — McFarland  has  collected  95  cases,  practically  all  American. 
Sixty-three  occurred  in  1901,  a  majority  of  which  could  be  traced  to  one  source 
of  supply,  in  which  E.  W.  Wilson  demonstrated  the  tetanus  bacillus.  Most  of 
the  cases  occurred  about  Philadelphia.  Since  that  date,  McFarland  tells  me 
that  very  few  cases  have  been  reported.  The  occurrence  of  this  terrible  com- 
plication emphasizes  the  necessity  of  the  most  scrupulous  care  in  the  prepara- 
tion of  the  animal  virus,  as  the  tetanus  bacillus  is  almost  constantly  present  in 
the  intestines  of  cattle. 

(e)  Influence  op  Vaccination  upon  other  Diseases, — A  quiescent 
malady  may  be  lighted  into  activity  by  vaccination.  This  has  happened  with 
congenital  syphilis,  occasionally  with  tuberculosis.  An  old  idea  was  prevalent 
that  vaccination  had  a  beneficial  influence  upon  existing  diseases.  Thomas 
Archer,  the  first  medical  graduate  in  the  United  States,  recommended  it  in 
whooping-cough,  and  said  that  it  had  cured  in  his  hands  six  or  eight  cases.  At 
the  height  of  the  vaccination  convulsions  may  occur  and  be  followed  by  hemi- 
plegia.   One  such  case  I  saw  with  Morris  J.  Lewis. 

Choice  of  Lymph. — If  bovine  lymph  is  not  available,  humanized  lymph 
should  be  taken  on  the  eighth  day,  and  only  from  perfectly  formed,  unbroken 
vesicles,  which  have  had  a  typical  course.  Pricking  or  scratching  the  surface, 
the  greatest  care  being  taken  not  to  draw  blood,  allows  the  lymph  to  exude,  and 
it  may  be  collected  on  ivory  points  or  in  capillary  tubes.  The  child  from 
which  the  lymph  is  taken  should  be  healthy,  strong,  and  known  to  be  of  good 
stock,  free  from  tuberculous  or  syphilitic  taint.  The  glycerinated  calf  lymph 
has  come  into  general  use.  The  Local  Government  Board  has  recently  issued 
a  valuable  report  on  the  subject  by  Thorne  and  Copeman,  giving  full  details 
as  to  the  method  of  preparation.  In  it  the  statement  is  made  that,  whereas  it 
was  usual  to  make  the  lymph  from  one  calf  serve  for  from  200  to  300  vaccina- 
tions, the  glycerinated  lymph  will  serve  for  from  4,000  to  5,000  vaccinations. 

Technique. — Far  too  little  attention  is  paid  in  American  schools  to  the 
instruction  of  students  in  the  art  of  vaccination.  That  part  of  the  arm  about 
the  insertion  of  the  deltoid  is  usually  selected  for  the  operation.  Mothers  "  in 
society  "  prefer  to  have  girl  babies  vaccinated  on  the  leg.  The  skin  should  be 
cleansed  and  put  upon  the  stretch.  Then,  with  a  lancet  or  the  ivory  point, 
cross-scratches  should  be  made  in  one  or  more  places.  When  the  lymph  has 
dried  on  the  points  it  is  best  to  moisten  it  in  warm  water.  The  clothing  of 
the  child  should  not  be  adjusted  until  the  spot  has  dried,  and  it  should  be 
protected  for  a  day  or  two  with  lint  or  a  soft  handkerchief.  If  erysipelas  is 
prevalent,  or  if  there  are  cases  of  suppuration  in  the  same  house,  it  is  well  to 
apply  a  pad  of  antiseptic  cotton.  Vaccination  is  usually  performed  at  the 
second  or  third  month.  If  unsuccessful,  it  should  be  repeated "  from  time  to 
time.  A  person  exposed  to  the  contagion  of  small-pox  should  always  be  revac- 
cinated.  This,  if  successful,  will  usually  protect;  but  not  always.  The  cases 
in  which  small-pox  is  taken  within  a  few  years  after  vaccination  are  probably 
instances  of  spurious  vaccination. 

The  Value  of  Vaccination. — Sanitation  can  not  account  for  the  diminution 
in  small-pox  and  for  the  low  rate  of  mortality.  Isolation,  of  course,  is  a  use- 
ful auxiliary,  but  it  is  no  substitute.     Vaccination  is  not  claimed  to  be  an 


128  SPECIFIC  INFECTIOUS  DISEASES, 

invariable  and  permanent  preventive  of  small-pox,  but  in  an  immense  majority 
of  cases  successful  inoculation  renders  the  person  for  many  3'ears  insusceptible. 
Communities  in  which  vaccination  and  revaccination  are  thoroughly  and  sys- 
tematically carried  out  are  those  in  which  small-pox  has  the  fewest  victims. 
The  German  army  since  187i,  the  date  of  the  stringent  laws,  has  enjoyed 
practical  immunity — not  a  single  death  from  small-pox  (to  the  date  of  the 
last  report,  1902),  except  an  isolated  case  under  peculiar  circumstances  in 
1884-'8o.  On  the  other  hand,  communities  in  which  vaccination  and  revac- 
cination are  persistently  neglected  are  those  in  which  epidemics  are  most  preva- 
lent. Owing  to  a  wide-spread  prejudice  against  vaccination  in  Montreal,  there 
grew  up,  between  the  years  1876  and  1884,  a  considerable  unprotected  popu- 
lation, and  the  materials  were  ripe  for  an  extensive  epidemic.  The  soil  had 
been  prepared  with  the  greatest  care,  and  it  only  needed  the  introduction  of 
the  seed,  which  in  due  time  came  with  the  Pullman-car  conductor  from  Chi- 
cago, on  the  28th  of  February,  1885  (see  page  113).  Within  the  next  ten 
months  thousands  of  persons  were  stricken  with  the  disease,  and  3,164  died. 
Although  the  effects  of  a  single  vaccination  may  wear  out,  as  we  say,  and 
the  individual  again  become  susceptible  to  small-pox,  yet  the  mortality  in 
such  cases  is  very  much  lower  than  in  persons  who  have  never  been  vaccinated. 
The  mortality  in  persons  who  have  been  vaccinated  is  from  6  to  8  per  cent, 
whereas  in  the  unvaccinated  it  is  at  least  35  per  cent.  There  is  evidence  that 
the  greater  the  number  of  marks,  the  greater  the  protection  in  relation  to 
small-pox;  thus  the  English  Vaccination  Eeport  states  that  out  of  4,754  cases 
the  death-rate  T\dth  one  mark  was  7.6  per  cent;  with  two  marks,  7  per  cent; 
with  three  marks,  4.2  per  cent ;  with  four  marks,  2.4  per  cent.  W.  M.  Welch's 
statistics  of  5,000  cases  on  this  point  give  with  good  cicatrices  8  per  cent; 
with  fair  cicatrices,  14  per  cent;  with  poor  cicatrices,  27  per  cent;  post-vac- 
cinal  cases.  16  per  cent;  unvaccinated  cases,  58  per  cent. 


VI.     VARICELLA  (CMcken-pox). 

Definition. — An  acute  contagious  disease  of  children,  characterized  by  an 
eruption  of  vesicles  on  the  skin. 

Etiology. — The  disease  occurs  in  epidemics,  but  sporadic  cases  are  also 
met  with.  It  may  prevail  at  the  same  time  as  small-pox  or  may  follow  or 
precede  epidemics  of  this  disease.  An  attack  of  chicken-pox  is  no  protection 
against  small-pox.  It  is  a  disease  of  childhood;  a  majority  of  the  cases  occur 
between  the  second  and  sixth  years.  Adults  who  have  not  had  the  disease  in 
childhood  are  very  liable  to  be  attacked.  The  specific  germ  has  not  yet  been 
discovered. 

There  can  be  no  question  that  varicella  is  an  affection  quite  distinct  from 
variola  and  without  at  present  any  relation  whatever  to  it.  An  attack  of  the 
one  does  not  confer  immunity  from  an  attack  of  the  other.  A  boy,  aged  five, 
was  admitted  to  St.  Thomas'  Hospital  with  a  vesicular  eruption,  and  was  iso- 
lated in  a  ward  on  the  same  floor  as  the  small -pox  ward.  The  disease  was 
pronounced  chicken-pox,  however,  by  Eisdon  Bennett  and  Bristowe.  The 
patient  was  then  removed  and  vaccinated,  with  a  result  of  four  vesicles  which 
ran  a  pretty  normal  course.    On  the  eighth  day  from  the  vaccination  the  child 


VARICELLA.  129 

became  feverish.  On  the  following  day  the  papules  appeared  and  the  child 
had  a  well-developed  attack  of  small-pox  with  secondary  fever  (Sharkey). 

Symptoms. — After  a  period  of  incubation  of  ten  or  fifteen  days  the  child 
becomes  feverish  and  in  some  instances  has  a  slight  chill.  There  may  be 
vomiting,  and  pains  in  the  back  and  legs.  Convulsions  are  rare.  The  erup- 
tion usually  occurs  within  twenty-four  hours.  It  is  first  seen  upon  the 
trunk,  either  on  the  back  or  on  the  chest.  It  may  begin  on  the  forehead  and 
face.  At  first  in  the  form  of  raised  red  papules,  these  are  in  a  few  hours 
transformed  into  hemispherical  vesicles  containing  a  clear  or  turbid  fluid.  As 
a  rule  there  is  no  umbilication,  but  in  rare  instances  the  pocks  are  flattened, 
and  a  few  may  even  be  umbilicated.  They  are  often  ovoid  in  shape  and  look 
more  superficial  than  the  variolous  vesicles.  The  skin  in  the  neighborhood 
is  not  often  infiltrated  or  hypersemic.  At  the  end  of  thirty-six  or  forty-eight 
hours  the  contents  of  the  vesicles  are  purulent.  They  begin  to  shrivel,  and 
during  the  third  and  fourth  days  are  converted  into  dark  brownish  crusts, 
which  fall  off  and  as  a  rule  leave  no  scar.  Fresh  crops  appear  during  the  first 
two  or  three  days  of  the  illness,  so  that  on  the  fourth  day  one  can  usually  see 
pocks  in  all  stages  of  development  and  decay.  They  are  always  discrete,  and 
the  number  may  vary  from  eight  or  ten  to  several  hundreds.  As  in  variola, 
a  scarlatinal  rash  occasionally  precedes  the  development  of  the  eruption.  The 
eruption  may  occur  on  the  mucous  membrane  of  the  mouth,  and  occasionally 
in  the  larynx.  In  adults  the  disease  may  be  much  more  severe,  the  initial 
fever  high,  the  rash  very  wide-spread,  and  the  constitutional  sjmiptoms  com- 
paratively severe,  so  that  the  diagnosis  of  variola  may  be  made — the  so-called 
varicellse  variolaformes. 

There  are  one  or  two  modifications  of  the  rash  which  are  interesting.  The 
vesicles  may  become  very  large  and  develop  into  regular  bullae,  looking  not 
unlike  ecthyma  or  pemphigus  (varicella  bullosa).  The  irritation  of  the  rash 
may  be  excessive,  and  if  the  child  scratches  the  pocks  ulcerating  sores  may 
form,  which  on  healing  leave  ugly  scars.  Indeed,  cicatrices  after  chicken-pox 
are  more  common  than  after  varioloid.  The  fever  in  varicella  is  slight,  but 
it  does  not  as  a  rule  disappear  with  the  appearance  of  the  rash.  The  course 
of  the  disease  is  in  a  large  majority  of  the  cases  favorable  and  no  ill  effects 
follow.  The  disease  may  recur  in  the  same  individual.  There  are  instances 
in  which  a  person  has  had  three  attacks. 

In  delicate  children,  particularly  the  tuberculous,  gangrene  (varicella 
escharotica)  may  occur  about  the  vesicles,  or  in  other  parts,  as  the  scrotum. 

Cases  have  been  described  of  hsemorrhagic  varicella  with  cutaneous  ecchy- 
moses  and  bleeding  from  the  mucous  membranes. 

Nephritis  may  occur.  Infantile  hemiplegia  has  occurred  during  an  attack 
of  the  disease.  Death  has  followed  in  an  uncomplicated  case  from  extensive 
involvement  of  the  skin. 

The  diagnosis  is  as  a  rule  easy,  particularly  if  the  patient  has  been  seen 
from  the  outset.  When  a  case  comes  under  observation  for  the  first  time  with 
the  rash  well  out,  there  may  be  considerable  difficulty.  The  abundance  of  the 
rash  on  the  trunk  in  varicella  is  most  important.  The  pocks  in  varicella  are 
more  superficial,  more  bleb-like,  have  not  so  deeply  an  infiltrated  areola  about 
them,  and  may  usually  be  seen  in  all  stages  of  development.  They  rarely  at 
the  outset  have  the  hard,  shotty  feeling  of  those  of  small-pox.     The  general 


130  SPECIFIC  INFECTIOUS  DISEASES. 

symptoms,  the  greater  intensity  of  the  onset,  the  prolonged  period  of  invasion, 
and  the  more  frequent  occurrence  of  prodromal  rashes  in  small-pox  are  im- 
portant points  in  the  diagnosis. 

Death  is  very  rare,  and,  unless  from  the  complications,  raises  a  suspicion 
of  the  correctness  of  the  diagnosis.  Thus  of  the  116  deaths  in  England  and 
Wales  in  1903  ascribed  to  chicken-pox,  it  is  probable,  as  Tatham  suggests, 
that  many  of  these  were  from  unrecognized  small-pox. 

No  special  treatment  is  required.  If  the  rash  is  abundant  on  the  face, 
great  care  should  be  taken  to  prevent  the  child  from  scratching  the  pustules. 
A  soothing  lotion  should  be  applied  on  lint. 

Vn.     SCARLET    FEVER. 

Definition. — An  infectious  disease  characterized  by  a  diffuse  exanthem  and 
an  angina  of  variable  intensity. 

History. — In  the  sixteenth  century  Ingrasseas  of  Naples  and  Coyttar  of 
Poitiers  recognized  the  disease;  but  Sydenham  in  1675  gave  a  full  account  of 
it  under  the  name  febris  scarlatina. 

Etiology. — Kg  one  of  the  acute  infections  varies  so  greatly  in  the  intensity 
of  the  outbreaks,  a  point  to  which  both  Sydenliam  and  Bretonneau  called 
attention.  In  some  years  it  is  mild;  in  others,  with  equally  wide-spread  epi- 
demics, it  is  fearfully  malignant.  It  is  a  wide-spread  affection,  occurring  in 
nearl}^  all  parts  of  the  globe  and  attacking  all  races. 

Sporadic  cases  occur  from  time  to  time.  The  epidemics  are  most  intense 
in  the  autumn  and  winter.  There  is  an  extraordinary  variability  in  the 
severity  of  the  outbreaks,  which  on  the  whole  appear  to  be  lessening  in  sever- 
ity; thus  in  Boston  from  1894  to  1903  the  ratio  of  cases  per  ten  thousand  has 
ranged  from  45.80  to  16.18,  and  the  mortality  from  3.94  to  .60.  In  England 
and  Wales  in  1903  there  were  4,158  deaths.  Only  in  1898,  1899,  and  1900 
did  the  deaths  fall  below  4,000.    In  1883  they  were  between  12,000  and  13,000. 

Seibert's  studies  in  New  York  show  that  the  disease  increases  steadily 
from  week  to  week  until  the  middle  of  May ;  the  frequency  diminishes  gradu- 
allj  until  the  end  of  June,  and  gradually  increases  through  October,  Novem- 
ber, and  December.  He  associates  the  remarkable  drop  in  July,  August,  and 
September  with  the  closure  of  the  schools  and  the  cessation  of  the  daily  con- 
gregation of  infectious  material  in  small  areas — school-houses  and  play- 
grounds— for  so  many  hours  each  day. 

Age  is  the  most  important  predisposing  factor.  Ninety  per  cent  of  the 
fatal  cases  are  under  the  tenth  year.  Sucklings  are  rarely  attacked.  The 
general  liability  to  the  disease  in  childhood  is  less  wide-spread  than  in  measles. 
Many  escape  altogether;  others  escape  until  adult  life;  some  never  take  it. 

Family  susceptibility  is  not  infrequently  illustrated  by  the  killing  in  rapid 
succession  of  four  or  five  members.  On  the  other  hand,  individual  resistance 
is  common,  and  many  physicians  constantly  exposed  escape.  An  attack  as  a 
rule  confers  subsequent  immunity.  In  rare  instances  there  have  been  one  or 
even  two  recurrences. 

The  natives  of  India  are  said  to  enjoy  comparative  immunity. 

Infedivity. — It  is  not  yet  accurately  known  where  in  the  body  the  poison 
is  formed,  how  it  is  given  off,  or  in  what  form  it  is  taken  by  another  person. 


SCARLET  FEVER.  131 

It  is  probably  given  off  with  the  secretions  of  the  nose,  throat,  and  respiratory 
tract.  The  mild  angina  of  the  ambulatory  cases  may  convey  the  disease,  and 
in  this  way  it  is  spread  in  schools,  and  the  "  return  cases,"  to  be  referred  to 
later,  may  find  in  this  way  their  explanation.  Much  more  attention  has  be^n 
paid  of  late  to  this  aspect  of  the  scarlatinal  infection,  and  it  has  even  been 
suggested  that  the  skin  is  only  infective  by  contamination  with  the  secre- 
tions. The  general  opinion,  however,  is  that  the  poison  is  given  off  chiefly 
from  the  skin,  particularly  when  desquamating.  Unlike  measles,  the  germ 
is  very  resistant  and  clings  tenaciously  to  clothing,  to  bedding,  the  furni- 
ture of  the  room,  etc.  Even  after  the  most  complete  disinfection  possible, 
children  who  have  been  removed  from  an  infected  house  may  catch  the 
disease  on  their  return.  The  possibility  here  of  throat  infection  must 
be  considered.  A  third  person  may  convey  the  disease,  but  undoubted 
instances  are  rare,  I  recall  one  instance  in  which  I  could  have  been  the  only 
possible  medium.  In  a  collective  investigation  on  this  point  among  physi- 
cians in  the  State  of  Connecticut,  Loveland  had  100  negative  and  10  positive 
replies. 

The  disease  is  stated  to  have  been  conveyed  by  milk.  Of  99  epidemics 
studied  by  Kober  the  disease  prevailed  in  68  either  at  the  dairy  or  the  milk 
farm.  There  appear  to  be  two  groups  of  cases:  first,  genuine  scarlet  fever, 
in  which  the  infection  is  conveyed  through  the  milk  having  come  in  contact 
with  infected  persons;  and  secondly,  outbreaks  of  an  infection  resembling 
scarlet  fever,  due  to  disease  of  the  udder  of  the  cows. 

By  surgical  scarlatina,  first  brought  to  the  attention  of  the  profession  by 
Sir  James  Paget  in  1864,  is  understood  an  erythematous  eruption  following 
an  operation  or  occurring  during  septic  infection.  It  differs  from  medical 
scarlatina  in  the  large  number  of  adults  attacked,  the  shorter  incubation, 
the  mildness  of  the  throat  symptoms,  the  starting  of  the  eruption  at  the 
wound,  and  the  precocious  desquamation.  Alice  Hamilton,  after  analyzing 
174  cases  reported  in  the  literature,  concludes  that  the  eruption  is  most  fre- 
quently due  to  septic  infection  and  is  not  truly  scarlatinal,  and  that  in  those 
cases  in  which  the  disease  was  undoubtedly  scarlatina  there  is  no  convincing 
evidence  that  the  relation  between  the  wound  and  the  scarlet  fever  was  any- 
thing more  than  one  of  coincidence. 

The  specific  germ  is  not  known.  It  is  claimed  to  be  only  a  modified 
streptococcus  infection.  The  streptococcus  pyogenes  has  often  been  found 
in  the  blood  during  life  and  after  death,  and  it  is  constantly  present  in  the 
throat  in  severe  cases;  but  there  is  no  agreement  on  the  subject  among  the 
best  workers.  Mallory's  researches  may  point  to  a  solution  of  the  problem. 
In  four  cases  he  found  between  the  epithelial  cells  of  the  epidermis  a  proto- 
zoon  which  formed  definite  rosettes  like  the  malarial  parasite.  Duval,  con- 
tinuing these  observations,  has  found  this  organism  in  the  serum  of  blisters 
on  the  skin  of  scarlet  fever  patients,  and  has  traced  it  through  a  cycle  of 
changes  which  show  at  any  rate  that  it  is  a  definite  parasite.  Controls  were 
negative  in  other  diseases.  Whatever  the  germ  may  be,  there  is  no  question 
that  in  severe  cases  the  streptococcus  infection  plays  an  important  role  in 
causing  the  septic  symptoms  of  the  disease. 

Morbid  Anatomy. — Except  in  the  haemorrhagie  form,  the  skin  after  death 
shows  no  traces  of  the  rash.     There  are  no  specific  lesions.     Those  which 


132  SPECIFIC  INFECTIOUS  DISEASES. 

occur  in  the  internal  organs  are  due  partly  to  the  fever  and  partly  to  infec- 
tion with  pus-organisms. 

The  anatomical  changes  in  the  throat  are  those  of  simple  inflammation, 
follicular  tonsillitis,  and,  in  extreme  grades,  of  diphtheroid  angina.  In 
severe  cases  there  is  intense  lymphadenitis  and  much  inflammatory  oedema 
of  the  tissues  of  the  neck,  which  may  go  on  to  suppuration,  or  even  to  gan- 
grene. Streptococci  are  found  abundantly  in  the  glands  and  in  the  foci  of 
suppuration.  The  lymph  glands  and  the  lymphoid  tissue  may  show  hyper- 
plasia, and  the  spleen,  liver,  and  other  organs  may  be  the  seat  of  wide-spread 
focal  necroses. 

Endocarditis  and  pericarditis  are  not  infrequent.  Myocardial  changes 
are  less  common.  The  renal  changes  are  the  most  important,  and  have  been 
thoroughly  studied  by  Coats,  Klebs,  Wagner,  and  others.  The  special  nephri- 
tis of  scarlet  fever  will  be  considered  with  the  diseases  of  the  kidney. 

Affections  of  the  respiratory  organs  are  not  frequent.  When  death  results 
from  the  pseudo-membranous  angina,  broncho-pneumonia  is  not  uncommon. 
Cerebro-spinal  changes  are  rare. 

Symptoms. — Incubation. — "  From  one  to  seven  days,  oftenest  two  to 
four." 

Invasion. — The  onset  is  as  a  rule  sudden.  It  may  be  preceded  by  a 
slight,  scarcely  noticeable,  indisposition.  An  actual  chill  is  rare.  Vomit- 
ing is  one  of  the  most  constant  initial  symptoms;  convulsions  are  common. 
The  fever  is  intense ;  rising  rapidly,  it  may  on  the  first  day  reach  104°  or  even 
105°.  The  skin  is  unusually  dry  and  to  the  touch  gives  a  sensation  of  very 
pungent  heat.  The  tongue  is  furred,  and  as  early  as  the  first  day  there  may 
be  complaint  of  dryness  of  the  throat.  Cough  and  catarrhal  symptoms  are 
uncommon.  The  face  is  often  flushed  and  the  patient  has  all  the  objective 
features  of  an  acute  fever. 

Eruption. — Usually  on  the  second  day,  in  some  instances  within  the 
first  twenty-four  hours,  the  rash  appears  in  the  form  of  scattered  red  points 
on  a  deep  subcuticular  flush ;  at  first  on  the  neck  and  chest,  and  spreading 
so  rapidly  that  by  the  evening  of  the  second  day  it  may  have  invaded  the 
entire  skin.  After  persisting  for  two  or  three  days  it  gradually  fades.  At 
its  height  the  rash  has  a  vivid  scarlet  hue,  quite  distinctive  and  unlike  that 
seen  in  any  other  eruptive  disease.  It  is  an  intense  hypersemia,  and  the  anse- 
mia  produced  by  pressure  instantly  disappears.  There  may  be  fine  puncti- 
form  haemorrhages,  which  do  not  disappear  on  pressure.  In  some  cases  the 
rash  does  not  become  uniform  but  remains  patchy,  and  intervals  of  normal 
skin  separate  large  hypergemic  areas.  Tiny  papular  elevations  may  some- 
times be  seen,  but  they  are  not  so  common  as  in  measles.  With  each  day 
the  rash  becomes  of  a  darker  color,  and  there  may  be  in  parts  even  a  bluish- 
red  shade.  Smooth  at  the  beginning,  the  skin  gradually  becomes  rougher, 
and  to  the  touch  feels  like  "  goose  skin."  At  the  height  of  the  eruption 
sudaminal  vesicles  may  develop,  the  fluid  of  which  may  become  turbid.  The 
entire  skin  may  at  the  same  time  be  covered  with  small  yellow  vesicles  on  a 
deep  red  background — scarlatina  miliaris.  McCollom  lays  stress  upon  the 
appearance  of  a  punctate  eruption  in  the  arm-pits,  groins,  and  on  the  roof  of 
the  mouth  as  positive  proof  of  scarlet  fever. 

Occasionally  there  are  petechias,  which  in  the  malignant  t}^e  of  the  dis- 


SCARLET  FEVER. 


133 


Day 

1 

^ 

3 

-4 

5 

G 

7 

8 

9 

'   106'- 

loC 

loi 

100 
98° 

^ 

v> 

A 

A 

1 

Y 

J 

'\ 

Y 

\ 

v 

^ 

1 

V 

-> 

V 

-N 

\ 

^^ 

Chart  VIII. — Scarlet  Fever. 


ease  become  wide-spread  and  large.  The  eruption  does  not  always  appear  upon 
the  face.  There  may  be  a  good  deal  of  swelling  of  the  skin,  which  feels  uncom- 
fortable and  tense.  The  itching  is  variable ;  not  as  a  rule  intense  at  the  height 
of  the  eruption.  By  the  seventh  or  eighth  day  the  rash  has  disappeared. 
The  mucous  membrane  of  the  pal- 
ate, the  cheeks,  and  the  tonsils  pre- 
sent a  vivid  red,  punctiform  ap- 
pearance. The  tongue  at  first  is  red 
at  the  tip  and  edges,  furred  in  the 
centre;  and  through  the  white  fur 
are  often  seen  the  swollen  red  papil- 
lae, which  give  the  so-called  "  straw- 
berry^' appearance  to  the  tongue, 
particularly  if  the  child  puts  out 
the  tip  of  the  tongue  between  the 
lips.  In  a  few  days  the  "  fur " 
desquamates  and  leaves  the  surface 
red  and  rough,  and  it  is  this  condi- 
tion which  some  writers  call  the 
"  strawberry,"  or,  better,  the  "  rasp- 
berry" tongue.  Enlargement  of  the  papillas  was  the  only  constant  sign  in 
1,000  cases  (McCollom).    The  breath  often  has  a  very  heavy,  sweet  odor. 

The  pharyngeal  symptoms  are — 

1.  Slight  redness,  with  swelling  of  the  pillars  of  the  fauces  and  of  the 
tonsils.  2.  A  more  intense  grade  of  swelling  and  infiltration  of  these  parts 
with  a  follicular  tonsillitis.  3.  Diphtheroid  angina  with  intense  inflamma- 
tion of  all  the  pharyngeal  structures  and  swelling  of  the  glands  below  the 
jaw,  and  in  very  severe  cases  a  thick  brawny  induration  of  all  the  tissues  of 
the  neck. 

The  fever,  which  sets  in  with  such  suddenness  and  intensity,  may  reach 
105°  or  even  106°.  It  persists  with  slight  morning  remissions,  gradually 
declining  with  the  disappearance  of  the  rash.  In  mild  cases  the  tempera- 
ture may  not  reach  103°;  on  the  other  hand,  in  very  severe  cases  there 
may  be  hyperpyrexia,  the  thermometer  registering  108°  or  before  death 
even  109°. 

The  pulse  ranges  from  130  to  150;  in  severe  cases  with  very  high  fever 
from  190  to  200.  The  respirations  show  an  increase  proportionate  to  the 
intensity  of  the  fever.  A  leucocytosis  is  usually  present,  which  may  be  high 
(30,000  to  50,000  per  c.cm.)  in  the  severe  cases.  The  gastro-intestinal  symp- 
toms are  not  marked  after  the  initial  vomiting,  and  food  is  usually  well  taken. 
In  some  instances  there  are  abdominal  pains.  The  edge  of  the  spleen  may 
be  palpable.  The  liver  is  not  often  enlarged.  With  the  initial  fever  nervous 
symptoms  are  present  in  a  majority  of  the  cases;  but  as  the  rash  comes  out 
the  headache  and  the  slight  nocturnal  wandering  disappear.  The  urine  has 
the  ordinary  febrile  characters,  being  scanty  and  high  colored.  Slight  albu- 
minuria is  by  no  means  infrequent  during  the  stage  of  eruption.  Careful 
examination  of  the  urine  should  he  made  every  day.  There. is  no  cause  for 
alarm  in  the  trace  of  albumin  which  is  so  often  present,  not  even  if  it  is  asso- 
ciated with  a  few  tube-casts. 


134  SPECIFIC  INFECTIOUS  DISEASES. 

Desqua:matiox. — With  the  disappearance  of  the  rash  and  the  fever  the 
skin  looks  somewhat  stained,  is  dry,  a  little  rough,  and  gradually  the  upper 
layer  of  the  cuticle  begins  to  separate.  The  process  usually  begins  about  the 
neck  and  chest,  and  flakes  are  gradually  detached.  The  degree  and  character 
of  the  desquamation  bear  some  relation  to  the  intensity  of  the  eruption.  "Wlien 
the  latter  has  been  very  vivid  and  of  long  standing,  large  flakes  ma}^  be  thrown 
off.  In  rare  instances  the  hair  and  even  the  nails  have  been  shed.  It  must 
not  be  forgotten  that  there  are  cases  in  which  the  desquamation  has  been 
prolonged,  according  to  Trousseau,  even  to  the  seventh  or  eighth  week.  The 
entire  process  lasts  from  ten  to  fifteen  or  even  twenty  days. 

Atypical  Scarlet  Fever. — ]\Iild  axd  Abortive  FoE:krs. — In  cases  of  excep- 
tional mildness  the  rash  may  be  scarcely  perceptible.  During  epidemics,  when 
several  children  of  a  household  are  affected,  one  child  sickens  as  if  with  scar- 
let fever,  and  has  a  sore  throat  and  the  "  strawberry  tongue,"  but  the  rash 
does  not  appear — scarlatina  sine  eruptione.  In  school  epidemics  a  third  or 
more  of  the  cases  may  be  without  the  rash.  Desquamation,  however,  may 
follow,  and  in  these  very  mild  forms  nephritis  ma}^  occur. 

Malignant  Scaelet  Fever. — Fulminant  Toxic  Variety. — With  all  the 
characteristics  of  an  acute  intoxication,  the  patient  is  overwhelmed  by  the 
intensit}^  of  the  poison  and  may  die  within  twenty-four  or  thirty-six  hours. 
The  disease  sets  in  with  great  severity — ^liigh  fever,  extreme  restlessness, 
headache,  and  delirium.  The  temperature  may  rise  to  107°  or  even  108°,  in 
rare  cases  even  higher.  Convulsions  may  occur  and  the  initial  delirium  rap- 
idly gives  place  to  coma.  The  dyspnoea  may  be  urgent;  the  pulse  is  very 
rapid  and  feeble. 

HEMORRHAGIC  FoRZsi. — HEBmorrliages  occur  into  the  skin,  and  there  are 
hgematuria  and  epistaxis.  In  the  erjihematous  rash  scattered  petechise  appear, 
which  gradually  become  more  extensive,  and  ultimately  the  skin  may  be  uni- 
versally involved.  Death  may  take  place  on  the  second  or  on  the  third  day. 
While  this  form  is  perhaps  more  common  in  enfeebled  children,  I  have  twice 
known  it  to  attack  adults  apparently  in  full  health. 

Angixose  Form. — The  throat  s^nnptoms  appear  early  and  progress  rap- 
idly; the  fauces  and  tonsils  swell  and  are  covered  with  a  thick  membranous 
exudate,  which  may  extend  to  the  posterior  wall  of  the  phar^mx,  forward  into 
the  mouth,  and  upward  into  the  nostrils.  The  glands  of  the  neck  rapidly 
enlarge.  Kecrosis  occurs  in  the  tissues  of  the  throat,  the  foetor  is  extreme, 
the  constitutional  disturbance  profound,  and  the  child  dies  with  the  clin- 
ical picture  of  a  malignant  diphtheria.  Occasionally  the  membrane  extends 
into  the  trachea  and  the  bronchi.  The  Eustachian  tubes  and  the  middle 
ear  are  usually  involved.  When  death  does  not  take  place  rapidlj^  from  tox- 
aemia there  may  be  extensive  abscess  formation  in  the  tissues  of  the  neck  and 
sloughing.  In  the  separation  of  deep  sloughs  about  the  tonsils  the  carotid 
artery  may  be  opened,  causing  fatal  hemorrhage. 

Complications  and  Sequelae. —  {a)  Xephritis. — At  the  height  of  the  fever 
there  is  often  a  slight  trace  of  albumin  in  the  urine,  which  is  not  of  special 
significance.  In  a  majorit)'-  of  cases  the  kidneys  escape  without  greater  dam- 
age than  occurs  in  other  acute  febrile  affections. 

iS^ephritis  is  most  common  in  the  second  or  third  week  and  may  follow 
a  very  mild  attack.     It  may  be  dela^^ed  until  the  third  or  fourth  week.     As 


SCARLET  FEVER.  I35 

a  rule,  the  earlier  it  occurs  the  more  severe  the  attack.     It  occurs  in  from 
10  to  20  per  cent  of  the  cases.    Three  grades  of  cases  may  be  recognized : 

1.  Acute  hsemorrhagic  nephritis.  There  may  be  suppression  of  urine  or 
only  a  small  quantity  of  bloody  fluid  laden  with  albumin  and  tube-casts. 
Vomiting  is  constant,  there  are  convulsions,  and  the  child  dies  with  the  symp- 
toms of  acute  uraemia.  In  severe  epidemics  there  may  be  many  cases  of  this 
sort,  and  an  acute,  rapidly  fatal,  nephritis  due  to  the  scarlet  fever  poison  may 
occur  without  an  exanthem. 

2.  Less  severe  cases  without  serious  acute  symptoms.  There  is  a  puffy 
appearance  of  the  eyelids,  with  slight  oedema  of  the  feet;  the  urine  is  dimin- 
ished in  quantity,  smoky,  and  contains  albumin  and  tube-casts.  The  kidney 
symptoms  then  dominate  the  entire  case,  the  dropsy  persists,  and  there  may 
be  effusion  into  the  serous  sacs.  The  condition  may  drag  on  and  become 
chronic,  or  the  patient  may  succumb  to  urgemic  accidents.  Fortunately,  in 
a  majorit}'^  of  the  cases  recovery  takes  place. 

3.  Cases  so  mild  that  they  can  scarcely  be  termed  nephritis.  The  urine 
contains  albumin  and  a  few  tube-casts,  but  rarely  blood.  The  oedema  is  ex- 
tremely slight  or  transient,  and  the  convalescence  is  scarcely  interrupted. 
Occasionally,  however,  serious  symptoms  may  supervene.  Oedema  of  the  glot- 
tis may  prove  rapidly  fatal,  and  in  one  case  of  the  kind  a  child  under  my  care 
died  of  acute  effusion  into  the  pleural  sacs. 

In  other  cases  the  oedema  disappears  and  the  child  improves,  though  he 
remains  pale,  and  a  slight  amount  of  albumin  persists  in  the  urine  for  months 
or  even  for  years.  Eecovery  may  ultimately  take  place  or  a  chronic  inter- 
stitial nephritis  may  follow. 

Occasionally  oedema  occurs  without  albuminuria  or  signs  of  nephritis. 
Possibly  it  may  be  due  to  the  anaemia;  but  there  are  instances  in  which 
marked  changes  have  been  found  in  the  kidney  after  death,  even  when  the 
urine  did  not  show  the  features  characteristic  of  nephritis. 

( & )  Arthritis. — There  are  two  forms :  first,  the  severe  scarlatinal 
pygemia,  with  suppuration  of  one  or  more  joints — part  of  a  wide-spread  strep- 
tococcus infection.  This  is  an  extremely  serious  and  fatal  form.  Secondly, 
the  true  scarlatinal  rheumatism,  so-called,  an  arthritis  analogous  to  that 
occurring  in  gonorrhoea  and  other  infections.  It  occurs  in  the  second  or  third 
week;  many  joints  are  attacked,  particularly  the  small  joints  of  the  hands. 
The  heart  may  be  involved.  Chorea,  subcutaneous  fibroid  nodules,  purpura, 
and  pleurisy  may  be  complications.    The  outlook  is  usually  good. 

(c)  Cardiac  Complications. — In  the  severe  septic  cases  a  malignant 
endocarditis,  sometimes  with  purulent  pericarditis,  closes  the  scene.  Simple 
endocarditis  is  not  uncommon.  It  may  not  be  easy  to  say  whether  the  apex 
systolic  murmur,  so  often  heard,  signifies  a  valvular  lesion.  The  persistence 
after  convalescence,  with  signs  of  slight  enlargement  of  the  heart,  may  alone 
decide  that  the  murmur  indicated  an  organic  change.  As  is  the  rule,  such 
cases  give  no  symptoms.  And,  lastly,  there  may  be  a  severe  toxic  myo- 
carditis, sometimes  leading  to  acute  dilatation  and  sudden  death.  It  is 
to  be  borne  in  mind  that  the  cardiac  complications  of  the  disease  are  often 
latent. 

(d)  Acute  Bronchitis  and  Broncho-pneumonia  are  not  common. 
Empyema  is  an  insidious  and  serious  complication. 


136  SPECIFIC  INFECTIOUS  DISEASES. 

(e)  Ear  Complications. — Common  and  serious,  due  to  extension  of  the 
inflammation  from  the  throat  through  the  Eustachian  tubes,  they  rank  among 
the  most  frequent  causes  of  deafness  in  children.  The  severe  forms  of  mem- 
branous angina  are  almost  always  associated  with  otitis,  which  goes  on  to 
suppuration  and  to  perforation  of  the  drum.  The  process  may  extend  to  the 
labyrinth  and  rapidly  produce  deafness.  In  other  instances  there  is  suppura- 
tion in  the  mastoid  cells.  In  the  necrosis  which  follows  the  middle-ear  dis- 
ease, the  facial  nerve  may  be  involved  and  paralysis  follow.  Later,  still  more 
serious  comjDiications  may  follow,  such  as  thrombosis  of  the  lateral  sinus, 
meningitis,  or  abscess  of  the  brain. 

(/)  Adenitis. — In  comparatively  mild  cases  of  scarlet  fever  the  sub- 
maxillary lymph-glands  may  be  swollen.  In  severer  cases  the  swelling  of  the 
neck  becomes  extreme  and  extends  beyond  the  limits  of  the  glands.  Acute 
phlegmonous  inflammations  may  occur,  leading  to  wide-spread  destruction  of 
tissue,  in  which  vessels  may  be  eroded  and  fatal  haemorrhage  ensue.  The  sup- 
purative processes  may  also  involve  the  retro-pharyngeal  tissues. 

The  swelling  of  the  lymph-glands  usually  subsides,  and  within  a  few  weeks 
even  the  most  extensive  enlargement  gradually  disappears.  There  are  rare 
instances,  however,  in  which  the  lymphadenitis  becomes  chronic,  and  the 
neck  remains  with  a  glandular  collar  which  almost  obliterates  its  outline. 
This  may  prove  intractable  to  all  ordinary  measures  of  treatment.  A  case 
came  under  my  observation  in  which,  two  years  after  scarlet  fever,  the  neck 
was  enormously  enlarged  and  surrounded  by  a  mass  of  firm  brawny  glands. 

{g)  Nervous  Complications. — Chorea  occasionally  complicates  the 
arthritis  and  endocarditis.  Sudden '  convulsions  followed  by  hemiplegia  may 
occur.  In  seven  of  my  series  of  130  cases  of  infantile  hemiplegia  the  trouble 
came  on  during  scarlet  fever.  Progressive  paralysis  of  the  limbs  with  wasting 
may  present  the  features  of  a  subacute,  ascending  spinal  paralysis.  Throm- 
bosis of  the  cerebral  veins  may  occur.  Mental  symptoms,  mania  and  melan- 
cholia, have  been  described. 

(h)  Other  rare  complications  and  sequelae  are  oedema  of  the  eyelids,  with- 
out nephritis  (S.  Phillips),  symmetrical  gangrene,  enteritis,  noma,  and  per- 
foration of  the  soft  palate  (Goodall).  Pearson  and  Littlewood  have  reported 
a  case  of  dry  gangrene  after  scarlet  fever  in  a  boy  of  four,  which  occurred 
on  the  ninth  day  of  the  disease,  and  involved  both  legs,  necessitating  amputa- 
tion at  the  upper  third  of  the  thighs.     The  child  recovered. 

(i)  The  fever  may  persist  for  several  weeks  after  the  disappearance  of 
the  rash,  and  the  child  may  remain  in  a  septic  or  typhoid  state.  This  so-called 
scarlatinal  typhoid  is  usually  the  result  of  some  chronic  suppurative  process 
about  the  throat  or  the  nose,  occasionally  the  result  of  a  chronic  adenitis,  and 
in  a  few  eases  nothing  whatever  can  be  found  to  account  for  the  fever. 

Relapse  is  rare.  It  was  noted  in  7  per  cent  of  12,000  (Caiger),  and  in 
1  per  cent  of  1,520  cases  (IsTewshohne). 

Diagnosis. — The  diagnosis  of  scarlet  fever  is  not  difficult,  but  there  are 
cases  in  which  the  true  nature  of  the  disease  is  for  a  time  doubtful.  The  fol- 
lowing are  the  most  common  conditions  with  which  it  may  be  confounded : 

1.  Acute  Exfoliating  Dermatitis. — This  pseudo-exanthem  simulates 
scarlet  fever  very  closely.  It  has  a  sudden  onset,  with  fever.  The  eruption 
spreads  rapidly,  is  uniform,  and  after  persisting  for  five  or  six  days  begins 


SCARLET  FEVER.  137 

to  fade.  Even  before  it  has  entirely  gone,  desquamation  usually  begins. 
Some  of  these  cases  can  not  be  distinguished  from  scarlet  fever  in  the  stage 
of  eruption.  The  throat  symptoms,  however,  are  usually  absent,  and  the 
tongue  rarely  shows  the  changes  which  are  so  marked  in  scarlet  fever.  In  the 
desquamation  of  this  affection  the  hair  and  nails  are  commonly  affected,  it 
is,  too,  a  disease  liable  to  recur.  Some  of  the  instances  of  second  and  third 
attacks  of  scarlet  fever  have  been  cases  of  this  form  of  dermatitis. 

2.  Measles,  which  is  distinguished  by  the  longer  period  of  invasion,  the 
characteristic  nature  of  the  prodromes,  and  the  later  appearance  of  the  rash. 
The  greater  intensity  of  the  measly  rash '  upon  the  face,  the  more  papular 
character  and  the  irregular  crescentic  distribution  are  distinguishing  features 
in  a  majority  of  the  cases.  Other  points  are  the  absence  in  measles  of  the 
sore  throat,  the  peculiar  character  of  the  desquamation,  the  absence  of  leuco- 
cytosis,  and  the  presence  of  Koplik's  sign. 

3.  EoTHELN.— The  rash  of  rubella  is  sometimes  strikingly  like  that  of 
scarlet  fever,  but  in  the  great  majority  of  cases  the  mistake  could  not  arise. 
In  cases  of  doubt  the  general  symptoms  are  our  best  guide. 

4.  Septicemia. — As  already  mentioned,  the  so-called  puerperal  or  sur- 
gical scarlatina  shows  an  eruption  which  may  be  identical  in  appearance  with 
that  of  true  scarlet  fever. 

5.  Diphtheria. — The  practitioner  may  be  in  doubt  whether  he  is  deal- 
ing with  a  case  of  scarlet  fever  with  intense  membranous  angina,  a  true  diph- 
theria with  an  erythematous  rash,  or  coexisting  scarlet  fever  and  diphtheria. 
In  the  angina  occurring  early  in,  and  during  the  course  of  scarlet  fever, 
though  the  clinical  features-  may  be  those  of  true  diphtheria,  Loeffler's  bacilli 
are  rarely  found.  On  the  other  hand^  in  the  membranous  angina  occurring 
during  convalescence,  the  bacilli  are  usually  present.  The  rash  in  diphtheria 
is,  after  all,  not  so  common,  is  limited  usually  to  the  trunk,  is  not  so  persist- 
ent, and  is  generally  darker  than  the  scarlatinal  rash. 

Scarlatina  and  diphtheria  may  coexist,  but  in  a  case  presenting  wide-spread 
erythema  and  extensive  membranous  angina  with  Loeffler's  bacilli,  it  would 
puzzle  Hippocrates  to  say  whether  the  tAvo  diseases  coexisted,  or  whether  it 
was  only  an  intense  scarlatinal  rash  in  diphtheria.  Desquamation  occurs  in 
either  case.  The  streptococcus  angina  is  not  so  -apt  to  extend  to  the  larynx, 
nor  are  recurrences  so  common;  but  it  is  well  to  bear  in  mind  that  general 
infection  may  occur,  that  the  membrane  may  spread  doAAOiward  with  great 
rapidity,  and,  lastly,  that  all  the  nervous  sequelae  of  the  Klebs-Loeffler  diph- 
theria may  follow  the  streptococcus  form. 

6.  Drug  Eashes. — These  are  partial,  and  seldom  more  than  a  transient 
hypersemia  of  the  skin.  Occasionally  they  are  diffuse  and  intense,  and  in  such 
cases  very  deceptive.  They  are  not  associated,  however,  with  the  characteristic 
symptoms  of  invasion.  There  is  no  fever,  and  with  care  the  distinction  can 
usually  be  made.  They  are  most  apt  to  follow  the  use  of  belladonna,  quinine, 
and  iodide  of  potassium.  The  antitoxin  erythema  is  a  frequent  cause  of 
doubt,  particularly  in  hospitals  for  infectious  diseases. 

Coexistence  of  other  Diseases. — Of  48,366  cases  of  scarlet  fever  in  the 
Metropolitan  Asylum  Board  Hospitals  which  were  complicated  by  some  other 
disease,  in  1,094  cases  the  secondary  infection  was  cliphtheria,  in  899  cases 
chicken-poxj  in  703  measles,  in  404  whooping-cough,  in  55  erysipelas,  in  H 


138  SPECIFIC  INFECTIOUS  DISEASES. 

enteric  fever,  and  in  1  typlms  fever  (F.  F.  Caiger).  Farnarier  (190J:)  could 
collect  onJ.y  39  undoubted  cases  of  the  coexistence  of  typhoid  and  scarlet  fever. 

Hovj  Long  is  a  Child  Infective^ — ^Usually  after  desquamation  is  complete, 
in  four  or  five  weeks  the  danger  is  thought  to  be  over,  but  the  occurrence  of 
so-called  "  return  cases "  shows  that  patients  remain  infective  even  at  this 
stage.  In  1894,  vrith  2,593  patients  from  the  Glasgow  fever  hospitals  sent 
to  their  homes  convalescent,  fresh  cases  appeared  in  70  of  the  houses  (Chal- 
mers). With  15,000  cases  submitted  to  an  average  period  of  isolation  of 
forty-nine  days  or  under,  the  percentage  of  return  cases  was  1.86 ;  with  an 
average  period  of  fifty  to  fifty-six  days,  the  percentage  was  1,12;  where  the 
isolation  extended  to  between  fifty-seven  and  sixty-five  days,  the  percentage 
of  return  cases  was  1  (l!^eech).  This  author  suggests  eight  weeks  as  a  mini- 
mum and  thirteen  weeks  as  a  maximum.  Special  care  should  be  taken  of 
cases  with  rhinorrhoea  and  otorrhoea  and  throat  trouble,  as  the  secretions  from 
these  parts  are  probablj^  of  greater  importance  than  the  skin  in  the  conveyance 
of  the  disease. 

Prognosis. — The  death-rate  has  been  falling  of  late  years.  Epidemics 
differ  remarkably  in  severit}^  and  the  mortality  is  extremely  variable.  Among 
the  better  classes  the  death-rate  is  much  lower  than  in  hospital  practice.  There 
are  physicians  who  have  treated  consecutively  a  hundred  or  more  cases  vrith- 
out  a  death.  On  the  other  hand,  in  hospitals  and  among  the  poorer  classes 
the  death-rate  is  considerable,  ranging  from  5  or  10  per  cent  in  mild  epidemics 
to  20  or  30  per  cent  in  the  very  severe.  In  1,000  cases  reported  from  the 
Boston  City  Hospital  by  McCoUom,  the  death-rate  was  9.8  per  cent.  There 
is  a  curious  variability  in  the  local  mortality  from  this  disease.  In  England, 
for  example,  in  some  j'^ears,  certain  counties  enjoy  almost  immunity  from 
fatal  scarlet  fever.  The  younger  the  child  the  greater  the  danger.  In  infants 
under  one  year  the  death-rate  is  ver}^  high.  The  great  proportion  of  fatal 
cases  occurs  in  children  under  six  years  of  age.  The  unfavorable  symptoms 
are  very  high  fever,  early  mental  disturbance  with  gTcat  jactitation,  the  occur- 
rence of  hEemorrhages  (cutaneous  or  visceral),  intense  diphtheroid  angina 
with  cervical  bubo,  and  signs  of  lar}Tigeal  obstruction.  Xephritis  is  always  a 
serious  complication,  and  when  setting  in  with  suppression  of  the  urine  may 
quickly  prove  fatal;  a  large  majority  of  the  cases  recover. 

Prophylaxis. — Much  may  be  done  to  prevent  the  spread  of  the  disease  if 
the  physician  exercises  scrupulous  care  in  each  case.  Much  is  to  be  expected 
from  a  rigid  system  of  school  inspection,  and  from  the  more  general  recogni- 
tion of  the  importance  of  the  latent  cases  and  the  persistence  of  the  infection 
in  the  secretions  of  the  nose  and  throat.  The  attendant  in  a  case  of  scarlet 
fever  should  take  the  most  careful  precautions  against  the  conveyance  of  the 
disease,  wearing  a  govm  in  the  room  and  thoroughly  washing  the  hands  and 
face  after  leaving  the  room.  To  the  very  busy  practitioner  the  minutiae  of 
proper  disinfection  are  very  irksome,  but  it  is  his  duty  to  carry  out  the  most 
rigid  disinfection  possible,  and  intelligent  people  now  expect  it. 

Treatment. — The  case  may  be  treated  at  home  or  sent  to  an  isolation  hos- 
pital. The  difficulty  in  liome  treatment  is  in  securing  complete  isolation.  The 
risks  are  well  illustrated  by  the  careful  studies  of  Chap  in,  of  Providence,  who 
found  that  during  eight  years  26.1  per  cent  of  the  4,412  persons  under  twenty- 
one  years  of  age  in  infected  families  took  the  disease.     When  practicable,  it 


SCARLET  FEVER.  139 

is  better  to  send  the  other  children  out  of  the  house.  Chapin's  experience  on 
this  point  is  most  interesting.  In  seventeen  years,  from  653  families  infected 
with  scarlet  fever,  1,051  children,  none  of  whom  had  had  the  disease,  were 
removed.  Only  5  per  cent  were  attacked  while  away  from  home.  Nineteen 
who  had  been  sent  away  from  the  infected  houses  were  attacked  on  their 
return. 

Hospital  treatment  is  not  carried  out  to  any  great  extent  in  the  United 
States.  In  Great  Britain  a  very  considerable  proportion  of  all  patients  are 
removed  from  their  homes.  In  the  segregation  hospital  groups  of  patients, 
from  ten  to  twenty,  are  treated  in  separate  wards.  In  the  true  isolation  hos- 
pital each  patient  is  in  a  separate  room,  and  patients  with  different  infectious 
diseases  may  be  in  adjacent  rooms. 

The  disease  can  not  be  cut  short.  In  the  presence  of  the  severer  forms  we 
are  still  too  often  helpless.  There  is  no  disease,  however,  in  which  the  suc- 
cessful issue  and  the  avoidance  of  complications  depend  more  upon  the  skilled 
judgment  of  the  physician  and  the  care  with  which  his  instructions  are  car- 
ried out. 

The  child  should  be  isolated  and  placed  in  charge  of  a  competent  nurse. 
The  temperature  of  the  room  should  be  constant  and  the  ventilation  thorough. 
The  child  should  wear  a  light  flannel  night-gown,  and  the  bedel  othing  should 
not  be  too  heavy.  The  diet  should  consist  of  milk,  broths,  and  fresh  fruits; 
water  should  be  freely  given.  With  the  fall  of  the  temperature,  the  diet  may 
be  increased  and  the  child  may  gradually  return  to  ordinary  fare.  When 
desquamation  begins  the  child  should  be  thoroughly  rubbed  every  day,  or 
every  second  day,  with  sweet  oil,  or  carbolated  vaseline,  or  a  5-per-cent  hydro- 
naphthol  soap,  which  prevents  the  drying  and  the  diffusion  of  the  scales. 
A  5-  or  10-per-cent  solution  of  ichthyol  in  lanolin  may  be  used.  An  occasional 
warm  bath  may  then  be  given.  At  any  time  during  the  attack  the  skin  may 
be  sponged  with  warm  water.  The  patient  may  be  allowed  to  get  up  after  the 
temperature  has  been  normal  for  ten  days,  but  for  at  least  three  weeks  from 
this  time  great  care  should  be  exercised  to  prevent  exposure  to  cold.  It  must 
not  be  forgotten,  also,  that  the  renal  complications  are  very  apt  to  occur  dur- 
ing the  convalescence,  and  after  all  danger  is  apparently  past.  Ordinary  cases 
do  not  require  any  medicine,  or  at  the  most  a  simple  fever  mixture,  and  dur- 
ing convalescence  a  bitter  tonic.     The  bowels  should  be  carefully  regulated. 

Special  symptoms  in  the  severe  cases  call  for  treatment. 

When  the  fever  is  above  103°  the  extremities  may  be  sponged  with  tepid 
water.  In  severe  cases,  with  the  temperature  rapidly  rising,  this  will  not 
suffice,  and  more  thorough  measures  of  hydrotherapy  should  be  practised. 
With  pronounced  delirium  and  nervous  symptoms  the  cold  pack  should  be 
used.  When  the  fever  is  rising  rapidly  but  the  child  is  not  delirious,  he  should 
be  placed  in  a  warm  bath,  the  temperature  of  which  can  be  gradually  lowered. 
The  bath  with  the  water  at  80°  is  beneficial.  In  giving  the  cold  pack  a  rubber 
sheet  and  a  thick  layer  of  blankets  should  be  spread  upon  a  sofa  or  a  bed,  and 
over  them  a  sheet  wrung  out  of  cold  water.  The  naked  child  is  then  laid 
upon  it  and  wrapped  in  the  blankets,  ^n  intense  glow  of  heat  quickly  follows 
the  preliminary  chilling,  and  from  time  to  time  the  blankets  may  be  unfolded 
and  the  child  sprinkled  with  cold  water.  The  good  effects  which  follow  this 
plan  of  treatment  are  often  striking,  particularly  in  allaying  the  delirium  and 


140  SPECIFIC  INFECTIOUS  DISEASES. 

jactitation,  and  procuring  quiet  and  refreshing  sleep.  Parents  will  ol)ject  less, 
as  a  rule,  to  the  warm  bath  gradually  cooled  than  to  any  other  form  of  hydro- 
theraj^y.  The  child  ma}^  be  removed  from  the  warm  liath,  placed  upon  a  sheet 
wrung  out  of  tolerably  cold  water,  and  then  folded  in  blankets.  The  ice-cap 
is  very  useful  and  may  be  kept  constantly  applied  in  cases  in  which  there  is 
high  fever.  Medicinal  antipyretics  are  not  of  much  service  in  comparison  with 
cold  water. 

The  throat  s}Tnptoms,  if  mild,  do  not  require  much  treatment.  If  severe, 
the  local  measures  mentioned  under  diphtheria  should  be  used.  A  SO-per- 
cent  alcoholic  solution  of  resorcin  may  be  thoroughly  swabbed  into  the  naso- 
pharjTix.  It  should  be  used  every  three  or  four  hours  in  severe  cases.  Cold 
applications  to  the  neck  are  to  be  preferred  to  hot,  though  it  is  sometimes  diffi- 
cult to  get  a  child  to  submit  to  them.  In  connection  with  the  throat,  the  ears 
should  be  specially  looked  after,  and  a  careful  disinfection  of  the  mouth  and 
fauces  by  suitable  antiseptic  solutions  should  be  practised.  When  the  inflamma- 
tion extends  through  the  tubes  to  the  middle  ear,  the  practitioner  should  either 
himself  examine  daily  the  condition  of  the  drum,  or,  when  available,  a  special- 
ist should  be  called  in  to  assist  him  in  the  case.  The  careful  watching  of  this 
membrane  day  by  day  and  the  puncturing  of  it  if  the  tension  becomes  too 
great  may  save  the  hearing  of  the  child.  With  the  aid  of  cocaine  the  drum 
is  readily  punctured.  The  operation  may  be  repeated  at  intervals  if  the  pain 
and  distention  return.  No  complication  of  the  disease  is  more  serious  than 
this  extension  of  the  inflammatory  process  to  the  ear. 

The  nephritis  should  be  dealt  with  as  in  ordinary  cases;  indications  for 
treatment  will  be  found  under  the  appropriate  section.  It  is  worth  men- 
tioning, however,  that  Jaccoud  insists  upon  the  great  value  of  milk  diet  in 
scarlet  fever  as  a  preventive  of  nephritis. 

Among  other  indications  for  treatment  in  the  disease  is  cardiac  weakness, 
which  is  usually  the  result  of  the  direct  action  of  the  poison,  and  is  best  met 
by  stimulants. 

Seeujii  Treatment. — On  the  view  that  the  disease,  or  at  any  rate  some 
of  its  serious  features,  are  caused  by  the  streptococcus,  attempts  have  been 
made  to  prepare  a  curative  serum  by  Marmorek,  Aronson,  Moser,  and  others. 
Moser's  serum,  which  has  been  used  extensively  in  Escherich's  clinic  in 
Vienna,  is  a  polyvalent  serum  prepared  from  a  number  of  definite  tj^es  of 
streptococci.  From  iSTovember,  1900,  to  July,  1904,  of  1,069  cases,  228  re- 
ceived the  serum  treatment,  usually  the  severer  or  lethal  cases.  The  mortality 
for  the  four  years  before  the  serum  treatment  averaged  14.5  per  cent,  for  the 
four  years  since  its  emploj^ment  8  per  cent  (H.  L.  K.  Shaw). 


VIII.     MEASLES. 

(Morbilli.     Rubeola.) 

Definition. — An  acute,  highly  contagious  fever  with  specific  localization 
in  the  upper  air  passages  and  in  the  skin. 

History. — Ehazes,  an  Arabian  physician,  in  the  ninth  century  described 
the  disease  with  small-pox,  of  which  it  was  believed  to  be  a  mild  form,  until 
Sydenham  separated  them  in  the  seventeenth  century. 


MEASLES.  141 

Etiology. — As  a  cause  of  death  measles  ranks  high  among  the  acute  fevers 
of  children.  In  1903  there  were  9,150  deaths  from  measles  in  England  and 
Wales,  being  fewer  by  1,559  than  the  decennial  average  number.  Ninety-four 
per  cent  of  the  total  deaths  were  in  children  under  five  years  of  age  (Tatham). 

The  liability  to  infection  is  almost  universal  in  persons  unprotected  by  a 
previous  attack.  It  is  a  disease  of  childhood,  but,  as  shown  in  the  wide-spread 
epidemics  in  the  Faroe  Islands  and  in  the  Fiji  Islands,  unprotected  adults  of 
all  ages  are  attacked.  Within  the  first  three  months  of  life  there  is  a  relative 
immunity.  Occasionally  infants  of  a  month  or  six  weeks  take  the  disease. 
Intra-uterine  cases  have  been  described,  and  a  mother  with  measles  may  give 
birth  to  a  child  with  the  eruption,  or  the  rash  may  appear  in  a  few  days. 

The  disease  is  endemic  in  cities,  and  becomes  epidemic  at  intervals,  pre- 
vailing most  extensively  in  the  cooler  months,  though  this  is  by  no  means  a 
fixed  rule. 

The  germ  of  the  disease  is  unknown.  The  contagion  is  present  in  the 
blood  and  secretions,  and  in  the  skin.  In  the  eighteenth  century  Monro  and 
others  demonstrated  the  inoculability  of  the  disease.  Direct  contagion  is  the 
most  common.  The  poison  is  probably  not  in  the  expired  air,  but  in  the 
particles  of  mucus  and  in  tile  sputum  and  the  secretions  of  the  mouth  and 
nose,  which,  dried,  are  conveyed  with  the  dust.  An  all-important  point  is 
the  contagiousness  of  the  disease  in  the  pre-eruptive  stage.  A  child  with  only 
the  catarrhal  symptoms  may  be  at  school  and  a  source  of  active  infection. 
Indirect  contagion  by  means  of  fomites  is  very  common.  Measles  may  be 
thus  conveyed  by  a  third  person,  by  clothes,  and  by  infected  toys.  The  germs 
of  measles  soon  lose  their  virulence. 

Eecurrence  is  rare.  Very  many  cases  of  the  supposed  second  and  third 
attack  represent  mistakes  in  diagnosis.  Eelapse  is  occasionally  seen,  the  symp- 
toms recurring  at  intervals  from  ten  to  forty  days;  but  it  is  not  always  easy 
to  say  in  a  given  case  whether  there  may  not  have  been  new  infection  from 
without. 

Morbid  Anatomy. — The  catarrhal  and  inflammatory  appearances  seen  post 
mortem  have  nothing  characteristic.  Fatal  cases  show,  as  a  rule,  broncho- 
pneumonia and  an  intense  bronchial  catarrh.  The  lymphatic  elements  all  over 
the  body  are  swollen,  the  tonsils,  the  lymph  glands,  and  the  solitary  and  agmi- 
nated  follicles  of  the  intestines.  The  spleen  is  rarely  much  enlarged.  During 
convalescence  latent  tuberculous  foci  are  very  apt  to  become  active. 

Symptoms. — Incubation. — "  From  seven  to  eighteen  days ;  of tenest  four- 
teen." The  child  shows  no  special  changes.  A  leucocytosis  has  been  observed, 
and  the  pulse  is  said  to  be  slow. 

Invasion. — In  this  period,  lasting  from  three  to  four  days,  very  rarely 
five  or  six,  the  child  presents  the  symptoms  of  a  feverish  cold.  The  onset 
may  be  insidious,  or  it  may  start  with  great  abruptness,  even  with  a  con- 
vulsion. There  is  not  often  a  definite  chill.  Headache,  nausea,  and  vomit- 
ing may  usher  in  the  severe  cases.  The  common  catarrhal  symptoms  are 
sneezing  and  running  at  the  nose,  redness  of  the  eyes  and  lids,  and  cough. 
The  fever  is  .slight  at  first,  but  gradually  there  is  pungent  heat  of  the  skin 
with  turgescence  of  the  face.  Prodromal  rashes  precede  the  true  eruption  in 
a  few  cases,  usually  a  blotchy  erythema  or  scattered  macules.  The  tongue  is 
furred  and  the  mucous  membranes  of  the  mouth  and  throat  are  hypergemic, 


142 


SPECIFIC  INFECTIOUS  DISEASES. 


Day 

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and  frequently  show  a  distinct  punctiform  rash.  The  fever  of  the  stage 
of  invasion  may  rise  abruptly;  more  frequently  it  takes  twenty-four  or 
forty-eight  hours  to  reach  the  fastigium.  The  pulse-rate  increases  with 
the  fever,  and  may  reach  140  or  160  per  minute,  gradually  falling  with 
defervescence. 

Eruption-. — "  The  symptoms  increase  till  the  fourth  day.  At  that  period 
(although  sometimes  a  day  later)  little  red  spots,  just  like  flea-bites,  begin  to 
come  out  on  the  forehead  and  the  rest  of  the  face.    These  increase  both  in  size 

and  number,  group  themselves  in  clus- 
ters, and  mark  the  face  with  largish 
red  spots  of  different  figures.  These 
red  spots  are  formed  by  small  red 
papules,  thick  set,  and  just  raised 
above  the  level  of  the  skin.  The  fact 
that  they  really  protrude  can  scarcely 
be  determined  by  the  eye.  It  can, 
however,  be  ascertained  by  feeling  the 
surface  with  the  fingers.  From  the 
face — where  the}^  first  appear — these 
spots  spread  downward  to  the  breast 
and  belly;  afterward  to  the  thighs 
and  legs"  (Sydenham).  The  pap- 
ules may  feel  quite  shotty,  but  do  not 
extend  deeply.  On  the  trunk  and  ex- 
tremities the  swelling  of  the  skin  is 
not  so  noticeable,  the  color  of  the  rash 
The  mottled,  blotchy  character  is  seen 
most  clearly  on  the  chest  and  the  abdomen.  It  is  hj^pergemic  and  disappears  on 
pressure,  but  in  the  malignant  cases  it  may  become  of  a  deep  rose,  inclining  to 
purple.  Then  general  symptoms  do  not  abate  with  the  occurrence  of  the  erup- 
tion, but  persist  until  the  end  of  the  fifth  or  the  sixth  day,  when  they  lessen. 
Among  peculiarities  of  the  rash  may  be  mentioned  the  development  of  numer- 
ous miliary  vesicles  and  the  occurrence  of  petechia?,  which  are  seen  occasionally 
even  in  cases  of  moderate  severity.  Recession  of  the  rash,  so  much  dwelt  upon 
by  older  writers,  is  rarely  seen.  When  the  ''  measles  sink  in  suddenly  after  they 
have  begun  to  come  out,  and  then  the  patient  is  seized  with  anxiety  and  a 
swooning  comes  on,  it  is  a  sign  of  speedy  death"  (Rhazes).  In  reality  it  is 
the  failing  circulation  which  causes  the  rash  to  fade. 

Buccal  spots  were  described  by  Filatow  in  1895,  and  by  Koplik  in  1896. 
They  are  seen  on  a  level  with  the  bases  of  the  lower  milk  molars  on  either 
side,  or  at  the  line  of  junction  of  the  molars  when  the  jaws  are  closed.  They 
are  white  or  bluish-white  specks,  surrounded  by  red  areolae.  Their  importance 
depends  upon  the  fact  of  their  early  appearance  and  remarkable  constancy  in 
the  disease — six-sevenths  of  all  cases  (Heubner),  97.7  per  cent  of  214  cases 
(Balme). 

The  fauces  may  be  injected,  and  there  is  sometimes  an  eruption  of  scat- 
tered spots  over  the  entire  mucous  membrane  of  the  mouth.  Ringer  was  in 
the  habit  of  calling  attention  to  opaque  white  spots  on  the  mucous  membrane 
of  the  lips. 


Chart  IX. — Measles. 


not  so  intense  and  often  less  uniform. 


MEASLES.  143 

Desquamation. — After  the  rash  fades  desquamation  begins,  usually  in 
the  form  of  fine  scales,  more  rarely  in  large  flakes.  It  bears  a  definite  rela- 
tionship to  the  extent  and  intensity  of  the  rash.  In  mild  cases  desquamation 
may  take  only  a  few  days,  in  severe  cases  several  weeks. 

The  tonsils  and  the  cervical  lymph  glands  may  be  slightly  swollen  and 
sore;  sometimes  there  is  a  polyadenitis. 

During  the  course  leucocytosis  is  absent.  Its  presence  generally  points 
to  a  complication.  Myelocytes  are  often  present  in  small  numbers  during  the 
eruption   ( Tiliston ) . 

Atypical  Measles. — Variations  in  the  course  of  the  disease  are  not  com- 
mon. There  is  an  attenuated  form,  in  which  the  child  may  be  well  by  the 
fourth  or  fifth  day.  An  abortive  form,  in  which  the  initial  symptoms  may  be 
present,  but  no  eruption  appears — morhilli  sine  morhillis. 

Malignant  or  blade  measles  is  seen  most  frequently  in  the  wide-spread 
epidemics,  but  it  is  also  met  with  in  institutions,  and  occasionally  in  general 
practice  among  children,  more  rarely  in  adults.  Hemorrhages  occur  into  the 
skin  and  from  the  mucous  membranes;  there  is  very  high  fever,  and  all  the 
features  of  a  profound  toxaemia,  often  with  cyanosis,  dyspnoea,  and  extreme 
cardiac  weakness.    Death  may  occur  from  the  second  to  the  sixth  day. 

Complications. — Those  of  the  air  passages  are  the  most  serious.  The 
coryza  may  become  chronic  and  lead  to  irritation  of  the  lymphoid  tissues  of 
the  naso-pharynx,  leaving  enlarged  tonsils  and  adenoids,  and  not  improbably 
leaving  these  parts  less  able  to  resist  tuberculous  invasion.  Epistaxis  may 
sometimes  be  serious.  Laryngitis  is  not  uncommon :  the  voice  becomes  husky 
and  the  cough  croupy  in  character.  (Edema  of  the  glottis  and  pseudo-mem- 
branous infiammation  are  rare.  Ulceration,  abscess,  and  even  perichondritis 
may  occur. 

Bronchitis  and  Broncho-pneumonia. — In  every  case  of  severe  measles  the 
possibility  of  the  existing  bronchitis  extending  to  the  small  tubes  and  caus- 
ing lobular  pneumonia  has  to  be  considered.  It  is  more  apt  to  occur  at  the 
height  of  the  eruption  or  as  desquamation  begins.  The  high  mortality  in 
institutions  is  due  to  this  complication,  which,  as  Sydenham  remarked,  kills 
more  than  the  small-pox.     (For  the  s3^mptoms,  see  the  section  on  the  subject.) 

Lobar  pneumonia  is  less  common. 

Severe  stomatitis  may  follow  the  slight  catarrhal  form.  In  institutions 
cancrum  oris  or  gangrenous  stomatitis  is  a  terrible  complication,  attacking 
sometimes  many  children.  Parotitis  occasionally  occurs.  Intestinal  catarrh 
and  acute  colitis  are  special  complications  of  some  epidemics. 

Nephritis  is  less  rare  than  is  stated.  It  is  not  very  uncommon  to  see  cases 
of  chronic  Bright's  disease  which  date  from  an  attack  of  measles.  Vulvitis 
may  be  present  as  part  of  the  general  catarrhal  condition. 

Endocarditis  is  rare.  Arthritis  may  follow  the  fever,  or  come  on  at  its 
height.  It  may  be  general  and  severe.  I  saw  an  instance  in  which  anchylosis 
of  the  jaw  followed  an  attack  of  measles  in  a  child  of  four  years.  The  con- 
junctivitis may  be  followed  by  keratitis.  Otitis  media  is  not  at  all  uncom- 
mon and  may  lead  to  perforation  of  the  drum  or  mastoid  disease.  Hemiplegia 
is  a  most  serious  complication.  In  4  of  my  series  of  120  cases  the  hemiplegia 
came  on  during  measles.  It  usually  persists.  Paraplegia  due  to  acute  myelitis 
has  been  described  by  Barlow,  Bruce,  and  others.    Polyneuritis  may  occur  with 


144  SPECIFIC  INFECTIOUS  DISEASES. 

wide-spread  atrojjliy.  Meningitis,  abscess  of  the  hrain,  and  multiple  sclerosis 
are  among  the  rare  comj^lications  or  sequelae.  Whooping-cough  not  infre- 
quently follows  measles. 

Diagnosis. — During  the  prevalence  of  an  epidemic  the  disease  is  easil}^ 
recognized.  Physicians  to  isolation  hospitals  appreciate  the  practical  difficul- 
ties. On  several  occasions  I  had  patients  with  measles  sent  to  the  small-pox 
hospital,  and  it  is  well  to  bear  in  mmd  that  in  adults  the  beginning  of  the 
eruption  on  the  face,  its  nodular  character,  and  the  isolation  of  the  spots  may 
be  suggestive  of  variola.  From  scarlet  fever  measles  is  distinguished  by  the 
longer  initial  stage  with  characteristic  symptoms,  and  the  blotchy  irregular 
character  of  the  rash,  so  unlike  the  diffuse  uniform  erythema.  In  measles 
the  mouth  (with  the  early  Koplik  sign),  in  scarlet  fever  the  throat,  is  chiefly 
affected.  Occasionally  in  measles,  when  the  throat  is  very  sore  and  the  erup- 
tion pretty  diffuse,  there  may  at  first  be  difficulty  in  determining  which  dis- 
ease is  present,  but  a  few  days  should  suffice  to  make  the  diagnosis  clear.  As 
a  rule  there  is  no  leucocytosis.  It  may  be  extremely  difficult  to  distinguish 
from  rotheln.  I  have  more  than  once  known  practitioners  of  large  experience 
unable  to  agree  upon  a  diagnosis.  The  shorter  prodromal  stage,  the  absence 
of  oculo-nasal  catarrh,  and  the  slighter  fever  in  many  cases,  are  perhaps  the 
most  important  features.  It  is  difficult  to  speak  definitely  about  the  distinc- 
tions in  the  rash,  though  perhaps  the  more  uniform  distribution  and  the 
absence  of  the  crescentic  arrangement  are  more  constant  in  rotheln.  In  Afri- 
cans the  disease  is  easily  recognized;  the  papules  stand  out  with  great  plain- 
ness, often  in  groups;  the  hypersemia  is  to  be  seen  on  all  but  the  very  black 
skins.  The  distribution  of  the  rash,  the  coryza,  and  the  rash  in  the  mouth 
are  important  points.  The  conditions  under  which  measles  may  be  mistaken 
for  small-pox  have  already  been  described.  Of  drug  eruptions,  that  induced 
by  copaiba  is  very  like  measles,  but  is  readily  distinguished  by  the  absence  of 
fever  and  catarrh.  Antipyrin,  chloral,  and  quinine  rashes  rarely  cause  any 
difficulty  in  diagnosis.  The  serum  exanthem  of  the  diphtheria  antitoxin  may 
be  difficult  to  recognize.  In  adults  the  acute  malignant  measles  may  resemble 
typhus  fever.     Occasionally  erythema  multiforme  may  simulate  measles. 

Prophylaxis. — The  difficulty  is  inherent  in  the  prolonged  incubation  and 
the  four  days  of  invasion,  during  which  the  catarrhal  symptoms  are  marked, 
and  in  which  the  disease  is  probably  contagious,  and  one  often  finds  that  the 
quarantine  which  has  been  carried  out  so  efficiently  has  been  in  vain.  From 
contact  with  cases  in  the  stage  of  invasion  and  mild  cases  with  scarcely  any 
fever  the  disease  is  readily  disseminated  through  schools  and  conveyed  to 
healthy  children  in  the  every-day  contact  with  each  other  on  the  streets,  in 
the  squares  and  play-grounds.  Once  manifested,  the  child  should  be  carefully 
quarantined  and  all  possible  precautions  taken  against  the  spread  of  the  dis- 
ease in  the  house.  As  the  germ  of  measles  seems  to  have  a  feeble  vitality  the 
quarantine  need  not.be  so  protracted  as  in  scarlet  fever. 

Prognosis. — Among  the  eruptive  fevers  measles  ranks  third  in  the  death- 
rate.  The  mortality  from  the  disease  itself  is  not  high,  but  the  pulmonary 
complications  render  it  one  of  the  most  serious  of  the  diseases  of  children. 
In  some  epidemics,  particularly  in  institutions  and  in  armies,  the  death-rate 
may  be  high,  not  so  much  from  the  fever  itself  as  from  the  extension  of  the 
catarrhal  sjonptoms  to  the  finer  bronchial  tubes.     Imported  in  1875  from 


RUBELLA.  145 

Sydney  by  H.M.S.  Dido  to  the  Fiji  Islands,  40,000  out  of  150,000  of  the 
inhabitants  died  in  four  months.  Panum,  tlie  distinguished  Danish  physician, 
described  the  wide-spread  and  fatal  epidemic  which  decimated  the  inhabitants 
of  the  Faroe  Islands  in  1846.  In  private  practice  the  mortality  is  from  2  to 
3  per  cent;  in  hospitals  from  6  to  8  or  10  per  cent. 

Treatment. — Confinement  to  bed  in  a  well- ventilated  room  and  a  light 
diet  are  the  only  measures  necessary  in  cases  of  uncomplicated  measles.  The 
fever  rarely  reaches  a  dangerous  height.  If  it  does  it  may  be  lowered  by 
sponging  or  by  the  tepid  bath  gradually  reduced.  If  the  rash  does  not  come 
out  well,  warm  drinks  and  a  hot  bath  will  hasten  its  maturation.  The  bowels 
should  be  freely  opened.  If  the  cough  is  distressing,  paregoric  and  a  mixture 
of  ipecacuanha  wine  and  squills  should  be  given.  The  patient  should  be  kept 
in  bed  for  a  few  days  after  the  fever  subsides.  During  desquamation  the  skin 
should  be  oiled  daily,  and  warm  baths  given  to  facilitate  the  process.  The 
mouth  and  nostrils  should  be  carefully  cleansed,  even  in  mild  cases.  The 
convalescence  from  measles  is  the  most  important  stage  of  the  disease.  Watch- 
fulness and  care  may  prevent  serious  pulmonary  complications.  The  frequency 
with  which  the  mothers  of  children  with  simple  or  tuberculous  broncho-pneu- 
monia tell  us  that  "  the  child  caught  cold  after  measles,"  and  the  contempla- 
tion of  the  mortality  bills,  should  make  us  extremely  careful  in  our  manage- 
ment of  this  affection. 

IX.    RUBELLA    (Rotheln.    German  Measles). 

This  exanthem  has  also  the  names  of  rubeola  notha,  or  epidemic  roseola, 
and,  as  it  is  supposed  to  present  features  common  to  both,  has  been  also  known 
as  hybrid  measles  or  hybrid  scarlet  fever.  It  is  now  generally  regarded,  how- 
ever, as  a  separate  and  distinct  affection. 

Etiology. — It  is  propagated  by  contagion  and  spreads  with  great  rapidity. 
It  frequently  attacks  adults,  and  the  occurrence  of  either  measles  or  scarlet 
fever  in  childhood  is  no  protection  against  it.  The  epidemics  of  it  are  often 
very  extensive. 

Symptoms. — These  are  usually  mild,  and  it  is  altogether  a  less  serious 
affection  than  measles.  Very  exceptionally,  as  in  the  epidemics  studied  by 
Cheadle,  the  symptoms  are  severe. 

The  stage  of  incubation  is  two  weeks  or  even  longer. 

In  the  stage  of  invasion  there  are  chilliness,  headache,  pains  in  the  back 
and  legs,  and  coryza.  A  macular,  rose-red  eruption  on  the  throat  is  a  constant 
symptom,  and,  indeed,  it  was  on  this  account  that  it  was  originally  regarded 
as  a  hybrid,  having  the  sore  throat  of  scarlet  fever  and  the  rash  of  measles. 
There  may  be  very  slight  fever.  In  30  per  cent  of  Edwards's  cases  the  tem- 
perature did  not  rise  above  100°.  The  duration  of  this  stage  is  somewhat 
variable.  The  rash  usually  appears  on  the  first  day,  some  writers  say  on  the 
second,  and  others  again  give  the  duration  of  the  stage  of  invasion  as  three 
days.  Griffith  places  it  at  two  days.  The  eruption  comes  out  first  on  the 
face,  then  on  the  chest,  and  gradually  extends  so  that  within  twenty-four 
hours  it  is  scattered  over  the  whole  body.  It  may  be  the  first  symptom  noted 
by  the  mother.  The  eruption  consists  of  a  number  of  round  or  oval,  slightly 
raised  spots,  pinkish-red  in  color,  usually  discrete,  but  sometimes  confluent. 
11 


146  SPECIFIC  INFECTIOUS  DISEASES. 

The  color  of  the  rash  is  somewhat  brighter  than  in  measles.  The  patches 
are  less  distinctly  crescentic.  After  persisting  for  two  or  three  days  (some- 
times longer),  it  gradually  fades  and  there  is  a  slight  furfnraceous  desquama- 
tion. The  rash  persists  as. a  rule  longer  than  in  scarlet  fever  or  measles,  and 
the  skin  is  slightly  stained  after  it.  In  some  cases  the  rash  is  scarlatiniform, 
which  may  even  follow  a  measly  eruption.  The  Ijonphatic  glands  of  the 
neck  are  frequently  swollen,  and,  when  the  eruption  is  very  intense  and  dif- 
fuse, the  lymph-glands  in  the  other  parts  of  the  body. 

There  are  no  special  complications.  The  disease  usually  progresses  favor- 
ably; but  in  rare  instances,  as  in  those  reported  by  Cheadle,  the  s}miptoms  are 
of  greater  severity.  Albuminuria,  arthritis,  or  even  nephritis  may  occur. 
Pneumonia  and  colitis  have  been  present  in  some  epidemics.  Icterus  has 
been  seen. 

Diagnosis. — The  slightness  of  the  prodromal  s3T.nptoms,  the  mildness,  or 
the  absence  of  the  fever,  the  more  diffuse  character  of  the  rash,  its  rose-red 
color,  and  the  early  enlargement  of  the  cervical  glands,  are  the  chief  points  of 
distinction  between  rotheln  and  measles. 

The  treatment  is  that  of  a  simple  febrile  affection. 

"  Fourth  Disease." — Clement  Dukes,  in  a  paper  on  the  confusion  of  two 
different  diseases  under  the  name  rubella,  describes  what  he  calls  a  "  fourth 
disease,"  in  which  the  body  is  covered  in  a  few  hours  with  a  diffuse  exanthem 
of  a  bright  red  color,  almost  scarlatiniform  in  appearance.  The  face  may 
remain  quite  free.    The  desquamation  is  more  marked  than  in  rotheln. 

Erythema  Infectiosum. — Under  this  term  there  has  been  described  of  late 
years  in  Germany,  particularly  by  Escherich,  a  feebly  contagious  disease,  char- 
acterized by  a  rose-red,  maculo-papular  rash,  appearing  chiefly  between  the 
ages  of  four  and  twelve.  It  has  occurred  in  epidemic  form  in  the  spring  and 
summer.  It  has  followed  outbreaks  of  measles  or  of  rotheln.  The  most  char- 
acteristic feature  is  the  morbilliform  eruption  on  the  extremities,  chiefly  on 
the  extensor  surfaces.     The  trunk  as  a  rule  remains  free. 


X.    EPIDEMIC   PAROTITIS    (Mumps). 

Definition. — A  specific  infectious  disease,  characterized  by  swelling"  of  the 
salivary  glands  and  a  special  liability  to  orchitis. 

Hippocrates  described  the  disease  and  its  peculiarities — an  affection  of 
children  and  young  male  adults,  the  absence  of  suppuration,  and  the  orchitis. 

Etiology. — The  nature  of  the  virus  is  unknown. 

It  is  endemic  in  large  centres  of  population,  and  at  certain  seasons,  par- 
ticularly spring  and  autumn,  the  cases  increase  rapidly.  It  is  met  most  fre- 
quently in  childhood  and  adolescence.  Very  young  infants  and  adults  are 
seldom  attacked.  Males  are  somewhat  more  frequently  affected  than  females. 
In  institutions,  barracks,  and  schools  the  disease  has  been  known  to  attack 
over  90  per  cent  of  the  residents.  It  may  be  curiously  localized  in  a  city  or 
district,  or  even  in  one  part  of  a  school  or  barrack.  The  disease  is  contagious 
and  spreads  from  patient  to  patient.  The  infection  may  persist  for  as  long  as 
six  weeks.  It  may  be  congenital,  and  Hale  White  has  reported  a  case  in  which 
the  mother  and  her  new-born  child  were  attacked  at  the  same  time. 


EPIDEMIC  PAROTITIS,  147 

A  remarkable  idiopathic,  non-specific  parotitis  may  follow  injury  or  dis- 
ease of  the  abdominal  or  pelvic  organs  (see  Diseases  of  the  Salivary  Glands), 

Symptoms. — The  period  of  incubation  is  from  two  to  three  weeks,  and  there 
are  rarely  any  symptoms  during  this  stage.  The  invasion  is  marked  by  fever, 
which  is  usually  slight,  rarely  rising  above  101°,  but  in  exceptionally  severe 
cases  going  up  to  103°  or  104°.  The  child  complains  of  pain  just  below  the 
ear  on  one  side.  Here  a  slight  swelling  is  noticed,  which  increases  gradually, 
until,  within  forty-eight  hours,  there  is  great  enlargement  of  the  neck  and 
side  of  the  cheek.  The  swelling  passes  forward  in  front  of  the  ear,  the  lobe 
of  which  is  lifted,  and  back  beneath  the  sterno-mastoid  muscle.  The  other 
side  usually  becomes  affected  within  a  day  or  two,  and  the  whole  neck  is  sur- 
rounded by  a  collar  of  doughy  infiltration.  Only  one  gland  may  be  involved, 
or  an  interval  of  four  or  five  days  may  elapse  before  the  other  side  is  involved. 
The  submaxillary  and  sublingual  glands  become  swollen,  though  not  always; 
in  a  few  cases  they  may  be  alone  attacked.  The  lachrymal  glands  may  be 
involved.  The  greatest  inconvenience  is  experienced  in  taking  food,  for  the 
patient  is  unable  to  open  the  mouth,  and  even  speech  and  deglutition  become 
difficult.  There  may  be  an  increase  in  the  secretion  of  the  saliva,  but  the 
reverse  is  sometimes  the  case.  The  mucous  membrane  of  the  mouth  and  throat 
may  be  slightly  inflamed.  There  is  seldom  great  pain,  but  an  unpleasant  feel- 
ing of  tension  and  tightness.  There  may  be  earache,  even  otitis  media,  and 
slight  impairment  of  hearing. 

After  persisting  for  from  seven  to  ten  days,  the  swelling  gradually  sub- 
sides and  the  child  rapidly  regains  his  strength  and  health  and  is  none  the 
worse  for  the  attack. 

Occasionally  the  disease  is  very  severe  and  characterized  by  high  fever, 
delirium,  and  great  prostration.  The  patient  may  even  lapse  into  a  typhoid 
condition. 

Eelapse  is  rare,  but  there  may  be  within  a  few  weeks  two  or  three  slight 
recurrences,  in  which  I  have  known  the  cervical  glands  to  enlarge.  A  second 
or  even  a  third  attack  may  occur. 

Orchitis. — Excessively  rare  before  puberty,  it  occurs  usually  about  the 
eighth  day,  and  more  particularly  if  the  boy  is  allowed  to  leave  his  bed 
(Dukes),  One  or  both  testicles  may  be  involved.  The  swelling  may  be  great, 
and  occasionally  effusion  takes  place  into  the  tunica  vaginalis.  The  orchitis 
may  occur  before  the  parotitis,  or  in  rare  instances  may  be  the  only  mani- 
festation of  the  infection  (orchitis  parotidea).  The  inflammation  increases 
for  three  or  four  days,  and  resolution  takes  place  gradually.  There  may  be 
a  muco-purulent  discharge  from  the  urethra.  In  severe  cases  atrophy  may 
follow,  fortunately  as  a  rule  only  in  one  organ;  occurring  in  both  before 
puberty  the  natural  development  is  usually  checked.  Even  when  both  testicles 
are  atrophied  and  small,  sexual  vigor  may  be  retained.  The  proportion  of 
cases  of  orchitis  varies  in  different  epidemics;  211  cases  occurred  in  699  cases, 
and  103  cases  of  atrophy  followed  163  instances  of  orchitis  (Comby).  JSTo 
satisfactory  explanation  of  this  remarkable  metastasis  has  been  given.  Mili- 
tary, surgeons,  who  see  so  much  of  the  disease  in  young  recruits,  have  sug- 
gested the  transference  of  the  virus  to  the  penis  with  the  fingers  and  its  trans- 
mission along  the  urethra. 

A  vulvo-vaginitis  sometimes  occurs  in  girls,  and  the  breasts  may  become 


148  SPECIFIC  INFECTIOUS  DISEASES. 

enlarged  and  tender.  Mastitis  has  been  seen  in  boys.  Involvement  of  the 
ovaries  is  rare.  The  thyroid  gland  may  enlarge  in  the  attack,  and  there  have 
been  features  suggestive  of  acute  pancreatitis. 

Complications  and  Sequelae. — Of  these  the  cerebral  affections  are  jDcrhaps 
the  most  serious.  As  already  mentioned,  there  may  be  delirium  and  high 
fever.  In  rare  instances  meningitis  has  been  found.  Hemiplegia  and  coma 
may  also  occur.  A  majority  of  the  fatal  cases  are  associated  with  meningeal 
symptoms.  These,  of  course,  are  very  rare  in  comparison  with  the  frequency 
of  the  disease;  3'et,  in  the  Index  Catalogue,  under  this  caption,  there  are  six 
fatal  cases  mentioned.  In  some  epidemics  the  cerebral  complications  are  much 
more  marked  than  in  others.  Acute  mania  has  occurred,  and  there  are  in- 
stances on  record  of  insanity  following  the  disease. 

Arthritis,  albuminuria,  even  acute  uraemia  with  convulsions,  endocarditis, 
pleurisy,  facial  paralysis,  hemiplegia,  and  peripheral  neuritis  are  occasional 
complications. 

Suppuration  of  the  gland  is  an  extremely  rare  complication.  Gangrene 
has  occasionally  occurred.  The  special  senses  may  be  seriously  involved. 
Deafness  may  occur,  and  may  be  permanent.  Affections  of  the  eye  are  rare, 
but  optic  neuritis  with  atrophy  has  been  described. 

Chronic  hj^pertrophy  of  the  gland  may  follow. 

The  diagnosis  of  the  disease  is  usually  easy.  The  position  of  the  swelling 
in  front  of  and  below  the  ear  and  the  elevation  of  the  lobe  on  the  affected  side 
definitely  fix  the  locality  of  the  swelling.  In  children  inflammation  of  the 
parotid,  apart  from  ordinary  mumps,  is  excessively  rare. 

Treatment. — It  is  well  to  keep  the  patient  in  bed  during  the  height  of  the 
disease.  The  bowels  should  be  freely  opened,  and  the  patient  given  a  light 
liquid  diet.  E'o  medicine  is  required  unless  the  fever  is  high,  in  which  case 
aconite  may  be  given.  Cold  compresses  may  be  placed  on  the  gland,  but  chil- 
dren, as  a  rule,  prefer  hot  applications.  A  pad  of  cotton  wadding  covered  with 
oil  silk  is  the  best  application.  Suppuration  is  hardly  ever  to  be  dreaded,  even 
though  the  gland  become  very  tense.  Should  redness  and  tenderness  develop, 
leeches  may  be  used.  With  delirium  and  head  symptoms  the  ice-cap  may  be 
applied.  For  the  orchitis,  rest,  with  support  and  protection  of  the  swollen 
gland  with  cotton-wool,  is  usually  sufficient. 


XI.     WHOOPING-COUGH. 

Definition. — A  specific  affection  characterized  by  catarrh  of  the  respiratory 
passages  and  a  series  of  convulsive  coughs  which  end  in  a  long-drawn  inspira- 
tion or  "whoop." 

History. — Ballonius,  in  his  Ephemerides,  describes  the  disease  as  it  ap- 
peared in  1578.  Glisson  and  Sj^denham  in  the  following  century  gave  brief 
accounts.  Willis  (Pharmaceutice  Eationalis,  second  part,  1674)  gave  a  much 
better  description  and  called  it  an  "  epidemical  disorder." 

Etiology. — The  disease  occurs  in  epidemic  form,  but  sporadic  cases  appear 
in  a  community  from  time  to  time.  It  is  directly  contagious  from  person  to 
person;  but  dwelling-rooms,  houses,  school-rooms,  and  other  localities  may  be 
infected  by  a  sick  child.    It  is,  however,  in  this  way  less  contagious  than  other 


WHOOPING-COUGH.  149 

diseases,  and  is  probably  most  often  taken  by  direct  contact.  Epidemics  pre- 
vail for  two  or  three  months,  usually  during  the  winter  and  spring,  and  have 
a  curious  relation  to  other  diseases,  often  preceding  or  following  epidemics  of 
measles,  less  frequently  of  scarlet  fever. 

Children  between  the  first  and  second  dentitions  are  most  liable  to  be 
attacked.  Sucklings  are,  however,  not  exempt,  and  I  have  seen  very  severe 
attacks  in  infants  under  six  weeks.  Congenital  cases  are  described.  It  is 
stated  that  girls  are  more  subject  to  the  disease  than  boys.  Adults  and  old 
people  are  sometimes  attacked,  and  in  the  aged  it  may  be  a  very  serious  affec- 
tion. It  appears  to  be  most  contagious  in  the  catarrhal  period.  A  natural 
immunity  has  been  mentioned,  but  it  must  be  remembered  that  a  child  may 
have  the  disease  in  a  very  mild  form.  As  a  rule,  one  attack  protects;  second 
attacks  are  excessively  rare.  Delicate  anaemic  children  with  nasal  or  bronchial 
catarrh  are  more  subject  to  the  disease  than  others.  According  to  the  United 
States  Census  Eeports,  the  disease  is  more  than  twice  as  fatal  in  the  negro 
race  than  in  others. 

Czaplewski,  Koplik,  and  Hensel  describe  a  small  bacillus  with  rounded 
ends.  A  serum  even  has  been  prepared.  More  recently  Bordet  has  described 
a  special  germ,  and  Fraenkel  a  small  ovoid  bacterium.  The  influenza  bacillus 
has  been  found  in  some  cases. 

Morbid  Anatomy. — Whooping-cough'  itself  has  no  special  pathological 
changes.  In  fatal  cases  pulmonary  complications,  particularly  broncho-pneu- 
monia, are  usually  present.  Collapse  and  compensatory  emphysema,  vesicular 
and  interstitial,  are  found,  and  the  tracheal  and  bronchial  glands  are  enlarged. 

Symptoms. — There  is  a  variable  period  of  incubation  of  from  seven  to  ten 
days.  Catarrhal  and  paroxysmal  stages  can  be  recognized.  In  the  catarrhal 
stage  the  child  has  the  symptoms  of  an  ordinary  cold,  which  may  begin  with 
slight  fever,  running  at  the  nose,  injection  of  the  eyes,  and  a  bronchial  cough, 
usually  dry,  and  sometimes  giving  indications  of  a  spasmodic  character. 
Trousseau  calls  attention  to  the  incessant  character  of  the  early  cough.  The 
fever  is  usually  not  high,  and  slight  attention  is  paid  to  the  symptoms,  which 
are  thought  to  be  those  of  a  simple  catarrh.  After  lasting  for  a  week  or  ten 
days,  instead  of  subsiding,  the  cough  becomes  worse  and  more  convulsive  in 
character. 

The  paroxysmal  stage,  marked  by  the  characteristic  cough,  dates  from  the 
first  appearance  of  the  "  whoop."  The  fit  begins  with  a  series  of  from  fifteen 
to  twenty  forcible  short  coughs  of  increasing  intensity,  between  which  no 
inspiratory  effort  is  made.  The  child  gets  blue  in  the  face,  and  then  with  a 
deep  inspiration  the  air  is  drawn  into  the  lungs,  making  the  "  whoop,^'  which 
may  be  heard  at  a  distance,  and  from  which  the  disease  takes  its  name.  A 
deep  inspiration  may  precede  the  series  of  spasmodic  expiratory  efforts.  Sev- 
eral coughing-fits  may  succeed  each  other  until  a  tenacious  mucus  is  ejected, 
usually  small  in  amount,  but  after  a  series  of  coughing-fits  a  considerable 
quantity  may  be  expectorated.  Vomiting  often  takes  place  at  the  end  of  a  par- 
oxysm, and  may  recur  so  frequently  in  the  day  that  the  child  does  not  get 
enough  food  and  becomes  emaciated.  There  may  be  only  four  or  five  attacks  in 
the  day,  or  in  severe  cases  they  may  recur  every  half -hour.  In  severe  and  fatal 
cases  the  paroxysms  may  exceed  one  hundred  daily.  During  the  paroxysm 
the  thorax  is  very  strongly  compressed  by  the  powerful  expiratory  efforts,  and. 


150  SPECIFIC  INFECTIOUS  DISEASES. 

as  very  little  air  passes  in  through  the  glottis,  there  are  signs  of  defective 
aeration  of  the  blood ;  the  face  Ijecomes  SAVollen  and  congested,  the  veins  are 
prominent,  the  e3^eballs  protrude,  and  the  conjunctivae  become  deeply  engorged. 
Suffocation  indeed  seems  imminent,  when  with  a  deep,  crowing  inspiration  air 
enters  the  lungs  and  the  color  is  quickly  restored.  The  child  knows  for  a 
few  moments  when  the  attack  is  coming  on,  and  tries  in  every  way  to  check 
it,  but  failing  to  do  so,  runs  terrified  to  the  nurse  or  mother  to  be  supported, 
or  clutches  anything  near  by.  Few  diseases  are  more  painful  to  witness.  In 
severe  paroxysms  the  sphincters  may  be  opened.  The  urine  is  said  to  be  of 
high  specific  gravity  (1022-1032),  pale  3'ellow,  and  to  contain  much  uric  acid. 

An  ulcer  may  form  under  the  tongue  from  rubbing  on  the  teeth  (Riga's 
disease). 

During  the  attack,  if  the  chest  be  examined,  the  resonance  is  defective  in 
the  expiratory  stage,  full  and  clear  during  the  deep,  crowing  insj^iration ;  but 
on  auscultation  during  the  latter  there  may  be  no  vesicular  murmur  heard, 
owing  to  the  slowness  with  which  the  air  passes  the  narrowed  glottis.  Bron- 
chial rales  are  occasionally  heard. 

Among  circumstances  which  precipitate  a  paroxysm  are  emotion,  such  as 
crying,  and  any  irritation  about  the  throat.  Even  the  act  of  swallowing  some- 
times seems  sufficient.  In  a  close  dusty  atmosphere  the  coughing-fits  are  more 
frequent.  After  lasting  for  three  or  four  weeks  the  attacks  become  lighter 
and  finalh'  cease.  In  cases  of  ordinary  severity  the  course  of  the  disease  is 
rarel}'  under  six  weeks. 

The  complications  and  sequelae  of  whooping-cough  are  important.  During 
the  extensive  venous  congestion  hgemorrhages  are  very  apt  to  occur  in  the 
form  of  petechige,  particularly  about  the  forehead,  ecchymosis  of  the  conjunc- 
tivge,  and  even  bleeding  tears  of  blood  (Trousseau)  from  the  rupture  of  the 
vessels,  epistaxis,  bleeding  from  the  ears,  and  occasionally  hemoptysis. 
Hsemorrhage  from  the  bowels  is  rare.  Convulsions  are  not  very  uncommon, 
due  perhaps  to  the  extreme  engorgement  of  the  cerebral  cortex.  Death  has 
occurred  from  spasm  of  the  glottis.  Sudden  death  has  been  caused  by  exten- 
sive subdural  hemorrhage.  Paralysis  is  a  rare  event.  It  was  associated  with 
3  of  my  series  of  120  cases,  but  in  none  of  them  did  the  hemiplegia  come  on 
during  the  paroxysm,  as  in  a  case  reported  by  S.  West.  Valentine  (1901)  has 
collected  79  cases,  chiefly  hemiplegias.  A  spastic  paraplegia  may  follow. 
Acute  pohnieuritis  is  a  rare  sequel. 

The  persistent  vomiting  may  induce  marked  angemia  and  wasting.  The 
pulmonary  complications  are  extremely  serious.  During  the  severe  coughing- 
spells  interstitial  emphysema  may  be  induced,  more  rarely  pneumothorax.  I 
saw  one  instance  in  which  rupture  occurred,  evidently  near  the  root  of  the 
lung,  and  the  air  passed  along  the  trachea  and  reached  the  subcutaneous  tis- 
sues of  the  neck,  a  condition  which  has  been  knoAvn  to  become  general. 
Capillary  bronchitis,  lobular  and  pseudo-lobar  pneumonia  are  the  dangerous 
complications,  responsible  for  nine  out  of  ten  deaths  in  the  disease.  In  some 
cases  the  process  is  tuberculous.  Pleurisy  is  sometimes  met  with  and  occa- 
sionally lobar  pneumonia.  Enlargement  of  the  bronchial  glands  is  very  com- 
mon in  whooping-cough,  and  has  been  thought  to  cause  the  disease.  It  may 
sometimes  be  sufficient  to  produce  dulness  over  the  manubrium.  During  the 
spasm  the  radial  pulse  is  small,  the  right  heart  engorged,  and  during  and 


I 


WHOOPING-COUGH.  151 

after  the  attack  the  cardiac  action  is  very  much  disturbed.  Serious  damage 
may  result,  and  possibly  some  of  the  cases  of  severe  valvular  disease  in  chil- 
dren who  have  had  neither  rheumatism  nor  scarlet  fever  may  be  attributed 
to  the  terrible  heart  strain  during  a  prolonged  attack.  Koplik  regards  the 
swelling  about  the  face  and  eyes  as  an  important  sign  of  the  heart  strain. 
Serious  renal  complications  are  very  uncommon,  but  albumin  sometimes  and 
sugar  frequently  are  found  in  the  urine.  A  distressing  sequel  in  adults  is 
asthma,  which  may  recur  at  intervals  for  a  year  or  more.  An  unusually 
marked  leucocytosis  appears  early,  chiefly  of  the  lymphocytes  (Meunier). 

Diagnosis. — So  distinctive  is  the  "  whoop  "  of  the  disease  that  the  diag- 
nosis is  very  easy;  but  occasionally  there  are  doubtful  cases,  particularly  dur- 
ing epidemics,  in  which  a  series  of  expiratory  coughs  occurs  without  any 
inspiratory  crow. 

Prognosis. — If  we  include  its  complications,  whooping-cough  is  a  very  fatal 
affection,  ranking  first  among  the  acute  infections  as  a  cause  of  death  in  chil- 
dren under  five  years  of  age.  It  exceeds  diphtheria  and  scarlet  fever  in  gross 
mortality.  In  1903  there  were  9,522  deaths  in  England  and  Wales,  97  per 
cent  in  children  under  five  years  of  age  (Tatham).  The  disease  should  be 
placed  on  the  list  of  reportable  infections.  As  it  is  highly  probable  that  the 
contagion  persists  for  a  very  long  time,  special  care  should  be  taken  in  the 
inspection  of  school  children  during  their  convalescence. 

Treatment. — The  gravity  of  the  disease  is  scarcely  appreciated  by  the  pub- 
lic. Children  with  the  disease  should  not  be  sent  to  school  or  exposed  in 
public  in  any  way.  There  is  more  reprehensible  neglect  in  connection  with 
this  than  with  any  other  disease.  The  patient  should  be  isolated,  and  if 
the  paroxysms  are  at  all  severe,  at  rest  in  bed.  Fresh  air,  night  and  day, 
is  important,  but  in  cities  in  the  winter  this  is  not  easy  to  manage.  The 
treatment  is  notoriously  unsatisfactory.  If  asked  the  two  most  important 
things,  I  should  say,  six  weeks  and  a  good  big  bottle  of  paregoric.  Antiseptic 
measures  have  been  extensively  tried.  Quinine  holds  its  own  with  many  -prac- 
titioners; a  sixth  of  a  grain  may  be  given  three  times  a  day  for  each  month 
of  age,  and  a  grain  and  a  half  for  each  year  in  children  under  five.  A  one- 
per-cent  solution  of  resorcin  swabbed  on  the  throat,  two  or  three  grains  of 
iodoform  to  an  ounce  of  starch  powder,  insufflated,  and  the  carbolic-acid  spray 
may  be  tried.  For  the  catarrhal  symptoms  moderate  doses  of  ipecac  are  prob- 
ably the  most  satisfactory.  Sedatives  are  by  far  the  most  trustworthy  drugs 
in  severe  cases,  and  paregoric  may  be  given  freely,  particularly  to  give  rest  at 
night.  Jacobi  advises  belladonna  in  full  doses,  as  much  as  one-sixth  of  a 
grain  of  the  extract  to  a  child  of  six  or  eight  months  three  times  a  day. 

Other  remedies,  such  as  antipyrin,  bromin,  and  bromoform,  may  be  tried. 
In  older  children  and  in  adults  it  would  be  worth  while,  I  think,  to  try  the 
intratracheal  injections  of  olive-oil  and  iodoform,  which  are  sometimes  so 
useful  in  allaying  severe  paroxysmal  cough.  It  is  impossible  to  mention  all 
the  drugs  which  have  been  recommended,  numbering  nearly  fifty  in  a  recent 
system  of  medicine. 

After  the  severity  of  the  attack  has  passed  and  convalescence  has  begun, 
the  child  should  be  watched  with  the  greatest  care.  It  is  just  at  this  period 
that  the  fatal  broncho-pneumonias  are  apt  to  develop.  The  cough  sometimes 
persists  for  months  and  the  child  remains  weak  and  delicate.    Change  of  air 


152  SPECIFIC  INFECTIOUS  DISEASES. 

should  be  tried.     Sucli  a  patient  should  be  fed  with  care,  and  given  tonics  and 
cod-liver  oil. 

XII.     INFLUENZA    (La  Grippe). 

Definition. — A  pandemic  disease,  appearing  at  irregular  intervals,  char- 
acterized by  extraordinary  rapidity  of  extension  and  the  large  number  of  peo- 
ple attacked.  Following  the  pandemic  there  are,  as  a  rule,  for  several  years 
endemic,  epidemic,  or  sporadic  outbreaks  in  different  regions.  Clinically,  the 
disease  has  protean  aspects,  but  a  special  tendency  to  attack  the  respiratory 
mucous  membranes. 

History. — Great  pandemics  have  been  recognized  since  the  sixteenth  cen- 
tury. There  were  four  with  their  succeeding  epidemics  during  the  last  cen- 
tury—1830-33,  1836-'37,  1847-48,  and  1889-90.  The  last  pandemic  seems 
to  have  begun,  as  many  others  had  before,  in  the  far  East.  It  may  have  started 
in  May,  1889,  in  Buchara,  reaching  Moscow  in  September,  the  Caucasus  and 
St.  Petersburg  in  October.  By  the  middle  of  November  Berlin  was  attacked. 
By  the  middle  of  December  it  was  in  London,  and  by  the  end  of  the  month 
it  had  invaded  New  York,  and  was  widely  distributed  over  the  entire  con- 
tinent.   Within  a  year  it  had  visited  nearlj''  all  parts  of  the  earth. 

The  duration  of  an  epidemic  in  any  one  locality  is  from  six  to  eight  weeks. 
With  the  exception,  perhaps,  of  dengue,  there  is  no  disease  which  attacks  in- 
discriminately so  large  a  proj)ortion  of  the  inhabitants,  about  40  per  cent  as 
a  rule.  Fortunately,  as  in  dengue,  the  rate  of  mortality  is  very  low.  Of 
55,263  cases  reported  in  the  German  army,  60  died,  or  about  0.1  per  cent. 
As  might  be  expected,  in  the  civil  population  the  mortality  is  somewhat  higher, 
reaching  133,  or  about  0.5  per  cent  of  the  32,973  cases  reported  in  Munich. 
Over  one-half  of  these  deaths  were  due  to  pneumonia.  In  1903  the  deaths  in 
England  and  Wales  numbered  6,333.  There  has  been  a  gradual  diminution 
of  the  death-rate  from  this  disease  •  during  the  past  three  years  (Tatham). 
The  opportunity  for  studying  the  disease  in  the  last  epidemic  has  thrown  much 
light  upon  many  problems.  Among  the  most  notable  productions  were  the 
work  of  Pfeiffer  on  the  etiology  of  the  disease,  the  elaborate  Berlin  report  by 
von  Leyden  and  Senator,  and  the  Local  Government  Board's  report  by  Par- 
sons. Leichtenstern's  article  in  Nothnagel's  Handbuch  is  the  most  masterly 
and  systematic  consideration  of  the  disease  in  the  literature. 

Etiolog-y. — What  relation  has  the  epidemic  influenza  to  the  ordinary  influ- 
enza cold  or  catarrhal  fever  (commonly  also  called  the  grippe),  which  is  con- 
stantly present  in  the  community?  Leichtenstern  answers  this  question  l)y 
making  the  following  divisions:  (1)  Epidemic  influenza  vera,  caused  by 
Pfeiffer's  bacillus;  (3)  endemic-epidemic  influenza  vera,  which  often  occurs 
for  several  years  in  succession  after  a  pandemic,  also  caused  by  the  same 
bacillus;  (3)  endemic  influenza  nostras,  pseudo-influenza  or  catarrhal  fever, 
commonly  called  the  grippe,  which  is  a  special  disease,  still  of  unknovni  etiol- 
ogy, and  which  bears  the  same  relation  to  the  true  influenza  as  cholera  nostras 
does  to  Asiatic  cholera. 

Since  the  last  pandemic  we  have  not  been  free  from  local  outbreaks  in 
some  part  of  the  world.  In  some  places  the  disease  seems  to  have  been  con- 
tinually present. 


INFLUENZA.  153 

Euhemann  reports  1,979  cases  of  typical  grippe  between  1895  and  1903. 
In  115  he  demonstrated  the  influenza  bacillus.  Lord  (in  Boston)  demonstrated 
influenza  bacilli  in  about  30  per  cent  of  100  unselected  cases  of  acute  and 
chronic  bronchitis.  Yet  during  this  period  there  was  no  epidemic  of  influenza 
in  the  city.  The  reports  are  sufficiently  numerous  to  show  that  the  influenza 
bacillus  is  probably  constantly  with  us.  Many  observations  show  that  it  is  a 
frequent  invader  of  the  respiratory  tract  in  the  inter-epidemic  periods  and  is 
probably  responsible  for  many  of  the  cases  of  Leichtenstern's  influenza  nostras. 
Indeed,  it  seems  to  bear  a  similar  relation  to  the  acute  infections  of  the 
respiratory  tract  as  other  common  organisms.  It  is  still  unexplained  why  it 
should  stand  in  a  different  relation  to  the  epidemics  of  influenza  as  the  sole 
cause  of  the  disease. 

The  disease  is  highly  contagious;  it  spreads  with  remarkable  rapidity, 
which,  however,  is  not  greater  than  modern  methods  of  conveyance.  In  the 
great  pandemic  of  1889-'90  some  of  the  large  prisons  escaped  entirely.  The 
outbreak  of  epidemics  is  independent  of  all  seasonal  and  meteorological  con- 
ditions, except  perhaps  sunshine.  The  worst  have  been  in  the  colder  seasons 
of  the  year.  One  attack  does  not  necessarily  protect  from  a  subsequent  one. 
A  few  persons  appear  not  to  be  liable  to  the  disease. 

Bacteriology. — In  1892  Pfeiffer  isolated  a  bacillus  from  the  nasal  and 
bronchial  secretions,  which  is  recognized  as  the  cause  of  the  disease.  It  is  a 
small,  non-motile  organism,  which  stains  well  in  Loefiler's  methylene  blue,  or 
in  a  dilute,  pale-red  solution  of  carbol-fuchsin  in  water.  On  culture  media 
it  grows  only  in  the  presence  of  haemoglobin.  In  the  presence  of  contaminat- 
ing organisms,  especially  the  staphylococcus  aureus,  the  growth  of  influenza 
colonies  is  particularly  luxuriant.  The  organism  is  probably  frequently  over- 
looked in  mixed  cultures  because  of  failure  to  recognize  the  character  of  these 
colonies  in  symbiosis.  The  bacilli  are  present  in  enormous  numbers  in  the 
nasal  and  bronchial  secretions  of  patients,  in  the  latter  almost  in  pure  cultures. 
They  persist  often  after  the  severe  symptoms  have  subsided. 

The  much-discussed  question  whether  during  the  presence  of  an  epidemic 
human  influenza  attacks  animals  must  be  answered  in  the  negative.  In  great 
pandemics  of  influenza  the  general  rule  seems  to  hold  that  other  diseases  do 
not  prevail  to  the  same  extent,  but  it  may  be  that  other  diseases  are  wrongly 
included  under  influenza. 

Symptoms. — The  incubation  period  is  "  from  one  to  four  days ;  of tenest 
three  to  four  days."  The  onset  is  usually  abrupt,  with  fever  and  its  associated 
phenomena. 

Types  of  the  Disease. — The  manifestations  are  so  extraordinarily  complex 
that  it  is  best  to  describe  them  under  types  of  the  disease. 

1.  Eespiratory. — The  mucous  membrane  of  the  respiratory  tract  from 
the  nose  to  the  air-cells  of  the  lungs  may  be  regarded  as  the  seat  of  election 
of  the  influenza  bacilli.  In  the  simple  forms  the  disease  sets  in  with  coryza,, 
and  presents  the  features  of  an  acute  catarrhal  fever,  with  perhaps  rather 
more  prostration  and  debility  than  is  usual.  In  other  cases  after  catarrhal 
symptoms  broncnitis  occurs,  the  iever"^increases,  there  is  delirium  and  much 
prostration,  and  the  picture  may  even  be  that  of  severe  typhoid  fever._  The 
graver  respiratory  conditions  are  bronchitis,  pleurisy,  and  pneumonia — The, 
bronchitis  has  really  no  special  peculiarities.     'I'he  sputum  is^pposed  by 


154  SPECIFIC  INFECTIOUS  DISEASES. 

man}'  to  be  distinctive.  Sometimes  it  is  in  extraordinary  amounts,  very  thin, 
and  containing  purulent  masses.  Pfeilt'er  regards  sputum  of  a  greenish-yellow 
color  and  m  coin-like  lumprf  atj  almost  characteristic  oi  mduenza.  In  other" 
cases  there  rday  b5  a  dark  rea.  bloody  sputum.  One  of  the  most  "distressing  _ 
sequels  of  the  influenza  bronchitis  is  diffuse  bronchiectasis,  of  vrhich  I  have 
seen  several  instances.  It  occasionally  happens  that  the  bronchitis  is  of  greats 
i-nfPTigify  flnrl  rpflpbps;  Ibp  finer  tnbes,  SO  that  the  patient  becomes  cyanosed  or 
even  asphyxiated. 

/-Influenza  pneumonia  is  one  of  the  most  serious  manifestations,  and  may 
depend  wpon  Pfeiffer's  bacillus  itself,  or  is  the  result  of  a  mixed  infection. 
The  true  influenza  pneumonia  is  most  commonly  lobular  or  catarrhal,  prob- 
ably never  croupous.  Much  of  the  mortality  of  the  disease  depends  upon  the 
fatal  character  of  this  complication.  The  clinical  course  of  the  cases  is  often 
irregular  and  the  s3'mptoms  are  obscure  or  masked. 

Influenza  pleurisy  is  more  rare,  but  cases  of  primary  involvement  of  the 
pleura  are  reported.  It  is  very  apt  to  lead  to  empyema.  Pulmonary  tubercu- 
losis is  usually  much  aggravated  by  an  attack  of  influenza. 

2.  Nervous  Form. — Without  any  catarrhal  sj^mptoms  there  are  severe 
headache,  pain  in  the  back  and  joints,  with  profound  prostration.  Among  the 
more  serious  complications  may  be  mentioned  meningitis  and  encephalitis,  the 
latter  leading  to  hemiplegia  or  monoplegia.  Abscess  of  the  brain  has  followed 
in  acute  cases.  Myelitis,  with  symptoms  like  an  acute  Landry's  paralysis,  has 
occurred,  and  spastic  paraplegia  or  a  pseudo-tabes  may  follow  an  attack. 

The  influenza  bacillus  has  been  demonstrated  by  lumbar  puncture  during 
life  and  in  the  meninges  after  death.  .  All  forms  of  neuritis  are  not  uncom- 
mon, and  in  some  cases  are  characterized  by  marked  disturbance  of  motion 
and  sensation.  Judging  from  the  accounts  in  the  literature,  almost  every 
form  of  disease  of  the  nervous  system  may  follow  influenza. 

Among  the  most  important  of  the  nervous  sequelge  are  depression  of  spirits, 
melancholia,  and  in  some  cases  dementia. 

3.  Gastro-ixtestinal  Form. — "With  the  onset  of  the  fever  there  may  be 
nausea  and  vomiting,  or  the  attack  may  set  in  with  abdominal  pain,  profuse 
diarrhoea,  and  collapse.  In  some  epidemics  jaundice  has  been  a  common 
symptom.  In  a  considerable  number  of  the  cases  there  is  enlargement  of  the 
spleen,  depending  chiefly  upon  the  intensity  of  the  fever.  This  was  a  very 
rare  form  in  the  United  States. 

4.  Febrile  Form. — The  fever  in  influenza  is  very  variable,  but  it  is  im- 
portant to  recognize  that  it  may  be  the  only  manifestation  of  the  disease.  It 
is  sometimes  markedly  remittent,  with  chills;  or  in  rare  cases  there  is  a  pro- 
tracted, continued  fever  of  several  weeks'  duration,  which  simulates  typhoid 
closely  (W.  W.  Johnston). 

Complications. — The  pericarditis  is  apt  to  be  latent.  Of  endocarditis,  a 
number  of  cases  have  been  reported.  There  have  been  at  least  three  caees 
at  the  Johns  Hopkins  Hospital  in  which  micro-organisms  morphologically 
like  influenza  bacilli  have  been  isolated  from  the  vegetations  (Mabel  Austin). 
The  malignant  form  may  occur.  Myocarditis  may  follow,  and  has  been  a 
cause  of  sudden  death.  Functional  disturbances  are  common,  palpitation, 
bradycardia,  tachycardia,  and  angina-like  attacks.  Phlebitis  and  thrombosis 
of  various  vessels  have  been  described. 


INFLUENZA.     ■  155 

Septiccemia  was  demonstrated  in  four  of  eight  cases  by  Meunier  in  the 
cultivation  of  influenza  bacilli  from  the  circulating  blood. 

Peritonitis  is  rare.  There  have  been  a  few  cases  published,  only  one,  so  far 
as  I  know,  by  Hill  and  Fisch,  in  which  the  bacillus  was  demonstrated  in  the 
exudate. 

Cholelithiasis  may  follow  an  attack.  Influenza  bacilli  were  demonstrated 
in  pure  culture  in  the  pus  from  the  gall-bladder  by  Heyroosky. 

The  increased  prevalence  of  appendicitis  has  been  attributed  to  influenza. 

Various  renal  affections  have  been  noted.  G.  Baumgarten  has  called  atten- 
tion to  the  frequency  of  nephritis.  Orchitis  has  been  also  seen.  Herpes  is 
common.  A  difl^use  erythema  sometimes  occurs,  occasionally  purpura.  Ca- 
tarrhal conjunctivitis  is  a  frequent  event.  Iritis,  and  in  rare  instances  optic 
neuritis,  have  been  met  with.  Acute  otitis  media  is  a  common  complication. 
I  have  seen  severe  and  persistent  vertigo  follow  influenza,  probably  from 
involvement  of  the  labyrinth.  Bronchiectasis  may  follow.  I  have  seen  sev- 
eral cases;  in  a  recent  fatal  one  of  three  years'  duration  the  bacilli  were  pres- 
ent in  the  sputa. 

Since  the  late  severe  epidemics  it  has  been  the  fashion  to  date  various 
ailments  or  chronic  ill-health  from  influenza.  In  many  cases  this  is  correct. 
It  is  astonishing  the  number  of  people  who  have  been  crippled  in  health  for 
years  after  an  attack. 

Diagnosis. — During  a  pandemic  the  cases  offer  but  slight  difflculty.  The 
profoundness  of  the  prostration,  out  of  all  proportion  to  the  intensity  of  the 
disease,  is  one  of  the  most  characteristic  features.  In  the  respiratory  form 
the  diagnosis  may  be  made  by  the  bacteriological  examination  of  the  sputum, 
a  procedure  which  should  be  resorted  to  early  in  a  suspected  epidemic.  The 
differentiation  of  the  various  forms  has  been  already  sufficiently  considered. 

Treatment. — Isolation  should  be  practised  when  possible,  and  old  people 
should  be  guarded  against  all  possible  sources  of  infection.  The  secretions, 
nasal  and  bronchial,  should  be  thoroughly  disinfected.  In  every  case  the 
disease  should  be  regarded  as  serious,  and  the  patient  should  be  confined  to 
bed  until  the  fever  has  completely  disappeared.  In  this  way  alone  can  serious 
complications  be  avoided.  From  the  outset  the  treatment  should  be  support- 
ing, and  the  patient  should  be  carefully  fed  and  well  nursed.  The  bowels 
should  be  opened  by  a  dose  of  calomel  or  a  saline  draught.  At  night  10  grains 
of  Dover's  powder  may  be  given.  At  the  onset  a  warm  bath  is  sometimes 
grateful  in  relieving  the  pain  in  the  back  and  limbs,  but  great  care  should  be 
taken  to  have  the  bed  well  warmed,  and  the  patient  should  be  given  after  it 
a  drink  of  hot  lemonade.  If  the  fever  is  high  and  there  is  delirium,  small 
doses  of  antipyrin  may  be  given  and  an  ice-cap  applied  to  the  head.  The 
medicinal  antipyretics  should  be  used  with  caution,  as  profound  prostration 
sometimes  occurs  after  their  employment.  Too  much  stress  should  not  be 
laid  upon  the  mental  features.  Delirium  may  be  marked  even  with  slight 
fever.  In  the  cases  with  great  cardiac  weakness  stimulants  should  be  given 
freely,  and  during  convalescence  strychnia  in  full  doses. 

The  intense  bronchitis,  pneumonia,  and  other  complications  should  re- 
ceive their  appropriate  treatment.  The  convalescence  requires  careful  man- 
agement, and  it  may  be  weeks  or  months  before  the  patient  is  restored  to  full 
health.    A  good  nutritious  diet,  change  of  air,  and  pleasant  surroundings  are 


156  SPECIFIC  INFECTIOUS  DISEASES. 

essential.     The  depression  of  spirits  following  this  disease  is  one  of  its  most 
unpleasant  and  obstinate  features. 

XIII.     DENGUE. 

Definition. — An  acute  infectious  disease  of  tropical  and  subtropical  re- 
gions, characterized  by  febrile  paroxysms,  pains  in  the  joints  and  muscles,  an 
initial  erythematous,  and  a  terminal  polymorphous  eruption. 

It  is  knoT\Ti  as  treah-hone  fever  from  the  atrocious  character  of  the  pain, 
and  dandy  fever  from  the  stiff,  dandified  gait.  The  word  dengue  is  sup- 
posed to  be  derived  from  a  Si)anish,  or  j)ossibly  Hindostanee,  equivalent  of 
the  word  dandy. 

History  and  Geographical  Distribution. — The  disease  was  first  recognized 
in  1779  in  Cairo  and  in  Java,  where  Brylon  described  the  outbreak  in  Batavia. 
The  description  by  Benjamin  Eush  of  the  epidemic  in  Philadelphia  in  1780 
is  one  of  the  first  and  one  of  the  very  best  accounts  of  the  disease.  Between 
1821  and  1828  it  was  ^^revalent  at  intervals  in  India  and  in  the  Southern 
States.  S.  H.  Dickson  gives  a  graphic  description  of  the  disease  as  it  appeared 
in  Charleston  in  1828.  Since  that  date  there  have  been  four  or  five  wide- 
spread epidemics  in  tropical  countries  and  on  this  continent  along  the  Gulf 
States,  the  last  in  the  summer  of  1897.  None  of  the  recent  epidemics  have 
extended  into  the  Northern  States,  but  in  1888  it  prevailed  as  far  north  as 
Virginia.  It  has  prevailed  in  the  Philippine  Islands  among  the  United  States 
troops  and  among  the  natives. 

Etiology. — The  rapidity  of  diffusion  and  the  pandemic  character  are  the 
two  most  important  features  of  dengue.  There  is  no  disease,  not  even  influ- 
enza, which  attacks  so  large  a  proportion  of  the  population.  In  Galveston,  in 
1897,  20,000  people  were  attacked  within  two  months.  Ashburn  and  Craig 
have  shown  that  it  is  transmitted  by  the  bite  of  a  mosquito,  Culex  fatigans. 
The  specific  germ  is  still  undetermined,  but  is  probably  ultramicroscopic. 

As  the  disease  is  rarely  fatal,  no  observations  have  been  made  upon  its 
pathological  anatomy. 

Symptoms. — The  period  of  incubation  is  from  three  to  five  daj^s,  during 
which  the  patient  feels  well.  The  attack  sets  in  suddenly  with  headache,  chilly 
feelings,  and  intense  aching  pains  in  the  joints  and  muscles.  The  tempera- 
ture rises  graduall}^,  and  may  reach  106°  or  107°.  The  pulse  is  rapid,  and 
there  are  the  other  phenomena  associated  with  acute  fever — ^loss  of  appetite, 
coated  tongue,  slight  nocturnal  delirium,  and  concentrated  urine.  The  face 
has  a  suffused,  bloated  appearance,  the  eyes  are  injected,  and  the  visible  mu- 
cous membranes  are  flushed.  There  is  a  congested,  erythematous  state  of  the 
skin.  Eush's  description  of  the  pains  is  worth  quoting,  as  in  it  the  epithet 
break-bone  occurs  in  the  literature  for  the  first  time.  "  The  pains  which 
accompanied  this  fever  were  exquisitely  severe  in  the  head,  back,  and  limbs. 
The  pains  in  the  head  were  sometimes  in  the  back  parts  of  it,  and  at  other 
times  they  occupied  only  the  eyeballs.  In  some  people  the  pains  were  so  acute 
in  their  backs  and  hips  that  they  could  not  lie  in  bed.  In  others,  the  pains 
affected  the  neck  and  arms,  so  as  to  produce  in  one  instance  a  difficulty  of 
moving  the  fingers  of  the  right  hand.  They  all  complained  more  or  less  of  a 
soreness  in  the  seats  of  these  pains,  particularly  when  they  occupied  the  head 


CEREBROSPINAL  FEVER.  157 

and  eyeballs.  A  few  complained  of  their  flesh  being  sore  to  the  touch  in  every 
part  of  the  body.  From  these  circumstances  the  disease  was  sometimes  be- 
lieved to  be  a  rheumatism,  but  its  more  general  name  among  all  classes  of 
people  was  the  break-bone  fever."  The  large  and  small  joints  are  affected^ 
sometimes  in  succession,  and  become  swollen,  red,  and  painful.  In  some  cases 
cutaneous  hypersesthesia  has  been  noted.  Haemorrhage  from  the  mucous  mem- 
branes was  noted  by  Kush,  Black  vomit  has  also  been  described  by  several 
observers. 

The  fever  gradually  reaches  its  maximum  by  the  third  or  fourth  day;  the 
patient  then  enters  upon  the  apyretic  period,  which  may  last  from  two  to 
four  days,  and  in  which  he  feels  prostrated  and  stiff.  A  second  paroxysm 
of  fever  then  occurs,  and  the  pains  return.  In  a  large  number  of  cases  an 
eruption  is  common,  which,  judging  from  the  description,  has  nothing  dis- 
tinctive, being  sometimes  macular,  like  that  of  measles,  sometimes  diffuse  and 
scarlatiniform,  or  papular,  or  lichen-like.  In  other  instances  the  rash  has 
been  described  as  urticarial,  or  even  vesicular.  The  rash  may  persist  for  a 
month  after  the  symptoms  have  disappeared  (Woolley).  Certain  writers  de- 
scribe inflammation  and  hyperaamia  of  the  mucous  membrane  of  the  nose, 
mouth,  and  pharynx.  Enlargement  of  the  lymph-glands  is  not  uncommon, 
and  may  persist  for  weeks  after  the  disappearance  of  the  fever.  Convalescence 
is  often  protracted,  and  there  is  a  degree  of  mental  and  physical  prostration 
out  of  all  proportion  to  the  severity  of  the  primary  attack.  The  pains  in 
the  joints  or  muscles,  sometimes  very  local,  may  persist  for  weeks.  Rush 
refers  to  the  former,  stating  that  a  young  lady  after  recovery  said  it  should 
be  called  break-heart,  not  break-bone,  fever.  The  average  duration  of  a  mod- 
erate attack  is  from  seven  to  eight  days.  Dengue  is  very  seldom  fatal.  Dick- 
son saw  three  deaths  in  the  Charleston  epidemic. 

Complications  are  rare.  Insomnia  and  occasionally  delirium,  resembling 
somewhat  the  alcoholic  form,  have  been  observed,  and  convulsions  in  children. 
Atrophy  of  the  muscles  may  occur  after  the  attack  (Woolley).  A  relapse  may 
occur  even  as  late  as  two  weeks. 

Diagnosis. — The  diagnosis  of  the  disease,  prevailing,  as  it  does  in  epidemic 
form  and  attacking  all  classes  indiscriminately,  rarely  offers  any  special  diffi- 
culty. Isolated  cases  might  be  mistaken  at  first  for  acute  rheumatism.  The 
important  question  of  the  differentiation  between  yellow  fever  and  dengue 
will  be  considered  later. 

Treatment. — This  is  entirely  symptomatic.  Quinine  is  stated  to  be  a 
prophylactic,  but  on  insufficient  grounds.  Hydrotherapy  may  be  employed 
to  reduce  the  fever.  The  salicylates  or  antipyrin  may  be  tried  for  the  pains, 
which  usually,  however,  require  opium.  During  convalescence  iodide  of  potas- 
sium is  recommended  for  the  arthritic  pains,  and  tonics  are  indicated. 

XIV.     CEREBRO-SPINAL    FEVER. 

Definition. — An  infectious  disease,  occurring  sporadically  and  in  epidem- 
ics, caused  by  the  diplococcus  intraceUidaris,  characterized  by  inflammation 
of  the  cerebro-spinal  meninges  and  a  clinical  course  of  great  irregularity. 

The  affection  is  also  known  by  the  names  of  malignant  purpuric  fever, 
petechial  fever,  and  spotted  fever. 


158  SPECIFIC  INFECTIOUS  DISEASES. 

History. — Vieusseux  first  described  a  small  outbreak  in  Genera  in  1805. 
In  1806  L.  Danielson  and  E.  Mann  (Medical  and  Agricultural  Eegister,  Bos- 
ton) gave  an  account  of  "  a  singular  and  very  mortal  disease  which  lately 
made  its  appearance  in  Medfield,  Mass."  The  Massachusetts  Medical  Soci- 
ety, in  1809,  appointed  James  Jackson,  Thomas  Welch,  and  J.  C.  Warren  to 
investigate  it.  Elisha  Xorth's  little  book  (1811)  gives  a  full  account  of  the 
early  epidemics.  Stille's  monograph  (1867)  and  the  elaborate  section  in 
vol.  i  of  Joseph  Jones'  works  contain  details  of  the  later  American  outbreaks. 
In  his  Geographical  Patholog}^  Hirsch  divides  the  outbreaks  into  four  peri- 
ods: From  1805  to  1830,  in  which  the  disease  was  most  prevalent  through- 
out the  United  States;  a  second  period,  from  1837  to  1850,  when  the  disease 
prevailed  extensively  in  France,  and  there  were  a  few  outbreaks  in  the  United 
States;  a  third  period,  from  185-i  to  1871,  when  there  were  outbreaks  in 
Europe  and  several  extensive  epidemics  in  America.  During  the  Civil  War 
there  were  comparatively  few  cases.  It  prevailed  extensively  in  the  Ottawa 
Valley  early  in  the  seventies.  In  the  fourth  period,  from  1875  to  the  present 
time,  the  disease  has  broken  out  in  a  great  many  regions.  During  the  past 
fifteen  years  there  have  been  localized  outl^reaks  in  many  lands.  In  the  United 
States,  during  1898-'99,  it  prevailed  in  mild  form  in  27  states.  Since  1899 
there  have  been  extensive  outbreaks  in  Silesia,  and  in  the  cities  of  the  United 
States  on  the  Atlantic  coast.  In  Xew  York  in  190-1-5  there  were  6,755  cases 
and  3,155  deaths.  In  the  British  Isles  there  have  been  epidemics  in  Glasgow 
and  Belfast,  and  a  few  scattered  outbreaks.  In  Glasgow  in  1907  there  were 
nearly  1,000  cases  with  595  deaths  (Chalmers).  In  Belfast  in  the  18  months 
ending  June,  1908,  there  were  725  cases  with  518  deaths  (Eobb). 

Etiology. — Cerebro-spinal  fever  occurs  in  epidemic  and  in  sporadic 
forms.  The  epidemics  are  localized,  occurring  in  certain  regions,  and  are 
rarely  very  wide-spread.  As  a  rule,  country  districts  have  been  more  afflicted 
than  cities.  Mining  districts  and  seaports  have  sufl;ered  most  severely.  The 
outbreaks  have  occurred  most  frequently  in  the  winter  and  spring.  The  con- 
centration of  individuals,  as  of  troops  in  large  barracks,  seems  to  be  a  special 
factor,  and  epidemics. on  the  Continent  show  how  liable  recruits  and  young 
soldiers  are  to  the  disease.  In  civil  life  children  and  young  adults  are 
most  susceptible.  Of  Koplik's  77  cases  60  per  cent  were  under  two  years  of 
age.  Over-exertion,  long  marches  in  the  heat,  depressing  mental  and  bodily 
surroundings,  and  the  misery  and  squalor  of  the  large  tenement  houses  in 
cities  are  predisposing  causes.  The  disease  seems  not  to  be  directly  con- 
tagious, and  is  probably  not  transmitted  by  clothing  or  the  excretions.  It  is 
very  rare  to  have  more  than  one  or  two  cases  in  a  house,  and  in  a  city  epidemic 
the  distribution  of  the  cases  is  very  irregular.  Councilman  has  found  five 
instances  in  which  the  same  individual  is  reported  to  have  had  the  disease 
twice.  Meningitis  carriers,  persons  who  have  the  germ  in  their  throats  or 
noses,  but  who  are  themselves  unaffected,  play  an  important  role  in  transmit- 
ting the  disease. 

Sporadic  cerebro-spinal  fever  occurs  in  all  the  larger  cities  and  in  the 
country  districts  of  America.  The  disease  lingers  in  a  city  indefinitely  after 
an  outbreak,  and  in  Boston,  Philadelphia,  and  Baltimore  a  moderate  number 
of  cases  occur  every  year.  The  meningitis  in  children,  known  as  the  simple 
or  •posterior  basic,  is  the  sporadic  form.     It  has  two  suggestive  features  of 


CEREBROSPINAL  FEVER.  159 

similarity  in  the  seasonal  incidence  and  in  the  fact  that  cases  recover.  Still 
determined  the  identity  of  the  organism  with  the  meningococcus,  and  the 
view  has  been  confirmed  by  Koplik  and  many  others.  Houston  and  Rankin 
claim  that  while  the  cultural  peculiarities  are  the  same,  the  sporadic  form 
differs  in  its  opsonic  and  agglutinating  powers.  The  studies  of  Stuart  McDon- 
ald and  others  suggest  that  it  is  an  attenuated  form  of  the  germ. 

Bacteriology. — In  1887  Weichselbaum  described  an  organism,  the  Diplo- 
coccus  intracellularis  meningitidis,  which  was  probably  the  same  as  one  pre- 
viously found  by  Leichtenstern.  In  the  tissues  the  organism  is  almost  con- 
stantly within  the  polynuclear  leucocytes.  In  cultures  it  has  well-character- 
ized features,  and  is  distinguishable  from  the  pneumococcus.  Since  Weichsel- 
baum's  observations  this  organism  has  been  met  with  in  all  carefully  studied 
epidemics  of  the  disease.  The  studies  of  Councilman  in  Boston  and  the  numer- 
ous observers  in  the  Glasgow,  Belfast,  Kew  York,  and  Silesian  epidemics  have 
confirmed  the  constancy  of  this  organism  in  the  disease.  Three  important 
facts  have  been  brought  out — the  presence  of  the  germ  in  fully  half  the  cases 
in  the  naso-pharynx,  the  existence  of  it  in  healthy  contacts,  and  the  prepara- 
tion of  a  curative  serum,  to  be  referred  to  later. 

Morbid  Anatomy. — In  malignant  cases  there  may  be  no  characteristic 
changes,  the  brain  and  spinal  cord  showing  only  extreme  congestion,  which 
was  the  lesion  described  by  Vieusseux.  In  a  majority  of  the  acutely  fatal 
cases  death  occurs  within  the  first  week.  There  is  intense  injection  of  the 
pia-arachnoid.  The  exudate  is  usually  fibrino-purulent,  most  marked  at  the 
base  of  the  brain,  where  the  meninges  may  be  greatly  thickened  and  plastered 
over  with  it.  On  the  cortex  there  may  be  much  lymph  along  the  larger  fissures 
and  in  the  sulci ;  sometimes  the  entire  cortex  is  covered  with  a  thick,  purulent 
exudate.  It  deserves  to  be  recorded  that  Danielson  and  Mann  made  five  autop- 
sies and  were  the  first  to  describe  "  a  fluid  resembling  pus  between  the  dura 
and  pia  mater."  The  cord  is  always  involved  with  the  brain.  The  exudate  is 
more  abundant  on  the  posterior  surface,  and  involves,  as  a  rule,  the  dorsal 
and  lumbar  regions  more  than  the  cervical  portion. 

In  the  more  chronic  cases  there  is  general  thickening  of  the  meninges  and 
scattered  yellow  patches  mark  where  the  exudate  has  been.  The  ventricles  in 
the  acute  cases  are  dilated  and  contain  a  turbid  fluid,  or  in  the  posterior 
cornua  pure  pus.  In  the  chronic  cases  the  dilatation  may  be  very  great.  The 
brain  substance  is  usually  a  little  softer  than  normal  and  has  a  pinkish  tinge ; 
foci  of  hsemorrhage  and  of  encephalitis  may  be  found.  The  cranial  nerves  are 
usually  involved,  particularly  the  second,  fifth,  seventh,  and  eighth.  The 
spinal  nerve  roots  are  also  found  imbedded  in  the  exudate. 

Microscopically,  the  exudate  consists  largely  of  polynuclear  leucocytes 
closely  packed  in  a  fibrinous  material.  In  some  instances  there  are  foci  of 
purulent  infiltration  and  haemorrhage.  The  neuroglia  cells  are  swollen,  with 
large,  clear,  and  vesicular  nuclei.  The  ganglion  cells  show  less  marked  changes. 
Diplococci  are  found  in  variable  numbers  in  the  exudate,  being  more  numer- 
ous in  the  brain  than  in  the  cord. 

Lesions  in  Other  Parts. — In  one  of  the  Boston  cases,  examination  of  the 
nasal  secretion  during  life  showed  diplococci,  and  in  this  instance  there  was 
found  post  mortem  a  purulent  infiltration  of  the  mucous  membrane.  In  two 
other  cases  this  membrane  was  normal. 


160  SPECIFIC  INFECTIOUS  DISEASES. 

Lungs. — Pneumonia  and  pleurisy  have  been  described  in  the  disease. 
Councilman  reports  that  in  the  recent  epidemic  in  13  cases  there  was  con- 
gestion Avith  cedema,  in  7  broncho-pneumonia,  in  3  characteristic  croupous 
pneumonia  with  pneuinococci ;  in  8  pneumonia  due  to  the  diplococcus  intra- 
cellularis  was  present. 

Spleex. — The  organ  varies  a  good  deal  in  size.  In  only  three  of  the 
Boston  fatal  cases  was  it  found  much  enlarged.  The  liver  is  rarely  abnormal. 
Acute  nepliriiis  is  sometimes  present.  The  intestines  show  sometimes  swelling 
of  the  follicles. 

Symptoms. — Cases  differ  remarkably  in  their  characters.  Many  different 
forms  have  been  described.    These  are  perhaps  best  grouped  into  three  classes : 

1.  Malignant  Form. — This  fulminant  or  apoplectic  t^-pe  is  found  with 
variable  frequenc}^  in  epidemics.  It  may  occur  sporadically.  The  onset  is 
sudden,  usuall}"  with  violent  cliills,  headache,  somnolence,  spasms  in  the  mus- 
cles, great  depression,  moderate  elevation  of  temperature,  and  feeble  pulse, 
which  may  fall  to  fifty  or  sixty  in  the  minute.  Usually  a  purpuric  rash  devel- 
ops. In  a  Philadelphia  case,  in  1888,  a  young  girl,  apparently  quite  well, 
died  within  twenty  hours  of  this  form.  There  are  cases  on  record  in  which 
death  has  occurred  within  a  shorter  time.  Stille  tells  of  a  child  of  five  years, 
in  whom  death  occurred  after  an  illness  of  ten  hours;  and  refers  to  a  case 
reported  by  Gordon,  in  which  the  entire  duration  of  the  illness' was  onh'  five 
hours.     Two  of  Yieusseux's  cases  died  within  twent3'-four  hours. 

2.  Ordinary  PoRii. — The  stage  of  incubation  is  not  known.  The  disease 
usually  sets  in  suddenly.  There  may  be  premonitory  s^nnptoms:  headache, 
pains  in  the  back,  and  loss  of  appetite.  More  commonly,  the  onset  is  with 
headache,  severe  chill,  and  vomiting.  The  temperature  rises  to  101°  or  103°. 
The  pulse  is  full  and  strong.  An  early  and  important  s}Tnptom  is  a  painful 
stiffness  of  the  muscles  of  the  neck.  The  headache  increases,  and  there  are 
photophobia  and  great  sensitiveness  to  noises.  Children  become  very  irritable 
and  restless.  In  severe  cases  the  contraction  of  the  muscles  of  the  neck  sets 
in  early,  the  head  is  drawn  back,  and,  when  the  muscles  of  the  back  are 
also  involved,  there  is  orthotonos,  which  is  more  common  than  opisthotonos. 
The  pains  in  the  back  and  in  the  limbs  may  be  very  severe.  The  motor  symp- 
toms are  most  characteristic.  Tremor  of  the  muscles  may  be  present,  with 
tonic  or  clonic  spasms  in  the  arms  or  legs.  Eigidity  of  the  muscles  of  the 
back  or  neck  is  very  common,  and  the  patient  lies  with  the  body  stiff  and  the 
head  drawn  so  far  back  that  the  occiput  may  be  between  the  shoulder-blades. 
Except  in  early  childhood  convulsions  are  not  common.  Strabismus  is  a 
frequent  and  important  s}Tiiptom.  Spasm  of  the  muscles  of  the  face  may  also 
occur.  Cases  have  been  described  in  which  the  general  rigidity  and  stiffness 
was  such  that  the  body  could  be  moved  like  a  statue.  Paralysis  of  the  trunk 
muscles  is  rare,  but  paralysis  of  the  muscles  of  the  eye  and  the  face  is  not 
uncommon. 

Of  sensory  symptoms,  headache  is  the  most  dominant  and  persists  from 
the  outset.  It  is  chiefly  in  the  back  of  the  head,  and  the  pain  extends  into 
the  neck  and  back.  There  may  be  great  sensitiveness  along  the  spine,  and  in 
many  cases  there  is  general  hypersesthesia. 

The  psychical  s}TQptoms  are  pronounced.  Delirium  occurs  at  the  onset, 
occasionally  of  a  furious  and  maniacal  kind.    The  patient  may  display  at  the 


1 


CEREBROSPINAL  FEVER.  161 

start  marked  erotic  symptoms.  The  delirium  gives  place  in  a  few  days  to 
stupor,  which,  as  the  effusion  increases,  deepens  to  coma. 

The  temperature  is  irregular  and  variable.  Remissions  occur  frequently, 
and  there  is  no  uniform  or  typical  curve  during  the  disease.  In  some  instances 
there  has  been  little  or  no  fever.  In  others  the  temperature  may  reach  105° 
or  106°,  or,  before  death,  108°.  The  pulse  may  be  very  rapid  in  children; 
in  adults  it  is  at  first  usually  full  and  strong.  In  some  cases  it  is  remark- 
ably slow,  and  may  not  be  more  than  fifty  or  sixty  in  the  minute.  Sighing 
respirations  and  Cheyne-Stokes  breathing  are  met  with  in  some  instances. 
Unless  there  is  pneumonia  the  respirations  are  not  often  increased  in 
frequency. 

The  cutaneous  symptoms  of  the  disease  are  important.  Herpes  occurs  with 
a  frequency  almost  equal  to  that  in  pneumonia  or  intermittent  fever.  The 
petechial  rash,  which  has  given  the  name  spotted  fever  to  the  disease,  is  very 
variable.  Stille  states  that  of  98  cases  in  the  Philadelphia  Hospital,  no  erup- 
tion was  observed  in  37.  In  the  Montreal  cases  peteehise  and  purple  spots 
were  common.  They  appear  to  have  been  more  frequent  in  the  epidemics  on 
this  continent  than  in  Europe.  The  petechias  may  be  numerous  and  cover  the 
entire  skin.  An  erythema  or  dusky  mottling  may  be  present.  In  some  in- 
stances there  have  been  rose-colored  hypergemic  spots  like  the  typhoid  rash. 
Urticaria  or  erythema  nodosum,  ecthyma,  pemphigus,  and  in  rare  instances 
gangrene  of  the  skin  have  been  noted. 

Leucocytosis  is  an  early  and  constant  feature,  and  ranges  from  25,000  to 
40,000  per  cubic  millimetre.  It  persists  even  in  the  most  protracted  cases. 
In  one  of  our  cases  the  diplococcus  intracellularis  was  isolated  from  the  blood 
during  life. 

As  already  stated,  vomiting  may  be  a  special  feature  at  the  onset;  but,  as 
a  rule,  it  gradually  subsides.  In  some  instances,  however,  it  persists  and 
becomes  the  most  serious  and  distressing  of  the  symptoms.  Diarrhoea  is  not 
common.  The  bowels  are  usually  confined.  The  abdomen  is  not  tender.  In 
the  acute  form  the  spleen  is  usually  enlarged. 

The  urine  is  sometimes  albuminous  and  the  quantity  may  be  increased. 
Glycosuria  has  been  noted  in  some  instances,  and  in  the  malignant  types 
hgematuria. 

The  course  of  the  disease  is  extremely  variable.  Hirsch  rightly  states  that 
it  may  range  between  a  few  hours  and  several  months.  More  than  half  of  the 
deaths  occur  within  the  first  five  days.  In  favorable  cases,  after  the  symptoms 
have  persisted  for  five  or  six  days,  improvement  is  indicated  by  a  lessening  of 
the  spasm,  reduction  of  the  fever,  and  a  return  of  the  intelligence.  A  sudden 
fall  in  the  temperature  is  of  bad  omen.  Convalescence  is  extremely  tedious, 
and  may  be  interrupted  by  complications  and  sequelae  to  be  noted. 

3.  Anomalous  Forms. 

(a)  Atoriive  Type. — The  attack  sets  in  with  great  severity,  but  in  a  day 
or  two  the  symptoms  subside  and  convalescence  is  rapid.  Striimpell  would 
distinguish  between  this  abortive  variety,  which  begins  with  such  intensity, 
and  the  mild  ambulant  cases  described  by  certain  writers.  He  reports  a  case 
in  which  the  meningeal  symptoms  set  in  with  the  greatest  intensity  and  per- 
sisted for  four  days,  the  temperature  rising  to  105.6°  F.  On  the  fifth  day 
the  patient  entered  upon  a  rapid  and  satisfactory  convalescence.  In  the  mild 
12 


162  SPECIFIC  INFECTIOUS  DISEASES. 

cases,  as  distinguished  from  the  abortive,  the  patients  complain  of  headache,, 
nausea,  sensations  of  discomfort  in  the  back  and  limbs,  and  stiffness  in  the 
neck.  There  is  little  or  no  fever,  and  only  moderate  vomiting.  These  cases- 
could  be  recognized  only  during  the  prevalence  of  an  epidemic. 

(h)  An  Intermittent  Type  has  been  observed  in  many  epidemics,  and  is 
recognized  by  von  Ziemssen  and  Stille.  It  is  characterized  by  exacerbations, 
of  fever,  which  may  recur  daily  or  every  second  day,  or  follow  a  curve  of  an 
intermittent  or  remittent  character.  The  pyrexia  resembles  that  of  pyaemia 
rather  than  malaria. 

(c)  Chronic  Form. — Heubner  states  that  this  is  a  relatively  frequent 
form,  though  it  does  not  seem  to  be  recognized  by  many  writers  on  the  subject. 
An  attack  may  be  protracted  for  from  two  to  five  or  even  six  months,  and 
may  cause  the  most  intense  marasmus.  It  is  characterized  by  a  series  of  recur- 
rences of  the  fever,  and  may  present  the  most  complex  symptomatology.  It 
is  not  improbable  that  in  these  protracted  cases  chronic  hydrocephalus  or 
abscess  of  the  brain  is  present.  This  form  differs  distinctly  from  the  inter- 
mittent type.  Three  cases  in  our  series  were  of  this  chronic  form;  in  one 
the  disease  persisted  for  ninety  days. 

Complications. — Pleurisy,  pericarditis,  and  parotitis  are  not  uncommon. 

Pneumonia  is  described  as  frequent  in  certain  outbreaks.  Immermann 
found,  during  the  Erlangen  epidemic,  many  instances  of  the  combination  of 
pneumonia  with  meningitis,  but  it  does  not  seem  possible  to  determine  whether, 
in  such  cases>  pneumonia  is  the  primary  disease  and  the  meningitis  secohdary, 
or  vice  versa.  The  frequency  with  which  inflammation  of  the  meninges  of 
the  brain  complicates  pneumonia  is  well  known.  Councilman  suggests  that 
the  pneumonia  of  the  disease  is  not  the  true  croupous  form,  but  due  to  the 
diplococcus  meningitidis.  This  was  found  in  eight  of  the  Boston  cases,  and 
in  one  it  was  so  extensive  that  it  could  have  been  mistaken  for  the  ordinary 
croupous  pneumonia.  Cerebro-spinal  fever  sometimes  prevails  extensively  with 
ordinary  pneumonia,  as  in  ISTew  York  in  the  winter  of  1903-'04.  Arthritis 
has  been  the  most  frequent  complication  in  certain  epidemics.  Many  joints 
are  affected  simultaneously,  and  there  are  swelling,  pain,  and  exudation,  some- 
times serous,  sometimes  purulent.  This  was  first  observed  by  James  Jack- 
son, Sr.,  in  the  epidemic  which  he  described.    Enteritis  is  rare. 

Headache  may  persist  for  months  or  years  after  an  attack.  Chronic  hydro- 
cephalus occurs  in  certain  instances  in  children.  The  symptoms  of  this  are 
"  paroxysms  of  severe  headache,  pains  in  the  neck  and  extremities,  vomiting, 
loss  of  consciousness,  convulsions,  and  involuntary  discharges  of  f^ces  and 
urine"  (von  Ziemssen).  Mental  feebleness  and  aphasia  have  occasionally 
been  noted. 

Paralysis  of  individual  cranial  nerves  or  of  the  lower  extremities  may  per- 
sist for  some  time.  In  some  of  these  cases  there  may  be  peripheral  neuritis, 
as  Mills  suggested. 

Special  Senses. — Eye. — Optic  neuritis  may  follow  involvement  of  the  nerve 
in  the  exudation  at  the  base.  Acute  papillitis  was  found  in  6  out  of  40  cases 
examined  by  Eandolph.  The  inflammation  may  extend  directly  into  the  eye 
along  the  pia-arachnoid  of  the  optic  nerve,  causing  purulent  choroido-iritiB 
or  even  keratitis.  A  neuritis  of  the  fifth  nerve  may  be  followed  by  keratiti!5 
and  purulent  conjunctivitis. 


I 

I 


CEREBROSPINAL  FEVER.  163 

Ear. — Deafness  very  often  follows  inflammation  of  the  labyrinth.  Otitis 
media,  with  mastoiditis,  may  occur  from  direct  extension.  In  64  cases  of 
meningitis  which  recovered,  Moos  found  that  55  per  cent  were  deaf.  He  sug- 
gests that  the  abortive  form  of  the  disease  may  be  responsible  for  many  cases 
of  early  acquired  deafness.  In  children  this  not  infrequently  leads  to  deaf- 
mutism.  Von  Ziemssen  states  that  in  the  deaf  and  dumb  institutions  of  Bam- 
berg and  Nuremberg,  in  1874,  a  majority  of  the  pupils  had  become  deaf  from 
epidemic  cerebro-spinal  meningitis. 

Nose. — Coryza  is  not  infrequent  early  in  the  disease,  and  Striimpell  says 
that  in  many  of  his  cases  nasal  catarrh  preceded  the  meningitis.  He  suggests 
that  the  latter  may  be  caused  by  infection  from  the  nose.  Certainly  the  nasal 
secretion  appears  frequently  to  contain  the  diplococci — in  18  cases  examined  by 
Scherrer,  and  in  10  out  of  15  of  the  Boston  cases. 

Diagnosis. — Much  has  been  done  of  late  to  enable  the  practitioner  to 
recognize  definitely  the  existence  of  meningitis  and  of  the  various  forms. 

(a)  The  fever,  headache,  delirium,  retraction  of  the  neck,  tremor,  and 
rigidity  of  the  muscles  are  most  important  signs.  As  already  mentioned,  in 
the  meningitis  of  cerebro-spinal  fever  the  spinal  symptoms  are  very  much 
more  marked  than  in  the  other  forms.  One  has  constantly  to  bear  in  mind 
that  certain  cases  of  typhoid  fever  and  of  pneumonia  closely  simulate  cerebro- 
spinal meningitis.  Long  ago  Stokes  made  the  wise  observation  that  "  there  is 
no  single  nervous  symptom  which  may  not  and  does  not  occur  independently 
of  any  appreciable  lesion  of  the  brain,  nerves,  or  spinal  cord." 

(&)  Among  the  special  diagnostic  features  may  be  mentioned: 

Kernig's  Sign. — When  the  thigh  is  flexed  at  right  angles  to  the  abdomen, 
the  leg  can  be  extended  upon  the  thigh  nearly  in  a  straight  line.  If  menin- 
gitis be  present,  strong  contractures  of  the  flexors  prevent  the  full  extension 
of  the  leg  on  the  thigh. 

Lumbar  Puncture. — The  procedure  is  quite  harmless,  and  in  a  majority 
of  the  cases  can  be  done  without  general  anaesthesia,  with  the  aid  of  a  local 
freezing  mixture.  As  a  rule,  it  is  best  in  children  to  give  a  whiff  or  two  of 
chloroform.  The  patient  is  turned  on  the  right  side  with  the  back  bowed,  the 
knees  drawn  up,  and  the  left  shoulder  forward.  As  a  rule,  there  is  no  diffi- 
culty in  finding  the  spinal  processes,  and  with  the  thumb  or  index  finger  of 
the  left  hand  as  a  guide,  a  small  aspirator  needle  or  that  of  the  antitoxin 
syringe  is  inserted  to  one  side  of  the  median  line  and  thrust  deeply  into  the 
third  lumbar  interspace  in  an  upward  and  inward  direction.  At  a  variable 
distance,  according  to  the  age  and  musculature,  the  needle  enters  the  spinal 
canal — about  two  and  a  half  centimetres  in  infants  and  from  four  to  six  centi- 
metres in  adults. 

The  fluid  runs,  as  a  rule,  drop  by  drop,  and  when  meningitis  is  present 
it  is  usually  turbid,  sometimes  purulent,  occasionally  bloody.  Meningitis 
may  be  present  with  a  clear  fluid.  The  pressure  under  which  the  fluid 
flows  may  reach  250-300  mm.,  the  normal  being  about  120  mm.  Cover- 
glass  preparations  should  be  made  and  studied,  and  the  character  of  the 
organisms  carefully  noted.  The  cover-slip  preparations  may  give  the 
diagnosis  at  once.  In  acute  cases  of  cerebro-spinal  fever  the  organisms 
may  be  present  in  large  numbers.  There  is  rarely  any  difficulty  in  de- 
termining  between   the   pneumococcus    and    the   diplococcus    intracellularis. 


164  SPECIFIC  INFECTIOUS  DISEASES. 

Should  the  fluid  be  sterile  and  tuberculosis 'suspected;,  a  guinea-pig  may  be 
inoculated.  .  , 

Prognosis. — Hirsch  states  that  the'  mortality  has  ranged  in  various  epi- 
demics from  20  to  75  per  cent.  In  children  the  death-rate  is  much  higher 
than  in  adults. 

Treatment. — The  high  rate  of  mortality  which  has  existed  in  most  epi- 
demics indicates  the  fu.iility  of  the  various  therapeutical  agents  which  have 
been  recommended.  When  we  consider  the  nature  of  the  local  disease  and 
the  fact  that,  so  far  as  we  know,  tuberculous  and  other  secondary  forms  of 
cerebro-spinal  meningitis  are  invariably  fatal,  we  may  wonder  rather  that 
recovery  follows  in  any  case. 

In  strong  robust  patients  the  local  abstraction  of  blood  by  wet  cups  on 
the  nape  of  the  neck  relieves  the  pain.  General  bloodletting  is  rarely  indi- 
cated. Cold  to  the  head  and  spine,  which  was  used  in  the  first  epidemics  by 
New  England  physicians,  is  of  great  service.  A  bladder  of  ice  to  the  head, 
or  an  ice-cap,  and  the  spinal  ice-l^a^  may  be  continuously  employed.  The 
latter  is  very  beneficial.  Hydrotherapy  should  be  systematically  used,  in  the 
form  of  the  tub  bath,  at  98°,  as  recommended  by  Aufrecht.  Netter  speaks 
highly  of  its  good  effects,  and  we  have  alsovseen  it  do  good.  It  may  be  given 
every  third  hour.  If  any  counter-irritation  is  thought  necessary,  the  skin  of 
the  back  of  the  neck  may  be  lightly  touched  with  the  Paquelin  thermocautery. 
Blisters,  which  have  been  used,  so  much,  are  of  doubtful  benefit.  The  lumbar 
puncture  seems  helpful  in  cases  with  coma  or  convulsions,  and  in  any  case  it 
does  no  harm.  Of  internal  remedies  opium  may  be  given  freely,  best  as  mor- 
phia hypodermically.  Mercury  has  no  special  influence  on  meningeal  inflam- 
mation. Iodide  of  potassium  is  warmly  recommended  by  some  writers.  Quin- 
ine in  large  doses,  ergot,  belladonna  and  Calabar  bean  have  had  advocates. 
Bromide  of  potassium  may  be  employed  in  the  milder  cases,  but  it  is  not  so 
useful  as  morphia  to  control  the  spasms.  Intraspinal  injections  have  been 
tried,  and  in  one  of  our  cases  Cushing  opened  and  drained  the  spinal  canal. 
Diphtheria  antitoxin  has  been  used  with  success  in  the  recent  New  York 
epidemic. 

A  serum  has  been  prepared  and  has  been  used  with  encouraging  success. 
Flexner  recommends  doses  of  30  cc.  of  his  serum  to  be  injected  directly  into 
the  spinal  meninges  after  the  withdrawal  of  50  cc.  of  cerebro-spinal  fluid.  Of 
400  cases  thus  treated,  collected  by  Flexner  and  Jobling,  295  recovered. 

The  diet  should  be  nutritious,  consisting  of  milk  and  strong  broths  while 
the  fever  persists.  Many  cases  are  very  difficult  to  feed,  and  Heubner  recom- 
mends forced  alimentation  with  the  stomach-tube.  The  cases  seem  to  bear 
stimulants  well,  and  whisky  or  brandy  may  be  given  freely  when  there  are 
signs  of  a  failing  heart. 

XV.    LOBAR    PNEUMONIA. 

(Croupous  or  Fibrinous  Pneumonia ;  Pneumonitis ;  Lung  Fever.) 

Definition. — An  infectious  disease  characterized  by  inflammation  of  the 
lungs,  toxaemia  of  varying  intensity,  and  a  fever  that  usually  terminates  by 
crisis.  Secondary  infective  processes  are  common.  The  Micrococcus  lanceo- 
lafus  of  Fraenkel  is  present  in  a  large  proportion  of  the  cases. 


LOBAR  PNEUMONIA.  165 

History. — The  disease  was  known  to  Hippocrates  and  the  old  Greek  physi- 
cians, by  whom  it  was  confounded  with  pleurisy.  Among  the  ancients,  Are- 
tseus  gave  a  remarkable  description.  "  Euddy  in  countenance,  but  especially 
the  cheeks ;  the  white  of  the  eyes  very  bright  and  fatty ;  the  point  of  the  nose 
flat ;  the  veins  in  the  temples  and  neck  distended ;  loss  of  appetite ;  .pulse,  at 
first,  large,  empty,  very  frequent,  as  if  forcibly  accelerated ;  heat  indeed,  exter- 
nally, feeble,  and  more  humid  than  natural,  but,  internally,  dry  and  very  hot, 
by  means  of  which  the  breath  is  hot;  there  is  thirst,  dryness  of  the  tongue, 
desire  of  cold  air,  aberration  of  mind;  cough  mostly  dry,  but  if  anything  be 
brought  up  it  is  a  frothy  phlegm,  or  slightly  tinged  with  bile,  or  with  a  very 
florid  tinge  of  blood.  The  blood-stained  is  of  all  others  the  worst."  At  the 
end  of  the  seventeenth  and  the  beginning  of  the  eighteenth  century  Morgagni 
and  Valsalva  made  many  accurate  clinical  and  anatomical  observations  on  the 
disease.  Our  modern  knowledge  dates  from  Laennec  (1819),  whose  masterly 
description  of  the  physical  signs  and  morbid  anatomy  left  very  little  for  subse- 
quent observers  to  add  or  modify. 

Incidence. — One  of  the  most  wide-spread  and  fatal  of  all  acute  diseases, 
pneumonia  has  become  the  "  Captain  of  the  Men  of  Death,"  to  use  the  phrase 
applied  by  John  Bunyan  to  consumption.  In  England  and  Wales  in  1903 
there  were  40,725  deaths  from  this  cause;  13,308  were  attributed  to  lobar 
pneumonia,  17,435  to  broncho-pneumonia,  10  to  epidemic  pneumonia,  316 
to  septic  pneumonia,  while  19,869  were  registered  as  from  pneumonia  without 
further  qualification.  In  1903  there  were  36,536  deaths  from  all  forms  of 
pneumonia,  31,633  in  1901,  and  36,147  in  1900.  The  total  number  of  deaths 
rose  above  30,000  in  1890  and  1891  after  the  influenza,  and  fell  again  in  1894 
to  18,000  (Tatham).  The  United  States  Census  Keport  for  1900  gives  106.1 
deaths  from  pneumonia  per  1,000  deaths,  against  90.6  in  1890  and  83.30  in 
1880.  An  apparent  increase  is  noted  in  the  larger  cities,  particularly  N"ew 
York  and  Chicago.  In  Greater  New  York  in  1904,  out  of  a  total  of  43,700 
deaths,  there  were  8,360  deaths  from  pneumonia,  19.5  per  cent,  against  16.5 
per  cent  in  1903,  17  per  cent  in  1903,  16  per  cent  in  1901,  and  14.7  per  cent 
in  1898.  In  Chicago  for  the  year  1903,  out  of  a  total  of  38,914  deaths,  4,639, 
or  16  per  cent,  were  from  pneumonia,  an  increase  of  18  per  cent  since  the 
year  1900  (Eeynolds). 

Etiology. — Age. — To  the  sixth  year  the  predisposition  to  pneumonia  is 
marked;  it  diminishes  to  the  fifteenth  year,  but  then  for  each  subsequent 
decade  it  increases.  For  children  Holt's  statistics  of  500  cases  give:  First 
year,  15  per  cent;  from  the  second  to  the  sixth  year,  63  per  cent;  from  the 
seventh  to  the  eleventh  year,  31  per  cent;  from  the  twelfth  to  the  fourteenth 
year,  3  per  cent.  Lobar  pneumonia  has  been  met  with  in  the  new-born.  The 
relation  to  age  is  well  shown  in  the  last  U.  S.  Census  Eeport  for  1900.  The 
death-rate  in  persons  from  fifteen  to  forty-five  years  was  100.05  per  100,000 
of  population;  from  forty-five  to  sixty-five  years  it  was  363.13;  and  in  per- 
sons sixty-five  years  of  age  and  over  it  was  733.77.  Pneumonia  may  well 
be  called  the  friend  of  the  aged.  Taken  off  by  it  in  an  acute,  short,  not 
often  painful  illness,  the  old  man  escapes  those  "  cold  gradations  of  decay  " 
so  distressing  to  himself  and  to  his  friends. 

Sex. — Males  are  more  frequently  affected  than  females. 

Eace. — In  the  United  States  pneumonia  is  more  fatal  in  negroes  than 


166  SPECIFIC  INFECTIOUS  DISEASES. 

among  the  wMtes.  Among  the  former,  at  the  Johns  Hopkins  Hospital,  the 
mortality  was  rarely  under  30  per  cent,  against  an  average  of  about  25  per 
cent  in  the  latter. 

Social  Coxditiox. — The  disease  is  more  common  in  the  cities.  Individ- 
uals who  are  much  exposed  to  hardship  and  cold  are  particularly  liable  to  the 
disease.  N'ewcomers  and  immigrants  are  stated  to  be  less  susceptible  than 
native  inhabitants. 

Peesonal  Condition. — Debilitating  causes  of  all  sorts  render  individuals 
more  susceptible.  Alcoholism  is  perhaps  the  most  potent  predisposing  factor. 
Eobust,  healthy  men  are,  however,  often  attacked. 

Previous  Attack. — Xo  other  acute  disease  recurs  in  the  same  individual 
with  such  frequency.  Instances  are  on  record  of  individuals  who  have  had 
ten  or  more  attacks.  The  percentage  of  recurrences  has  been  placed  as  high 
as  50.  iNTetter  gives  it  as  31,  and  he  has  collected  the  statistics  of  eleven 
observers  who  place  the  percentage  at  26.8.  Among  the  highest  figures  for 
recurrences  are  those  of  Benjamin  Push,  28,  and  Andral,  16. 

Teauiia — Coxtusiox-pxeu:moxia. — Pneumonia  may  follow  directly  upon 
injury,  particularly  of  the  chest,  without  necessarily  any  lesion  of  the  lung. 
Litten  gives  4.-1  per  cent.  Stem  2.8  per  cent.  There  have  been  several  well- 
marked  cases  at  the  Jolms  Hopkins  Hospital.  Stern  describes  three  clini- 
cal varieties :  first,  the  ordinary  lobar  pneumonia  following  a  contusion  of  the 
chest  wall ;  secondly,  atypical  cases,  with  slight  fever  and  not  very  characteristic 
physical  signs ;  thirdly,  cases  with  the  physical  signs  and  features  of  broncho- 
pneumonia. The  last  two  varieties  have  a  favorable  prognosis.  According  to 
Ballard,  workers  in  certain  phosphate  factories,  where  they  breathe  a  very 
dusty  atmosphere,  are  particularly  prone  to  pneumonia. 

Cold  has  been  for  years  regarded  as  an  important  etiological  factor.  The 
frequent  occurrence  of  an  initial  chill  has  been  one  reason  for  this  wide-spread 
belief.  As  to  the  close  association  of  pneumonia  with  exposure  there  can  be 
no  question.  "We  see  the  disease  occur  either  promptly  after  a  wetting  or  a 
chilling  due  to  some  unusual  exposure,  or  come  on  after  an  ordinary  catarrh 
of  one  or  two  day's  duration.  Cold  is  now  regarded  simply  as  a  factor  in  low- 
ering the  resistance  of  the  bronchial  and  pulmonary  tissues. 

Cli:^iate  axd  Seasox. — Climate  does  not  appear  to  have  very  much  iaflu- 
ence,  as  pneumonia  prevails  equally  in  hot  and  cold  countries.  It  is  stated  to 
be  more  prevalent  ia  the  Southern  than  in  the  ISTorthem  States,  but  an  exam- 
ination of  the  Census  Eeports  shows  that  there  is  very  little  difference  in  the 
various  state  groups. 

Much  more  important  is  the  influence  of  season.  Statistics  are  almost 
unanimous  in  placing  the  highest  incidence  of  the  disease  in  the  winter  and 
spring  months.  In  ]\Iontreal,  January,  the  coldest  month  of  the  year,  but 
with  steady  temperature,  has  usually  a  comparatively  low  death-rate  from 
pneumonia.  The  large  statistics  of  Seitz  from  Munich  and  of  Seibert  of  New 
York  give  the  highest  percentage  in  February  and  March. 

Bacteriology  of  Acute  Lobar  Pneumonia. — (a)  Miceococcus  lanceola- 

TUS,  PXEUMOCOCCUS  OR  DiPLOCOCCUS  PXEUMOXI^  OF  FeAEXKEL  AND  WeICH- 

SELBAmi. — In  September,  1880,  Sternberg  inoculated  rabbits  with  his  own 
saliva  and  isolated  a  micrococcus.  The  publication  was  not  made  until  April, 
1881.     Pasteur  discovered  the  same  organism  ia  the  saliva  of  a  child  dead 


LOBAR  PNEUMONIA.  167 

of  hydrophobia  in  December,  1880,  and  the  priority  of  the  discovery  belongs 
to  him,  as  his  publication  is  dated  January,  1881.  There  was,  however,  no 
susoicion  that  this  organism  was  concerned  in  the  etiology  of  lobar  pneu- 
monia, and  it  was  not  really  until  April,  1884,  that  Fraenkel  determined  that 
the  organism  found  by  Sternberg  and  Pasteur  in  the  saliva,  and  known  as  the 
coccus  of  sputum  septicaemia,  was  the  most  frequent  germ  in  pneumonia. 

The  organism  is  a  somewhat  elliptical,  lance-shaped  coccus,  usually  occur- 
ring in  pairs ;  hence  the  term  diplococcus.  It  is  readily  demonstrated  in  cover- 
glass  preparations  with  the  usual  dyes  and  by  the  Gram  method.  About  the 
organism  in  the  sputum  a  capsule  can  always  be  demonstrated.  Its  cultural 
and  biological  properties  present  many  variations,  for  a  consideration  of  which 
the  student  is  referred  to  the  text-books  on  bacteriology.  Scarcely  any  pecul- 
iarity is  constant.  A  large  number  of  varieties  have  been  cultivated.  Its 
kinship  to  Streptococcus  pyogenes  is  regarded  by  many  as  very  close,  but  the 
alkaline  serum-water  medium,  containing  inulin,  recommended  by  His,  serves 
to  distinguish  the  pneumococcus  from  the  streptococcus. 

Distribution  in  the  Body. — In  the  bronchial  secretions  and  in  the  affected 
lung  the  pneumococcus  is  readily  demonstrated  in  smears,  and  in  the  latter 
in  sections.  By  using  large  quantities  of  blood  (3  to  6  cc.)  diluted  over 
twelve  times  with  a  liquid  culture  medium,  preferably  broth,  Kinsey  was  able 
to  isolate  the  pneumococcus  from  the  blood  during  life  in  19  of  25  cases, 

(&)  Pneumococcus  Under  Othee  Conditions. — (1)  In  the  Mouth. — 
The  studies  of  the  Kew  York  Pneumonia  Commission  have  shown  that  the 
pneumococcus  is  present  in  the  mouths  of  a  large  proportion  of  healthy  indi- 
viduals, the  various  observers  giving  80  to  90  per  cent  of  positive  results. 
The  virulence  is  not  always  uniform,  and  Langcope  and  Fox  were  able  to  show 
that  the  saliva  of  the  same  individual  increased  in  virulence  during  the  winter 
months.  Some  persons  always  harbor  a  virulent  variety.  Buerger  at  the  Mt. 
Sinai  Hospital  studied  the  communicability  of  the  organism  from  one  person 
to  another,  and  it  was  found  repeatedly  that  normal  individuals — i.  e.,  per- 
sons in  whose  mouths  the  pneumococcus  was  proved  by  repeated  examinations 
to  be  absent — acquired  the  organisms  by  association  with  cases  of  pneumonia, 
or  with  healthy  persons  in  whose  saliva  pneumococci  were  present. 

(2)  Outside  the  Body. — The  viability  of  the  pneumococcus  is  not  great. 
It  has  been  found  occasionally  in  the  dust  and  sweepings  of  rooms,  but  Wood 
has  shown  (New  York  Commission  Eeport)  that  the  germs  exposed  to  sun- 
light die  in  a  very  short  time — an  hour  and  a  half  being  the  limit.  In  moist 
sputum  kept  in  a  dark  room  the  germs  lived  ten  days,  and  in  a  badly  ven- 
tilated room  in  which  a  person  with  pneumonia  coughed,  the  germs  suspended 
in  the  air  retained  their  vitality  for  several  hours. 

(3)  The  Pneumococcus  in  Other  Diseases. — ^The  organism  is  very  widely 
distributed,  and  occurs  in  many  conditions  other  than  croupous  pneumonia. 
An  acute  septiccemia  without  local  lesion  may  occur,  resembling  the  typhoid 
septicaemia,  already  described.  In  a  case  reported  by  Townsend,  a  girl,  aged  six, 
had  pain  in  the  abdomen,  vomiting,  and  a  temperature  of  104.2°.  There 
was  no  exudate  in  the  throat.  She  died  thirty  hours  after  the  onset  of  the 
symptoms.  There  was  found  a  general  infection  with  the  pneumococcus  in 
blood,  lungs,  spleen,  and  kidneys.  As  Eosenau  has  shown,  a  bacteriasmia  may 
precede  the  development  of  the  local  lesion  in  the  lungs.     In  terminal  infec- 


168  SPECIFIC  INFECTIOUS  DISEASES. 

tions  the  pneiunococcus  plays  an  important  role.  Flexner  found  it  four  times 
in  acute  peritonitis,  eleven  times  in  acute  pericarditis,  five  times  in  acute  endo- 
carditis, and  three  times  both  in  pleurisy  and  in  acute  meningitis. 

The  germ  has  been  associated  with  wide-spread  epidemics  of  catarrh  of 
the  upper  air  passages,  pneumococcus  catarrh,  almost  like  influenza,  and  some- 
times with  gastro-intestinal  disturbances. 

An  extraordinary  number  of  local  affections  are  due  to  the  pneumococcus. 
It  is  a  common  cause  of  the  primary  and  secondary  hronclio-pneumonias. 
Infection  of  the  accessory  nasal  sinuses  is  most  important.  Darling  found 
them  involved  in  93  per  cent  of  all  pneumococcus  infections  coming  to  autopsy 
at  Panama.  Meningitis  may  be  associated  with  pneumonia  or  endocarditis, 
but  the  so-called  primary  pneumococcus  meningitis  is  almost  always  secondary 
to  sinus  infection,  90  per  cent  in  25  cases  (Darling).  Pericarditis,  endocar- 
ditis, empyema,  peritonitis,  arteritis,  conjunctivitis,  otitis  may  be  primary 
infections  with  this  ubiquitous  germ. 

(c)  Bacillus  pneumoxi^  of  Feiedlaxdee. — This  is  a  larger  organism 
than  the  pneumococcus,  and  appears  in  the  form  of  plump,  short  rods.  It  also 
shows  a  capsule,  but  presents  marked  biological  and  cultural  differences  from 
Fraenkel's  pneumococcus.  It  occurred  in  9  of  Weichselbaum's  129  cases.  It 
may  cause  broncho-pneumonia  and  other  affections,  but  probably  is  not  a 
cause  of  genuine  lobar  pneumonia.  The  exudate  in  pneumonias  caused  by 
this  bacillus  is  usually  more  viscid  and  pnnrpr  in  fibrin  than  tbat  in  dipla- 
coccus  pneumonias. 

(fZ)  Other  Organisms. — Various  bacteria  ma}^  be  associated  with  the 
pneumococcus  in  lobar  pneumonia,  the  most  common  of  these  being  Strep- 
tococcus pyogenes,  the  pyogenic  staphylococci,  and  Friedlander's  pneumo- 
bacillus;  but  while  these  latter  may  cause  broncho-pneumonias,  the)''  have 
not  been  satisfactorily  demonstrated  to  be  other  than  secondary  invaders 
in  lobar  pneumonia.  Likewise  the  pneumonias  caused  by  Bacillus  typhosus,. 
Bacillus  diphtherice,  and  the  influenza  bacillus  are  not  to  be  identified  with 
true  lobar  pneumonia. 

Clinically,  the  infectious  nature  of  pneumonia  was  recognized  long  before 
we  knew  anything  of  the  pneumococcus.  Among  the  features  which  favored 
this  view  were  the  following:  First,  the  disease  is  similar  to  other  infections 
in  its  mode  of  outbreak.  It  may  occur  in  endemic  form,  localized  in  certain 
houses,  in  barracks,  jails,  and  schools.  As  many  as  ten  occupants  of  one  house 
have  been  attacked.  I  have  seen  three  members  of  a  family  consecutively 
attacked  with  a  most  malignant  t}^pe  of  pneumonia.  Among  the  more  remark- 
able endemic  outbreaks  is  that  reported  by  W.  B.  Eodman,  of  Frankfort,  Ky. 
In  a  prison  with  a  population  of  735  there  occurred  in  one  year  118  cases  of 
pneumonia  with  25  deaths.  The  disease  may  assume  epidemic  proportions.  In 
the  Middlesborough  epidemic,  so  carefully  studied  by  Ballard,  there  were  682 
persons  attacked,  with  a  mortality  of  21  per  cent.  During  some  years  pneu- 
monia is  so  prevalent  that  it  is  practically  pandemic.  Direct  contagion  is 
suggested  by  the  fact  that  a  patient  in  the  next  bed  to  a  pneumonia  case  may 
take  th£^3ispasp,  or  !<3.fir_3  cases  may  follow  in  rapid  succession  m  a  ward.  iF 
is  very  exceptional,  however,  for  nurses  or  doctors  to  be  attacked. 

Secondly,  as  inother  acute  infections,  the  constitutional  symptoms  may 
bear^no_gro£ortion  whatever_to_the  severity  of  the  local  lesion.     As  is^  well 


LOBAR  PNEUMONIA.  169 

known,  a  patient  may  have  a  very  small  apex  pneumonia  which  does  not  seri- 
"on8ly~inrpair  the  breathing  capacity,  but  which  may  be  accompanied  with  the, 

most  intensetoxic  features,; 

■  Thirdly,  the"  clinical  course  of  the  disease  is  that  of  an  acute  infection. 
It  is  the  very  type  of  a  self -limited  disease,  running  a  definite  cycle  in  a 
way  seen  only  in  infectious  disorders. 

Conditions  Favoring  Infection. — Some  have  already  been  referred  to,  but 
of  many  we  are  still  ignorant.  The  one  all-important  fact,  emphasized  by 
the  work  of  the  New  York  Commission,  is  that  a  majority  of  us  harbor  the 
germ  in  mouth  or  nose  or  throat.  It  has  been  shown  that  the  virulence  varies 
at  different  periods,  and  with  this  may  be  associated  the  well-known  seasonal 
prevalence  of  the  disease.  Some  individuals  are  less  resistant,  and  in  no 
other  acute  disease  may  so  many  successive  attacks  occur  in  the  same  person. 
It  is  notorious  that  the  negro  race  in  the  United  States,  in  Panama,  and  in 
South  Africa  shows  an  extreme  susceptibility ;  on  the  other  hand,  the  Chinese 
in  the  South  African  compounds  show  an  extraordinary  resistance  to  the 
disease  (Porter).  Probably  for  each  one  of  us  it  is  a  battle  between  the 
degree  of  resistance  and  the  virulence  of  the  organism  which  we  harbor.  A 
catarrh  of  the  upper  air  passages,  exposure,  alcoholism,  etc.,  weaken  the 
defences,  and  give  the  ever-present  enemy  a  chance,  either  for  a  frontal  attack 
in  the  lungs,  in  an  acute  pneumonia,  or  to  make  a  flanking  assault,  on  some 
unprotected  region,  causing  a  peritonitis,  otitis,  sinusitis,  etc. 

Immunity  and  Serum  Therapy. — The  pneumococcus  does  not  produce  in 
artificial  cultures  any  strong,  soluble  toxin  analogous  to  the  diphtheria  toxin 
or  the  tetanus  toxin,  but  its  poison  is  contained  within  the  bacterial  cells, 
from  which  it  may  be  extracted  in  various  ways,  or  it  may  be  set  free  from 
the  dead  or  degenerated  cocci.  The  possibility  that  the  pneumococcus  may 
secrete  a  soluble  toxin  in  the  infected  human  or  animal  body  may  be  admitted, 
but  of  this  there  is  no  conclusive  demonstration.  By  the  use  of  living  or 
dead  pneumococci  or  their  extracts,  animals  may  be  vaccinated  against  this 
organism,  so  that  their  blood-serum  is  capable  of  protecting  susceptible  ani- 
mals against  many  times  the  minimal  fatal  dose  of  the  virulent  pneumococcus. 
Strong  protective  serum  has  thus  been  obtained  from  rabbits,  horses,  asses, 
cows,  and  other  animals  subjected  to  repeated  inoculations  with  dead  and  liv- 
ing cultures  of  the  pneumococcus.  This  specific  serum  is  neither  antitoxic 
nor  bactericidal.  Metchnikoft'  believes  that  it  acts  by  stimulating  the  leuco- 
cytes to  ingest  and  destroy  the  pneumococci,  but  A.  E.  Wright  and  Douglas 
have  shown  that  the  protective  constituent,  which  they  call  an  opsonin,  enters 
into  chemical  combination  with  the  cocci,  rendering  them  thereby  more  read- 
ily engulfed  and  digested  by  the  phagocytes.  Neufeld  and  Rimpau  have 
reached  a  similar  conclusion  as  to  the  mode  of  action  of  this  immune  serum. 
M.  Wassermann  fmds  that  the  specific  protective  substances  are  formed  in 
the  bone-marrow,  and  thence  distributed  to  the  blood.  There  is  evidence  that 
similar  specific  substances  are  produced  in  human  beings  infected  with  this 
organism,  and  the  crisis  of  pneumonia  is  explained  by  the  formation  and  accu- 
mulation of  these  substances  in  the  body. 

Many  trials  have  been  made  of  the  curative  value  of  antipneumococcic 
serum  in  the  treatment  of  pneumonia,  the  serum  made  by  Pane  having  been 
most  extensively  employed.    Thus  far  it  has  not  been  shown  that  this  serum 


170  SPECIFIC  INFECTIOUS  DISEASES. 

influences  in  any  marked  degree  the  course  of  the  disease  in  man.  Passler 
claims  to  have  observed  favorable  results  from  the  use  of  a  polyvalent  serum 
prepared  according  to  a  method  devised  by  Eomer,  and  he  advocates  its 
emplo3'ment  especially  in  patients  with  symptoms  of  severe  infection. 

Morbid  Anatomy. — Since  the  time  of  Laennec,  pathologists  have  recog- 
nized three  stages  in  the  inflamed  lung:  engorgement,  red  hepatization^  and 
gray  hepatization. 

In  the  stage  of  engorgement  the  lung  tissue  is  deep  red  in  color,  flrmer 
to  the  touch,  and  more  solid,  and  on  section  the  surface  is  bathed  with 
blood  and  serum.  It  still  crepitates,  though  not  so  distinctly  as  healthy  lung, 
and  excised  portions  float.  The  air-cells  can  be  dilated  by  insufflation  from 
the  bronchus.  The  capillary  vessels  are  greatly  distended,  the  alveolar  epi- 
thelium swollen,  and  the  air-cells  occupied  by  a  variable  number  of  blood- 
corpuscles  and  detached  alveolar  cells.  In  the  stage  of  red  hepatization  the 
lung  tissue  is  solid,  firm,  and  airless.  If  the  entire  lobe  is  involved  it  looks 
voluminous,  and  shows  indentations  of  the  ribs.  On  section,  the  surface  is 
dry,  reddish-brown  in  color,  and  has  lost  the  deeply  congested  appearance 
of  the  first  stage.  One  of  the  most  remarkable  features  is  the  friability;  in 
striking  contrast  to  the  healthy  lung,  which  is  torn  with  difficulty.  The  sur- 
face has  a  granular  appearance  due  to  the  fibrinous  plugs  filling  the  air-cells. 
The  distinctness  of  this  appearance  varies  greatly  "with  the  size  of  the  alveoli, 
which  are  about  0.10  mm.  in  diameter  in  the  infant,  0.15  or  0.16  in  the  adult, 
and  from  0.20  to  0.25  in  old  age.  On  scraping  the  surface  with  a  knife  a 
reddish  viscid  serum  is  removed,  containing  small  granular  masses.  The 
smaller  bronchi  often  contain  fibrinous  plugs.  If  the  limg  has  been  removed 
before  the  heart,  it  is  not  uncommon  to  find  solid  moulds  of  clot  filling  the 
blood-vessels.  Microscopically,  the  air-cells  are  seen  to  be  occupied  by  coagu- 
lated fibrin  in  the  meshes  of  which  are  red  blood-corpuscles,  mononuclear  and 
pohmuclear  leucocytes,  and  alveolar  epithelium.  The  alveolar  walls  are  infil- 
trated and  leucocytes  are  seen  in  the  interlobular  tissues.  Cover-glass  prepa- 
rations from  the  exudate,  and  thin  sections  show,  as  a  rule,  the  diplococci 
already  referred  to,  many  of  which  are  contained  within  cells.  Staphylococci 
and  streptococci  may  also  be  seen  in  some  cases.  In  the  stage  of  gray  hepatiza- 
tion the  tissue  has  changed  from  a  reddish-brown  to  a  grayish-white  color. 
The  surface  is  moister,  the  exudate  obtained  on  scraping  is  more  turbid,  the 
granules  in  the  acini  are  less  distinct,  and  the  lung  tissue  is  still  more  friable. 
The  air-cells  are  densely  filled  with  leucoc}i:es,  the  fibrin  network  and  the 
red  blood-corpuscles  have  largely  disappeared.  A  more  advanced  condition 
of  gray  hepatization  is  that  known  as  purulent  infiltration,  in  which  the  lung 
tissue  is  softer  and  bathed  with  a  purulent  fluid.  Small  abscess  cavities  may 
form,  and  by  their  fusion  larger  ones,  though  this  is  a  rare  event  in  ordinary 
pneumonia. 

Resolution. — The  changes  in  the  exudate  which  lead  to  its  resolution  are 
due  to  an  autolytic  digestion  by  proteohi:ic  enz}Tnes  which  are  present  much 
more  abundantly  in  gray  hepatization  than  in  the  preceding  stage.  The  dis- 
solved exudate  is  for  the  most  part  excreted  by  the  kidneys.  By  following  the 
nitrogen  excess  in  the  urine  the  progress  of  resolution  may  be  followed  and 
even  an  estimate  formed  of  the  amount  of  the  exudate  thus  eliminated.  In 
a  study  from  my  clinic  H.  W.  Cook  found  in  cases  of  delayed  resolution  that 


LOBAR  PNEUMONIA.  171 

the  nitrogen  excess  in  the  urine  (which  persisted  until  the  lung  was  clear) 
was  very  large,  and  he  suggests  that  delayed  resolution  may  really  be  a  matter 
of  continued  exudation. 

General  Details  of  the  Morbid  Anatomy. — In  100  autopsies,  made  by  me 
at  the  General  Hospital,  Montreal,  in  51  cases  the  right  lung  was  affected,  in 
32  the  left,  in  17  both  organs.  In  27  cases  the  entire  lung,  with  the  excep- 
tion, perhaps,  of  a  narrow  margin  at  the  apex  and  anterior  border,  was  con- 
solidated. In  34  cases,  the  lower  lobe  alone  was  involved;  in  13  cases,  the 
upper  lobe  alone.  When  double,  the  lower  lobes  were  usually  affected  together, 
but  in  three  instances  the  lower  lobe  of  one  and  the  upper  lobe  of  the  other 
were  attacked.  In  3  cases,  also,  both  upper  lobes  were  affected.  Occasion- 
ally the  disease  involves  the  greater  part  of  both  lungs;  thus,  in  one  instance 
the  left  organ  with  the  exception  of  the  anterior  border  was  uniformly  hepa- 
tized,  while  the  right  was  in  the  stage  of  gray  hepatization,  except  a  still 
smaller  portion  in  the  corresponding  region.  In  a  third  of  the  cases,  red  and 
gray  hepatization  existed  together.  In  22  instances  there  was  gray  hepatiza- 
tion. As  a  rule  the  unaffected  portion  of  the  lung  is  congested  or  oedematous. 
When  the  greater  portion  of  a  lobe  is  attacked,  the  uninvolved  part  may  be  in 
a  state  of  almost  gelatinous  oedema.  The  unaffected  lung  is  usually  congested, 
particularly  at  the  posterior  part.  This,  it  must  be  remembered,  may  be 
largely  due  to  post-mortem  subsidence.  The  uninflamed  portions  are  not 
always  congested  and  oedematous.  The  upper  lobe  may  be  dry  and  bloodless 
when  the  lower  lobe  is  uniformly  consolidated.  The  average  weight  of  a 
normal  lung  is  about  600  grammes,  while  that  of  an  inflamed  organ  may  be 
1.500,  2,000,  or  jeven  2,500  grammes. 

The  bronchi  contain,  as  a  rule,  at  the  time  of  death  a  frothy  serous  fluid, 
rarely  the  tenacious  mucus  so  characteristic  of  pneumonic  sputum.  The 
mucous  membrane  is  usually  reddened,  rarely  swollen.  In  the  affected  areas 
the  smaller  bronchi  often  contain  fibrinous  plugs,  which  may  extend  into  the 
larger  tubes,  forming  perfect  casts.  The  bronchial  glands  are  swollen  and 
may  even  be  soft  and  pulpy.  The  pleural  surface  of  the  inflamed  lung  is 
invariably  involved  when  the  process  becomes  superficial.  Commonly,  there 
is  only  a  thin  sheeting  of  exudate,  producing  slight  turbidity  of  the  mem- 
brane. In  only  two  of  the  hundred  instances  the  pleura  was  not  involved. 
In  some  cases  the  fibrinous  exudate  may  form  a  creamy  layer  an  inch  in  thick- 
ness.    A  serous  exudation  of  variable  amount  is  not  uncommon. 

Lesions  in  Other  Organs. — The  heart,  particularly  its  right  chamber,  is  dis- 
tended with  firm,  tenacious  coagula,  which  can  be  withdravm  from  the  vessels 
as  dendritic  moulds.  In  no  other  acute  disease  do  we  meet  with  coagula  of 
such  solidity.  The  spleen  is  often  enlarged,  though  in  only  35  of  the  100 
cases  was  the  weight  above  200  grammes.  The  kidneys  show  parenchymatous 
swelling,  turbidity  of  the  cortex,  and,  in  a  very  considerable  proportion  of  the 
cases — 25  per  cent — chronic  interstitial  changes. 

Pericarditis  is  not  infrequent,  and  occurs  more  particularly  with  pneu- 
monia of  the  left  side  and  with  double  pneumonia.  In  5  of  the  100  autop- 
sies it  was  present,  and  in  4  of  them  the  lappet  of  lung  overlying  the  peri- 
cardium with  its  pleura  was  involved.  Endocarditis  is  more  frequent  and 
occurred  in  16  of  the  100  cases.  In  5  of  these  the  endocarditis  was  of  the 
simple  character;  in  11  the  lesions  were  ulcerative.     Of  209  cases  of  malig- 


172  SPECIFIC  INFECTIOUS  DISEASES. 

nant  endocarditis  Avhich  I  collected  from  the  literature,  54  occurred  in  pneu- 
monia. Kanthack  found  an  antecedent  pneumonia  in  14.2  per  cent  of  cases 
of  infective  endocarditis.  In  the  recent  figures  collected  by  E.  F.  Wells,  of 
517  fatal  cases  of  acute  endocarditis,  22,3  per  cent  were  in  pneumonia.  It  is 
more  common  on  the  left  than  on  the  right  side  of  the  heart.  Of  61  of  a 
series  of  107  cases  of  endocarditis  in  Professor  Welch's  laboratory  in  which 
cultures  were  made,  pneumococci  were  found  in  21.  In  7  of  the  cases  there 
was  a  general  pneumoeoccic  infection.  Myocarditis  and  fatty  degeneration  of 
the  heart  may  be  present  in  protracted  cases. 

Meningitis,  which  is  not  infrequent,  may  be  associated  with  malignant 
endocarditis.  It  was  present  in  8  of  the  100  autopsies.  Of  20  cases  of  menin- 
gitis in  ulcerative  endocarditis  15  occurred  in  pneumonia.  The  meningitis  is 
usually  of  the  convex. 

Croupous  or  diphtheritic  inflammation  may  occur  in  other  parts.  A  croup- 
ous colitis,  as  pointed  out  by  Bristowe,  is  not  very  uncommon.  It  occurred 
in  5  of  my  100  post  mortems.  It  is  usually  a  thin,  flaky  exudation,  most 
marked  on  the  tops  of  the  folds  of  the  mucous  membrane.  In  one  case  there 
was  a  patch  of  croupous  gastritis,  covering  an  area  2  by  8  cm.,  situated  to  the 
left  of  the  cardiac  orifice. 

The  liver  shows  parenchymatous  changes,  and  often  extreme  engorgement 
of  the  hepatic  veins. 

Symptoms. — Course  of  the  Disease  in  Typical  Cases. — We  know  but 
little  of  the  incubation  period  in  lobar  pneumonia.  It  is  probably  very  short. 
There  are  sometimes  slight  catarrhal  symptoms  for  a  day  or  two.  As  a  rule, 
the  disease  sets  in  jhruptly  with  a  severe  chill,  which  lasts  from  fifteen  to 
thirty  minutes  or  longer!  In  no  acute  disease  is  an  initial  chill  so  constant 
or  so  severe.  The  patient  may  be  taken  abruptly  in  the  midst  of  his  work,  or 
may  awaken  out  of  a  sound  sleep  in  a  rigor.  The  temperature  taken  during 
the  chill  shows  that  the  fever  has  already  begun.  If  seen  shortly  after  the 
onset,  the  patient  has  usually  features  of  an  acute  fever,  and  complains  of 
headache  and  general  pains.  Within  a  few  hours  there  is  pain  in  the  side, 
often  of  an  agonizing  character;  a  short,  dry,  painful  cough  begins,  and  the 
respirations  are  increased  in  frequency.  Wlien  seen  on  the  second  or  third 
day,  the  picture  in  typical  pneumonia  is  more  distinctive  than  that  presented 
by  any  other  acute  disease.  The  patient  lies  flat  in  bed,  often  on  the  affected 
side;  the  face  is  flushed,  particularly  one  or  both  cheeks;  the  breathing  is 
hurried,  accompanied  often  with  a  short  expiratory  grunt;  the  alae  nasi  dilate 
with  each  inspiration ;  herpes  is  usually  present  on  the  lips  or  nose ;  the  eyes 
are  bright,  the  expression  is  anxious,  and  there  is  a  frequent  short  cough 
which  makes  the  patient  wince  and  hold  his  side.  The  expectoration  is 
blood-tinged  and  extremely  tenacious.  The  temperature  may  be  104°  or 
105°.  The  pulse  is  full  and  bounding  and  the  pulse-respiration  ratio  much 
disturbed.  Examination  of  the  lungs  shows  the  physical  signs  of  consolida- 
tion— ^blowing  breathing  and  fine  rales.  After  persisting  for  from  seven  to 
ten  days  the  crisis  occurs,  and  with  a  fall  in  the  temperature  the  patient  passes 
from  the  condition  of  extreme  distress  and  anxiety  to  one  of  comparative 
comfort. 

Special  Features. — The  fever  rises  rapidly,  and  the  height  may  be  104°  or 
105°  within  twelve  hours.     Having  reached  the  fastigium,  it  is  remarkably 


LOBAR   PNEUMONIA. 


173 


constant.     Often  the  tAvo-hour  temperature  chart  will  not  show  for  two  days 
more  than  a  degree  of  variation.    In  children  and  in  cases  without  chill  the 

Jan.   10  H  i2  i3  li  is  16  17  IS  10 


Beep. 


Euke 
190 


Temp, 
109 


96 
Temp. 


Reap, 
Stools 


Urine 
)ay  of 


BLACK,   TEMPERATURE  J  RED,    PULSE  J  BLUE,    RESPIRATiON. 

Chart  X. — Fever,  Pulse,  and  Respiration  in  Lobar  Pneumonia. 

rise  is  more  gradual.  In  old  persons  and  in  drunkards  the  temperature  range 
is  lower  than  in  children  and  in  healthy  individuals ;  indeed,  one  occasionally 
meets  with  an  afebrile  pneumonia. 


174  SPECIFIC  INFECTIOUS  DISEASES. 

The  Ceisis. — After  the  fever  has  persisted  for  from  five  to  nine  or  ten 
days  there  is  an  abrupt  drop,  known  as  the  crisis,  which  is  one  of  the  most 
characteristic  features  of  the  disease.  The  day  of  the  crisis  is  variable.  It 
is  very  uncommon  before  the  third  day,  and  rare  after  the  twelfth.  I  have 
seen  it  as  early  as  the  third  day.  From  the  time  of  Hippocrates  it  has  been 
thought  to  be  more  frequent  on  the  uneven  days,  particularly  the  fifth  and 
seventh.  A  precritical  rise  of  a  degree  or  two  may  occur.  In  one  case  the 
temperature  rose  from  105°  to  nearly  107°,  and  then  in  a  few  hours  fell  to 
normal.  ISTot  even  after  the  chill  in  malarial  fever  do  we  see  such  a  prompt 
and  rapid  drop  in  the  temperature.  The  usual  time  is  from  five  to  twelve 
hours,  but  often  in  an  hour  there  ma}^  occur  a  fall  of  sis  or  eight  degrees 
(S.  West).  The  temperature  may  be  subnormal  after  the  crisis,  as  low  as 
96°  or  97°.  Usually  there  is  an  abundant  sweat,  and  the  patient  sinks  into 
a  comfortable  sleep.  The  day  after  the  crisis  there  may  be  a  slight  post-critical 
rise.  A  pseudo-crisis  is  not  very  uncommon,  in  which  on  the  fifth  or  sixth 
day  the  temperature  drops  from  104°  or  105°  to  102°,  and  then  rises  again. 
When  the  fall  takes  place  gradually  witliin  twenty-four  hours  it  is  called  a 
protracted  crisis.  If  the  fever  persists  beyond  the  twelfth  day,  the  fall  is 
likely  to  be  by  lysis.  In  children  this  mode  of  termination  is  common,  and 
occurred  in  one-third  of  a  series  of  183  cases  reported  by  Morrill.  Occasion- 
ally in  debilitated  individuals  the  temperature  drops  rapidly  just  before  death; 
more  frequently  there  is  an  ante-mortem  elevation.  In  cases  of  delayed  reso- 
lution the  fever  may  persist  for  six  or  eight  weeks.  The  crisis  is  the  most 
remarkable  single  phenomenon  of  pneumonia.  With  the  fall  in  the  fever  the 
respirations  become  reduced  almost  to  normal,  the  pulse  slows,  and  the  patient 
passes  from  perhaps  a  state  of  extreme  hazard  and  distress  to  one  of  safety 
and  comfort,  and  yet,  so  far  as  the  physical  examination  indicates,  there  is 
with  the  crisis  no  special  change  in  the  local  condition  in  the  lung. 

Pain. — There  is  early  a  sharp,  agonizing  pain,  generally  referred  to  the 
region  of  the  nipple  or  lower  axilla  of  the  affected  side,  and  much  aggravated 
on  deep  inspiration  and  on  coughing.  It  is  associated,  as  Aretaus  remarks, 
with  involvement  of  the  pleura.  It  is  absent  in  central  pneumonia,  and  much 
less  frequent  in  apex  pneumonia.  The  pain  may  be  severe  enough  to  require 
a  hypodermic  injection  of  morphia.  As  has  been  recognized  for  many 
years,  the  pain  may  be  altogether  abdominal,  either  central  or  in  the  right 
iliac  fossa,  suggesting  appendicitis.  Crozer  Griffith,  calling  attention  to  the 
frequency  of  the  simulation  in  children,  reports  8  cases,  and  has  collected 
34  cases  from  the  literature,  many  in  adults.  The  operation  for  appendicitis 
has  been  performed. 

Dyspnoea  is  an  almost  constant  feature.  Even  early  in  the  disease  the  res- 
pirations may  be  30  in  the  minute,  and  on  the  second  or  third  day  between 
40  and  50.  The  movements  are  shallow,  evidently  restrained,  and  if  the 
patient  is  asked  to  draw  a  deep  breath  he  cries  out  with  the  pain.  Expiration 
is  frequently  interrupted  by  an  audible  grunt.  At  first  with  the  increased 
respiration  there  may  be  no  sensation  of  distress.  Later  this  may  be  present 
in  a  marked  degree.  In  children  the  respirations  may  be  80  or  even  100. 
Many  factors  combine  to  produce  the  shortness  of  breath — the  pain  in  the 
side,  the  toxaemia,  the  fever,  and  the  loss  of  function  in  a  considerable  area 
of  the  lung  tissue.     Sometimes  there  appear  to  be  nervous  factors  at  work. 


LOBAR  PNEUMONIA.  175 

That  it  does  not  depend  upon  the  consolidation  is  shown  by  the  fact  that 
after  the  crisis,  without  any  change  in  the  local  condition  of  the  lung,  the 
number  of  respirations  may  drop  to  normal.  The  ratio  between  the  respira- 
tions and  the  pulse  may  be  1  to  2  or  even  1  to  1.5,  a  disturbance  rarely  so^ 
marked  in  any  other  disease. 

Cough. — This  usually  comes  on  with  the  pain  in  the  side,  and  at  first  is 
dry,  hard,  and  without  any  expectoration.  Later  it  becomes  very  characteris- 
tic— frequent,  short,  restrained,  and  associated  with  great  pain  in  the  side. 
In  old  persons,  in  drunkards,  in  the  terminal  pneumonias,  and  sometimes  in 
young  children,  there  may  be  no  cough.  After  the  crisis  the  cough  usually 
becomes  much  easier  and  the  expectoration  more  easily  expelled.  The  cough 
is  sometimes  persistent,  continuous,  and  by  far  the  most  aggravated  and  dis- 
tressing symptom  of  the  disease.  Paroxysms  of  coughing  of  great  intensity 
after  the  crisis  suggest  a  pleural  exudate. 

Sputum. — A  brisk  haemoptysis  may  be  the  initial  symptom.  At  first  the 
sputum  may  be  mucoid,  but  usually  after  twenty-four  hours  it  becomes  blood- 
tinged,  viscid,  and  very  tenacious.  At  first  quite  red  from  the  unchanged 
blood,  it  gradually  becomes  rusty  or  of  an  orange  3'^ellow.-  The  tenacious 
viscidity  of  the  sputum  is  remarkable ;  it  often  has  to  be  wiped  from  the  lips 
of  the  patient.  When  jaundice  is  present  it  may  be  green  or  yellow.  In  low 
types  of  the  disease  the  sputum  may  be  fluid  and  of  a  dark  brown  color^ 
resembling  prune  juice.  The  amount  is  very  variable,  ranging  from  100  to 
300  cc.  in  the  twenty-four  hours.  In  100  cases  in  my  clinic  studied  by  Emer- 
son, in  16  there  was  little  or  no  sputum;  in  32  it  was  typically  rusty;  in  33 
blood-streaked ;  in  3  cases  the  sputum  was  very  bloody.  In  children  and  very 
old  people  there  may  be  no  sputum  whatever.  After  the  crisis  the  quantity 
is  variable,  abundant  in  some  cases,  absent  in  others. 

Microscopically,  the  sputum  consists  of  leucocytes,  mucus  corpuscles,  red 
blood-corpuscles  in  all  stages  of  degeneration,  and  bronchial  and  alveolar 
epithelium.  Hsematoidin  crystals  are  occasionally  met  with.  Of  micro-organ- 
isms the  pneumococcus  is  usually  present,  and  sometimes  Friedlander's  bacillus 
and  the  influenza  bacillus.  Very  interesting  constituents  are  small  cell  moulds 
of  the  alveoli  and  the  fibrinous  casts  of  the  bronchioles;  the  latter  may  be 
very  plainly  visible  to  the  naked  eye,  and  sometimes  may  form  good-sized 
dendritic  casts.  Chemically,  the  expectoration  is  particularly  rich  in  calcium 
chloride. 

Physical  Signs. — Inspection. — The  position  of  the  patient  is  not  con- 
stant. He  usually  rests  more  comfortably  on  the  affected  side,  or  he  is  propped 
up  with  the  spine  curved  toward  it.     Orthopnoea  is  rare. 

In  a  small  lesion  no  differences  may  be  noted  between  the  sides;  as  a 
rule,  movement  is  much  less  on  the  affected  side,  which  may  look  larger. 
With  involvement  of  a  lower  lobe,  the  apex  on  the  same  side  may  show  greater 
movement.  The  compensatory  increased  movement  on  the  sound  side  is  some- 
times very  noticeable  even  before  the  patient's  chest  is  bared.  The  intercostal 
spaces  are  not  usually  obliterated.  When  the  cardiac  lappet  of  the  left  upper 
lobe  is  involved  there  may  be  a  marked  increase  in  the  area  of  visible  cardiac 
pulsation.  Pulsation  of  the  affected  lung  may  cause  a  marked  movement  of 
the  chest  wall  (Graves).  Other  points  to  be  noticed  in  the  inspection  are  the 
frequency  of  the  respiration,  the  action  of  the  accessory  muscles,  such  as  the 


176  SPECIFIC  INFECTIOUS  DISEASES. 

sterno-cleido-mastoids  and  scaleni,  and  the  dilatation  of  the  nostrils  with  each 
inspiration. 

Mensuration  may  show  a  definite  increase  in  the  volume  of  the  side 
affected,  rarely  more,  however,  than  1  or  1^  cm. 

Palpation. — The  lack  of  expansion  on  the  affected  side  is  sometimes  more 
readily  perceived  by  touch  than  b}''  sight.  The  pleural  friction  may  be  felt. 
On  asking  the  patient  to  count,  the  voice  fremitus  is  greatly  increased  in  com- 
parison with  the  corresponding  point  on  the  healthy  side.  It  is  to  be  remem- 
bered that  if  the  bronchi  are  filled  with  thick  secretion,  or  if,  in  what  is 
known  as  massive  pneumonia,  they  are  filled  with  fibrinous  exudate,  the  tac- 
tile fremitus  may  be  diminished.  It  is  always  well  to  ask  the  patient  to  cough 
before  testing  the  fremitus. 

Percussion. — In  the  stage  of  engorgement  the  note  is  higher  pitched  and 
may  have  a  somewhat  tympanitic  quality,  the  so-called  Skoda's  resonance. 
This  can  often  be  obtained  over  the  lung  tissue  just  above  a  consolidated  area. 
L.  A.  Conner  calls  attention  to  a  point  which  all  observers  must  have  noticed, 
that,  when  the  patient  is  lying  on  his  side,  the  percussion  at  the  dependent 
base  is  "  deeper  and  more  resonant  than  that  of  the  upper  side,"  which  by  con- 
trast may  seem  abnormal,  and  there  may  even  be  a  faint  tubular  element  added 
to  the  vesicular  breathing  on  the  compressed  side.  When  the  lung  is  hepa- 
tized,  the  percussion  note  is  dull,  the  qualit}^  varying  a  good  deal  from  a  note 
which  has  in  it  a  certain  tympanitic  quality  to  one  of  absolute  flatness.  There 
is  not  the  wooden  flatness  of  effusion  and  the  sense  of  resistance  is  not  so  great. 
During  resolution  the  tympanitic  quality  of  the  percussion  note  usually  re- 
turns. For  weeks  or  months  after  convalescence  there  may  be  a  higher- 
pitched  note  on  the  affected  side.  Wintrich's  change  in  the  percussion  note 
when  the  mouth  is  open  may  be  very  well  marked  in  pneumonia  of  the  upper 
lobe.  Occasionally  there  is  an  almost  metallic  quality  over  the  consolidated 
area,  and  when  this  exists  with  a  very  pronounced  amphoric  quality  in  the 
breathing  the  presence  of  a  cavity  may  be  suggested.  In  deep-seated  pneu- 
monias there  may  be  for  several  days  no  change  in  the  percussion  note. 

Auscultation, — Quiet,  suppressed  breathing  in  the  affected  part  is  often 
a  marked  feature  in  the  early  stage,  and  is  always  suggestive.  Only  in  a  few 
cases  is  the  breathing  harsh  or  puerile.  Yery  early  there  is  heard  at  the  end 
of  inspiration  the  fine  crepitant  ]'ale,a  series  of  minute  cracklings  heard  close 
to  the  ear,  and  perhaps  not  audible  until  a  full  breath  is  drawn.  This  is  prob- 
ably a  fine  pleural  crepitus,  as  J.  B.  Leaming  maintained;  it  is  usually  be- 
lieved to  be  produced  in  the  air-cells  and  finer  bronchi  by  the  separation  of 
the  sticky  exudate.  In  the  stage  of  red  hepatization  and  when  dulness  is  well 
defined,  the  respiration  is  tubular,  similar  to  that  heard  in  health  over  the 
larger  bronchi.  It  is  heard  first  with  expiration  (a  point  noted  by  James 
Jackson,  Jr.),  and  is  soft  and  of  low  pitch.  Gradually  it  becomes  more  in- 
tense, and  finally  presents  an  intensit}^  unknown  in  any  other  pulmonary 
affection — of  high  pitch,  perfectly  dry.  and  of  equal  length  with  inspiration 
and  expiration.  It  is  simply  the  propagation  of  the  laryngeal  and  tracheal 
sounds  through  the  bronchi  and  the  consolidated  lung  tissue.  The  permea- 
bility of  the  bronchi  is  essential  to  its  production.  Tubular  breathing  is  absent 
in  the  excessively  rare  cases  of  massive  pneumonia  in  which  the  larger  bronchi 
are  completely  filled  with  exudation.     When  resolution  begins  mucous  rales 


LOBAR  PNEUMONIA.  177 

of  all  sizes  can  be  heard.  At  first  they  are  small  and  have  been  called  the 
redux-crepitus.  The  voice-sounds  and  the  expiratory  grunt  are  transmitted 
through  the  consolidated  lung  with  great  intensity.  This  bronchophony  may 
have  a  carious  nasal  quality,  to  which  the  term  aegophony  has  been  given. 
There  are  cases  in  which  the  consolidation  is  deeply  seated — so-called  central 
pneumonia,  in  which  the  physical  signs  are  slight  or  even  absent,  yet  the 
cough,  the  rusty  expectoration,  and  general  features  make  the  diagnosis 
certain. 

Circulatory  Symptoms. — During  the  chill  the  pulse  is  small,  but  in  the 
succeeding  fever  it  becomes  full  and  bounding.  In  cases  of  moderate  severity 
it  ranges  from  100  to  116.  It  is  not  often  dicrotic.  In  strong,  healthy  indi- 
viduals and  in  children  there  may  be  no  sign  of  failing  pulse  throughout 
the  attack.  With  extensive  consolidation  the  left  ventricle  may  receive  a 
very  much  diminished  amount  of  blood  and  the  pulse  in  consequence  may 
be  small.  In  the  old  and  feeble  it  may  be  small  and  rapid  from  the  outset. 
The  pulse  may  be  full,  soft,  very  deceptive,  and  of  no  value  whatever  in 
prognosis. 

Blood  Pressuee. — During  the  first  few  days  there  is  no  change.  The' 
extent  of  involvement  seems  to  have  no  effect  upon  the  peripheral  blood  pres- 
sure. In  the  toxic  cases  the  pressure  may  begin  to  fall  early;  a  drop  of  15-20 
mm.  Hg.  is  perfectly  safe,  but  a  progressive  fall  indicates  the  need  of  stimula- 
tion. A  sudden  drop  is  rarely  seen  except  just  before  death.  A  slow,  gradual 
fall  of  more  than  20  mm.  Hg.  means  cardio-vascular  asthenia,  and  calls  for  an 
increase  in  the  stimulation.  The  crisis  has  no  efl^ect  on  the  blood  pressure. 
The  heart-sounds  are  usually  loud  and  clear.  During  the  intensity  of  the  fever, 
particularly  in  children,  hruits  are  not  uncommon  both  in  the  mitral  and  in 
the  pulmonic  areas.  The  second  sound  over  the  pulmonary  artery  is  accen- 
tuated. :  Attention  to  this  sign  gives  a  valuable  indication  as  to  the  condition 
of  the  lesser  circulation.  With  distention  of  the  right  chambers  and  failure 
of  the  right  ventricle  to  empty  itself  completely  the  pulmonary  second  sound 
becomes  much  less  distinct.  When  the  right  heart  is  engorged  there  may  be 
an  increase  in  the  dulness  to  the  right  of  the  sternum.  With  gradual  heart 
weakness  and  signs  of  dilatation  the  long  pause  is  greatly  shortened,  the 
sounds  approach  each  other  in  tone  and  have  a  foetal  character  (embryo- 
cardia). 

There  may  be  a  sudden  early  collapse  of  the  heart  with  very  feeble,  rapid 
pulse  and  increasing  cyanosis.  I  have  known  this  to  occur  on  the  third  day. 
Even  when  these  symptoms  are  very  serious  recovery  may  take  place.  In 
other  instances  without  any  special  warning  death  may  occur  even  in  robust, 
previously  healthy  men.  The  heart  weakness  may  be  due  to  paralysis  of  the 
vaso-motor  centre  and  consequent  lowering  of  the  general  arterial  pressure. 
The  soft,  easily  compressed  pulse,  with  the  gray,  ashy  facies,  cold  hands  and 
feet,  the  clammy  perspiration,  and  the  progressive  prostration  tell  of  a  toxic 
action  on  the  vaso-motor  centres.  Endocarditis  and  pericarditis  will  be  con- 
sidered under  complications.  ' 

BLOODi — Anaemia  is  rarely  seen.     Bollinger  has  called  attention  to  an 

oligaemia  due  to  the  large  amount  of  exudate.    A  decrease  in  the  red  cells  may 

occur  %%  the,  time  of  the  crisis.     There  is  in  most  cases  a  leucocytosis,  which 

appears  early,  persists,  and  disappears  with  the  crisis.     The  leucocytes  may 

13 


178 


SPECIFIC  INFECTIOUS  DISEASES. 


number  from  12,000  to  40.000  or  even  100.000  per  cubic  millimetre.  The 
fall  in  the  leucoc].1:es  is  often  slower  than  the  drop  in  the  fever,  particularly 
when  resolution  is  delayed.  The  annexed  chart  shows  well  the  coincident 
drop  in  the  fever  and  in  the  number  of  the  leucocytes.  The  leucocytosis  bears 
relation  to  the  extent  of  the  exudate.     In  malignant  pneumonia  the  leucocy- 


Feb.,  1893 

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Chart  XI. 

tosis  may  be  absent,  and  in  any  case  the  continuous  absence  ma}''  be  regarded  as 
an  unfavorable  sign.  A  striking  feature  in  the  blood-slide  is  the  richness  and 
density  of  the  fibrin  network.  This  corresponds  to  the  great  increase  in  the 
fibrin  elements,  the  proportion  rising  from  4  to  10  parts  per  thousand.  The 
blood-plates  are  greatly  increased. 


LOBAR  PNEUMONIA.  179 

Digestive  Organs. — The  tongue  is  white  and  furred,  and  in  severe  toxic 
cases  rapidly  becomes  dry.  Vomiting  is  not  uncommon  at  the  onset  in  chil- 
dren. The  appetite  is  lost.  Constipation  is  more  common  than  diarrhoea. 
A  distressing  and  sometimes  dangerous  symptom  is  meteorism.  Fibrinous, 
pneumococcic  exudates  may  occur  in  the  conjunctivae,  nose,  mouth,  prepuce, 
and  anus  (Gary).  The  liver  may  be  depressed  by  the  large  right  lung,  or 
enlarged  from  the  engorged  right  heart,  or  as  a  result  of  the  infection.  The 
spleen  is  usually  enlarged,  and  the  edge  can  be  felt  during  a  deep  inspiration. 

Skin. — Among  cutaneous  symptoms  one  of  the  most  interesting  is  the 
association  of  herpes  with  pneumonia.  Not  excepting  malaria,  we  see  labial 
herpes  more  frequently  in  this  than  in  any  other  disease,  occurring,  as  it 
does,  in  from  12  to  40  per  cent  of  the  cases.  It  is  supposed  to  be  of  favorable 
prognosis,  and  figures  have  been  quoted  in  proof  of  this  assertion.  It  may 
also  occur  on  the  nose,  genitals,  and  anus.  Its  significance  and  relation  to 
the  disease  are  unknown.  At  the  height  of  the  disease  sweats  are  not  common, 
but  at  the  crisis  they  may  be  profuse.  Eedness  of  one  cheek  is  a  phenomenon 
long  recognized  in  connection  with  pneumonia,  and  is  usually  on  the  same 
side  as  the  disease.  A  diffuse  erythema  is  occasionally  seen,  and  in  rare  cases 
purpura.    Jaundice  is  referred  to  among  the  complications. 

Urine. — Early  in  the  disease  it  presents  the  usual  febrile  characters  of 
high  color,  high  specific  gravity,  and  increased  acidity.  A  trace  of  albumin 
is  very  common.  There  may  be  tube-casts,  and  in  a  few  instances  the  exist- 
ence of  albumin,  tube-casts,  and  blood  indicates  the  presence  of  an  acute 
nephritis.  The  urea  and  uric  acid  are  usually  increased  at  first,  but  may  be 
much  diminished  before  the  crisis,  to  increase  greatly  with  its  onset.  Eobert 
Hutchison's  researches  show  that  a  true  retention  of  chlorides  within  the 
body  takes  place,  the  average  amount  being  about  2  grams  daily.  It  is  a  more 
constant  feature  of  pneumonia  than  of  any  other  febrile  disease,  and  this 
being  the  ease,  a  diminution  of  the  chlorides  in  the  urine  may  be  of  value  in 
the  diagnosis  from  pleurisy  with  effusion  or  empyema.  It  is  to  be  remem- 
bered that  in  dilatation  of  the  stomach  chlorides  may  be  absent.  Hsematuria 
is  a  rare  complication. 

Cerebral  Symptoms. — Headache  is  common.  In  children  convulsions  occur 
frequently  at  the  outset.  Apart  from  meningitis,  which  will  be  considered 
separately,  one  may  group  the  cases  with  marked  cerebral  features  into — 

First,  the  so-called  cerebral  pneumonias  of  children,  in  which  the  disease 
sets  in  with  a  convulsion,  and  there  are  high  fever,  headache,  delirium,  great 
irritability,  muscular  tremor,  and  perhaps  retraction  of  the  head  and  neck. 
The  diagnosis  of  meningitis  is  usually  made,  and  the  local  affection  may  be 
overlooked. 

Secondly,  the  cases  with  maniacal  symptoms.  These  may  occur  at  the 
very  outset,  and  I  once  performed  an  autopsy  on  a  case  in  which  there  was 
no  suspicion  whatever  that  the  disease  was  other  than  acute  mania.  The 
house  physician  should  give  instructions  to  the  nurses  to  watch  such  cases 
very  carefully.  On  March  22,  1894,  a  patient  who  had  been  doing  very  well, 
with  the  exception  of  slight  delirium,  while  the  orderly  was  out  of  the  room 
for  a  few  moments,  got  up,  raised  the  window,  and  jumped  out,  sustaining 
a  fracture  of  the  leg  and  of  the  upper  lumbar  vertebrae,  of  which  he  died. 

Thirdly,  alcoholic  cases  with  the  features  of  delirium  tremens.    It  should 


180  SPECIFIC  INFECTIOUS  DISEASES. 

be  an  invariable  rule,  even  if  fever  be  not  present^  to  examine  the  lungs  in  a 
case  of  mania  a  potu. 

Fourthly,  cases  with  toxic  features,  resembling  rather  those  of  uraemia. 
Without  a  chill  and  without  cough  or  pain  in  the  side,  a  patient  may  have 
fever,  a  little  shortness  of  breath,  and  then  gradually  grow  dull  mentally,  and 
within  three  days  be  in  a  condition  of  profound  toxgemia  with  low,  muttering 
delirium. 

It  is  stated  that  apex  pneumonia  is  more  often  accompanied  with  severe 
delirium.  Occasionally  the  cerebral  sjonptoms  occur  immediately  after  the 
crisis.  3Iental  disturbance  may  persist  during  and  after  convalescence,  and 
in  a  few  instances  delusional  insanity  follows,  the  outlook  in  which  is 
favorable. 

Complications. — Compared  with  typhoid  fever,  pneumonia  has  but  few 
complications  and  still  fewer  sequelse.  The  most  important  are  the  fol- 
lowing : 

Pleurisy  is  an  inevitable  event  when  the  inflammation  reaches  the  surface 
of  the  lung,  and  thus  can  scarcely  be  termed  a  complication.  But  there  are 
cases  in  which  the  pleuritic  features  take  the  first  place — cases  to  which  the 
term  pleuro-pneumonia  is  applicable.  The  exudation  may  be  sero-fibrinous 
with  copious  effusion,  differing  from  that  of  an  ordinary  acute  pleurisy  in 
the  greater  richness  of  the  fibrin,  which  may  form  thick,  tenacious,  curdy 
layers.  Pneumonia  on  one  side  with  extensive  pleurisy  on  the  other  is  some- 
times a  puzzling  complication  to  diagnose,  and  an  aspirator  needle  may  be 
required  to  settle  the  question.  Empyema  is  one  of  the  most  common  com- 
plications, and  has  of  late  increased  in  frequency.  During  the  eight  3'ears, 
1883-'90,  there  were  at  Guy's  Hospital  7  cases  of  emp^-ema  among  445  cases 
of  pneumonia,  while  in  the  eight  years,  1891-'98,  there  were  38  cases  among 
896  cases  of  pneumonia  (Hale  White).  Influenza  may  be  responsible  for  the 
increase.  The  pneumococcus  is  usually  present;  in  a  few  the  streptococcus, 
in  which  case  the  prognosis  is  not  so  good.  Eecurrence  of  the  fever  after  the 
crisis  or  persistence  of  it  after  the  tenth  day,  with  sweats,  leucocytosis,  and 
perhaps  an  aggravation  of  the  cough,  are  suspicious  symptoms.  The  dulness 
persists  at  the  base,  or  may  extend.  The  breathing  is  feeble  and  there  are  no 
rales.  Such  a  condition  may  be  closely  simulated,  of  course,  by  the  thickened 
pleura.  Exploratory  aspiration  may  settle  the  question  at  once.  There  are 
obscure  cases  in  which  the  pus  has  been  found  only  after  operation,  as  the 
collection  may  be  very  small. 

Pericarditis  was  present  in  31  of  665  patients  in  my  wards  at  the  Johns 
Hopkins  Hospital  (Chatard).  It  is  often  a  terminal  afiair  and  overlooked. 
The  mortality  is  very  high;  29  of  the  31  cases  died.  Pleurisy  is  an  almost 
constant  accompaniment,  being  present  in  28  of  the  29  autopsies  in  our  series. 
In  only  3  cases  was  the  effusion  purulent  and  in  large  amount. 

Endocarditis. — ^^The  valves  on  the  left  side  are  more  commonly  attacked, 
and  particularly  if  the  seat  of  arterio-sclerosis.  It  is  particularly  liable  to 
attack  persons  with  old  valvular  disease.  There  may  be  no  symptoms  indica- 
tive of  this  complication  even  in  very  severe  cases.  It  may,  however, 
be  suspected  in  cases  (1)  in  which  the  fever  is  protracted  and  irregular; 
(2)  when  signs  of  septic  mischief  arise,  such  as  chills  and  sweats;  (3)  when 
embolic  phenomena  appear.     The  frequent  complication  of  meningitis  with 


LOBAR  PNEUMONIA.  181 

the  endocarditis  of  pneumonia,  which  has  already  been  mentioned,  gives 
prominence  to  the  cerebral  symptoms  in  these  cases.  The  physical  signs  may 
be  very  deceptive.  There  are  instances  in  which  no  cardiac  murmurs  have 
been  heard.  In  others  the  occurrence  under  observation  of  a  loud,  rough  mur- 
mur, particularly  if  diastolic,  is  extremely  suggestive. 

Thrombosis. — Ante-mortem  clotting  in  the  heart,  upon  which  the  old 
writers  laid  great  stress,  is  very  rare.  Thrombosis  in  the  peripheral  veins  is 
also  uncommon.  Two  cases  occurred  at  my  clinic,  which  have  been  reported 
by  Steiner,  who  was  able  to  collect  only  41  cases  from  the  literature.  In  37 
out  of  32  cases  which  were  fully  reported,  the  thrombosis  occurred  during  con- 
valescence. It  is  almost  always  in  the  femoral  veins.  A  rare  complication  is 
embolism  of  one  of  the  larger  arteries.  I  saw  in  Montreal  an  instance  of 
embolism  of  the  femoral  artery  at  the  height  of  pneumonia,  which  necessitated 
amputation  at  the  thigh.  The  patient  recovered.  Aphasia  has  been  met  with 
in  a  few  instances,  setting  in  abruptly  with  or  without  hemiplegia. 

Meningitis  is  perhaps  the  most  serious  complication  of  pneumonia.  It 
varies  very  much  at  different  times  and  in  different  regions.  My  Montreal 
experience  is  rather  exceptional,  as  8  per  cent  of  the  fatal  cases  had  this  com- 
plication. It  usually  comes  on  at  the  height  of  the  fever,  and  in  the  majority 
of  the  cases  is  not  recognized  unless,  as  before  mentioned,  the  base  is  involved, 
which  is  not  common.  Occurring  later  in  the  disease,  it  is  more  easily  diag- 
nosed. In  some  cases  it  is  associated  with  infective  endocarditis.  The  pneu- 
mococcus  has  been  found  in  the  exudate. 

Peripheral  neuritis  is  a  rare  complication,  of  which  several  cases  have  been 
described. 

Gastric  complications  are  rare.  A  croupous  gastritis  has  already  been 
mentioned.     The  croupous  colitis  may  induce  severe  diarrhoea. 

Abdominal  Pain. — It  is  by  no  means  uncommon  to  have  early  pain,  either 
in  the  region  of  the  umbilicus  or  in  the  right  iliac  fossa,  and  a  suspicion  of 
appendicitis  is  aroused;  indeed,  a  catarrhal  form  of  this  disease  may  occur 
eoincidently  with  the  pneumonia.  In  other  instances  so  localized  may  the  pain 
be  in  the  region  of  the  pancreas,  associated  with  meteorism  and  high  fever, 
that  the  diagnosis  of  acute  hsemorrhagic  pancreatitis  is  made.  Such  a  case 
occurred  in  February,  1905,  in  the  wards  of  my  colleague  Dr.  Halsted.  The 
patient  was  admitted  in  a  desperate  condition,  all  the  symptoms  were  abdom- 
inal, and  the  apex  pneumonia  was  not  discovered.  Peritonitis  is  a  rare  com- 
plication, of  which  we  have  had  only  two  or  three  instances.  It  is  sometimes 
in  the  upper  peritonaeum,  and  a  direct  extension  through  the  diaphragm.  It 
is  usually  in  the  severer  cases  and  not  easy  to  recognize.  In  one  case,  indeed, 
in  which  there  was  a  friction  along  the  costal  border,  which  we  thought  indi- 
cated a  peritonitis,  it  was  communicated  from  the  diaphragmatic  pleura. 
Meteorism  is  not  infrequent,  and  is  sometimes  serious.  In  some  cases  it  may 
be  due  to  a  defect  in  the  mechanical  action  of  the  diaphragm,  in  others  to  an 
acute  septic  catarrh  of  the  bowels,  or  to  a  toxic  paresis  of  the  walls,  occasion- 
ally to  peritonitis.  Jaundice  occurs  with  curious  irregularity  in  different 
outbreaks  of  the  disease.  In  Baltimore  it  was  more  common  among  the  negro 
patients.  It  sets  in  early,  is  rarely  very  intense,  and  has  not  the  characters 
of  obstructive  Jaundice.  There  are  cases  in  which  it  assumes  a  very  serious 
form.     The  mode  of  production  is  not  well  ascertained.     It  does  not  appear 


182  SPECIFIC  INFECTIOUS  DISEASES. 

to  bear  any  definite  relation  to  the  degree  of  hepatic  engorgement,  and  it  is 
not  always  due  to  catarrh  of  the  ducts.  Possibly  it  may  be,  in  great  part, 
hasmatogenons. 

Parotitis  occasionally  occurs,  commonly  in  association  with  endocarditis. 
In  children,  middle-ear  disease  is  not  an  infrequent  complication. 

B right's  disease  does  not  often  follow  pneumonia. 

The  relations  of  arthritis  and  pneiunonia  are  xers'  interesting.  It  may 
precede  the  onset,  and  the  pneumonia,  possibly  with  endocarditis  and  pleurisy, 
may  occur  as  complications.  In  other  instances  at  the  height  of  an  ordinary 
pneumonia  one  or  two  joints  may  become  red  and  sore.  On  the  other  hand, 
after  the  crisis  has  occurred  pains  and  swelling  may  come  on  in  the  joints. 

Relapse. — There  are  cases  in  which  from  the  ninth  to  the  eleventh  day  the 
fever  subsides,  and  after  the  temperature  has  been  normal  for  a  day  or  two  a 
rise  occurs  and  fever  may  persist  for  another  ten  days  or  even  two  weeks. 
Though  this  might  be  termed  a  relapse,  it  is  more  correct  to  regard  it  as  an 
instance  of  an  anomalous  course  of  delayed  resolution.  Wagner,  who  has 
studied  the  subject  carefully,  says  that  in  his  large  experience  of  1,100  cases 
he  met  with  only  3  doubtful  cases.  "WTien  it  does  occur,  the  attack  is  usually 
abortive  and  mild.  In  the  case  of  Z.  E.  (Medical  Xo.  J.  H.  H.,  4223),  with 
pneumonia  of  the  right  lower  lobe,  crisis  occurred  on  the  seventh  day,  and 
after  a  normal  temperature  for  thirteen  days  he  was  discharged.  That  night 
he  had  a  shaking  chill,  followed  by  fever,  and  he  had  recurring  chills  with 
reappearance  of  the  pneumonia.  In  a  second  case  (Medical  No.  J.  H.  H., 
4538)  crisis  occurred  on  the  third  day,  and  there  was  recurrence  of  pneumonia 
on  the  thirteenth  day. 

Recurrence  is  more  common  in  pneumonia  than  in  any  other  acute  disease. 
Eush  gives  an  instance  in  which  there  were  28  attacks.  Other  authorities  nar- 
rate cases  of  8,  10,  and  even  more  attacks. 

Convalescence  in  pneumonia  is  usually  rapid,  and  sequelge  are  rare.  After 
the  crisis,  sudden  death  has  occurred  when  the  patient  has  got  up  too  soon. 
With  the  onset  of  fever  and  persistence  of  the  leucocytosis  the  afEected  side 
should,  be  very  carefully  examined  for  pleurisy.  With  a  persistence  of  the 
dulness  the  physical  signs  may  be  obscure,  but  the  use  of  a  small  exploratory 
needle  will  help  to  clear  the  diagnosis. 

Clinical  Varieties. — Local  variations  are  responsible  for  some  of  the  most 
marked  deviations  from  the  usual  type. 

Apex  pneumonia  is  said  to  be  more  often  associated  with  ad}Tiamic  fea- 
tures and  with  marked  cerebral  symptoms.  The  expectoration  and  cough  may 
be  slight. 

Migratory  or  creeping  pneumonia.,  a  form  which  successively  involves  one 
lobe  after  the  other. 

Douhle  pneumonia  has  no  peculiarities  other  than  the  greater  danger  con- 
nected with  it. 

Massive  pneumonia  is  a  rare  form,  in  which  not  alone  the  air-cells  but 
the  bronchi  of  an  entire  lobe  or  even  of  a  lung  are  filled  with  the  fibrinous  exu- 
date. The  auscultatory  signs  are  absent;  there  is  neither  fremitus  nor  tubu- 
lar breathing,  and  on  percussion  the  lung  is  absolutely  flat.  It  closely  resem- 
bles pleurisy  with  effusion.  The  moulds  of  the  bronchi  may  be  expectorated 
in  violent  fits  of  coughing. 


LOBAR  PNEUMONIA,  183 

Central  Pneumonia. — The  inflammation  may  be  deep-seated  at  the  root 
of  the  lung  or  centrally  placed  in  a  lobe,  and  for  several  days  the  diagnosis 
may  be  in  doubt.  It  may  not  be  until  the  third  or  fourth  day  that  a  pleural 
friction  is  detected,  or  that  dulness  or  blowing  breathing  and  rales  are  recog- 
nized. I  saw  in  1898  with  Drs.  H.  Adler  and  Chew  a  young,  thin-chested  girl 
in  whom  at  the  end  of  the  fourth  day  all  the  usual  symptoms  of  pneumonia 
were  present  without  any  physical  signs  other  than  a  few  clicking  rales  at  the 
left  apex  behind.  The  thinness  of  the  patient  greatly  facilitated  the  examina- 
tion. The  general  features  of  pneumonia  continued,  and  the  crisis  occurred 
on  the  seventh  day. 

Pneumonia  in  Infants. — It  is  sometimes  seen  in  the  new-born.  In  in- 
fants it  very  often  sets  in  with  a  convulsion.  The  apex  of  the  lung  seems 
more  frequently  involved  than  in  adults,  and  the  cerebral  sjonptoms  are  more 
marked.  The  torpor  and  coma,  particularly  if  they  follow  convulsions,  and 
the  preliminary  stage  of  excitement,  may  lead  to  the  diagnosis  of  meningitis. 
Pneumonic  sputum  is  rarely  seen  in  children. 

Pneumonia  in  the  Aged. — The  disease  may  be  latent  and  set  in  with- 
out a  chill;  the  cough  and  expectoration  are  slight,  the  physical  signs  ill- 
defined  and  changeable,  and  the  constitutional  symptoms  out  of  all  propor- 
tion to  the  extent  of  the  local  lesion. 

Pneumonia  in  x4.lcoholic  Subjects. — The  onset  is  insidious,  the  symp- 
toms masked,  the  fever  slight,  and  the  clinical  picture  usually  that  of  delirium 
tremens.  The  thermometer  alone  may  indicate  the  presence  of  an  acute  dis- 
ease. Often  the  local  condition  is  overlooked,  as  the  patient  makes  no  com- 
plaint of  pain,  and  there  may  be  very  little  shortness  of  breath,  no  cough,  and 
no  sputum. 

Terminal  Pneumonia. — The  wards  and  the  post-mortem  room  show 
a  very  striking  contrast  in  their  pneumonia  statistics,  owing  to  the  occur- 
rence of  what  may  be  called  terminal  pneumonia.  During  the  winter  months 
patients  with  chronic  pulmonary  tuberculosis,  arterio-sclerosis,  heart  disease, 
Bright's  disease,  and  diabetes  are  not  infrequently  carried  off  by  a  pneu- 
monia which  may  give  few  or  no  signs  of  its  presence.  There  may  be  a  slight 
elevation  of  temperature,  with  increase  in  the  respirations,  but  the  patient 
is  near  the  end  and  perhaps  not  in  a  condition  in  which  a  thorough  physical 
examination  can  be  made.  The  autopsy  may  show  pneumonia  of  the  greater 
part  of  one  lower  lobe  or  of  the  apex,  which  had  entirely  escaped  notice. 
In  diabetic  patients  the  disease  often  runs  a  rapid  and  severe  course,  and  may 
end  in  abscess  or  gangrene. 

Some  of  the  most  remarkable  variations  in  the  clinical  course  of  pneu- 
monia depend  probably  upon  the  severity,  possibly  upon  the  nature  of  the 
infection.  Further  investigation  may  enable  us  to  say  how  far  the  associated 
organisms,  so  often  present,  may  be  responsible  for  the  differences  in  the 
clinical  course. 

Secondary  Pneumonias. — These  are  met  with  chiefly  in  the  specific 
fevers,  particularly  diphtheria,  typhoid  fever,  typhus,  infiuenza,  and  the 
plague.  Anatomically,  they  rarely  present  the  typical  form  of  red  or  gray 
hepatization.  The  surface  is  smoother,  not  so  dry,  and  it  is  often  a  pseudo- 
lobar  condition,  a  consolidation  caused  by  closely  set  areas  of  lobular  involve- 
ment.    Histologically,  they  are  characterized  in  many  instances  by  a  more 


184  SPECIFIC  INFECTIOUS  DISEASES. 

cellular,  less  fibrinous  exudate,  which  may  also  infiltrate  the  alveolar  walls, 
Bacteriologically,  a  large  number  of  different  organisms  have  been  found, 
the  specific  microbe  of  the  primary  disease,  usually  in  association  with  the 
streptococcus  pyogenes  or  the  staphylococcus;  in  some  instances  the  colon 
bacillus  has  been  present. 

The  symptoms  of  the  secondary  pneumonias  often  lack  the  striking  defi- 
niteness  of  the  primary  croupous  pneumonia.  The  pulmonary  features  may 
be  latent  or  masked  altogether.  There  may  be  no  cough  and  only  a  slight  in- 
crease in  the  number  of  respirations.  The  lower  lobe  of  one  lung  is  most  com- 
monly involved,  and  the  physical  signs  are  obscure  and  rarely  amount  to 
more  than  impaired  resonance,  feeble  breathing,  and  a  few  crackling  rales. 

Epidemic  pneumonia  has  already  been  referred  to.  It  is,  as  a  rule,  more 
fatal,  and  often  displays  minor  complications  which  differ  in  different  out- 
breaks. In  some  the  cerebral  manifestations  are  very  marked;  in  others,  the 
cardiac;  in  others  again,  the  gastro-intestinal. 

Larval  Pneumonia. — Mild,  abortive  types  are  seen,  particularly  in  insti- 
tutions when  pneumonia  is  prevailing  extensively.  A  patient  may  have  the 
initial  symptoms  of  the  disease,  a  slight  chill,  moderate  fever,  a  few  indefi- 
nite local  signs,  and  herpes.  The  whole  process  may  only  last  for  two  or  three 
days;  some  authors  recognize  even  a  one-day  pneumonia. 

Asthenic,  Toxic,  or  Typhoid  Pneumonia. — The  toxaemic  features 
dominate  the  scene  throughout.  The  local  lesions  may  be  slight  in  extent 
and  the  subjective  phenomena  of  the  disease  absent.  The  nervous  symptoms 
usually  predominate.  There  are  delirium,  prostration,  and  early  weakness. 
Very  frequently  there  is  jaundice.  Gastro-intestinal  symptoms  may  be  pres- 
ent, particularly  diarrhoea  and  meteorism.  In  such  a  case,  seen  about  the  end 
of  the  first  week,  it  may  be  difficult  to  say  whether  the  condition  is  one  of 
asthenic  pneumonia  or  one  of  typhoid  fever  which  has  set  in  with  early  local- 
ization in  the  lung.  Here  the  Widal  reaction  and  cultures  from  the  blood  are 
important  aids.  In  these  cases  there  is  really  a  pneumococcus  septicaemia, 
and  the  organisms  may  sometimes  be  isolated  from  the  blood.  Possibly,  too, 
there  is  a  mixed  infection,  and  the  streptococcus  pyogenes  may  be  in  large 
part  responsible  for  the  toxic  features  of  the  disease. 

Association  op  Pneumonia  v^^ith  Other  Diseases. — (a)  With  Malaria. 
— A  malarial  pneumonia  is  described  by  many  observers  and  thought  to  be 
particularly  prevalent  in  some  parts  of  the  United  States.  One  hears  of  it, 
indeed,  even  where  true  malaria  is  rarely  seen.  With  our  large  experience 
in  malaria,  amounting  now  to  between  two  and  three  thousand  cases,  and 
a  considerable  number  of  pneumonia  patients  every  year,  we  have  only  had 
a  few  cases  in  which  the  latter  disease  has  set  in  during  malarial  fever,  or  vice 
versa.  In  either  case  the  malaria  yields  promptly  to  the  action  of  quinine. 
A  special  form  of  pneumonia  due  to  the  malarial  parasite  is  unknown.  Yet 
there  are  cases  reported  by  Craig  and  others  in  which  in  an  acute  malarial 
infection  the  features  suggest  pneumonia  at  the  onset,  but  the  parasites  are 
found  in  the  blood,  and  under  the  use  of  quinine  the  fever  drops  rapidly  and 
the  pneumonia  symptoms  clear  up.  Such  a  case  as  the  following  we  see  occa- 
sionally:  A  patient  was  admitted,  March  16,  1894,  with  tertian  malarial  fever. 
The  lungs  were  clear.  A  pneumonia  began  thirty-six  hours  after  admission. 
Quinine  was  given  that  evening,  and  the  malarial  organisms  rapidly  disap- 


LOBAR  PNEUMONIA.  185 

peared  from  the  blood.  There  was  successive  involvement  of  the  right  lower, 
the  middle,  and  the  left  lower  lobe.  The  temperature  fell  by  crisis  on  the 
24th,  and  there  were  no  features  in  the  disease  whatever  suggestive  of  malaria. 
In  other  instances  we  have  found  a  chill  in  the  course  of  an  ordinary  pneu- 
monia to  be  associated  with  a  malarial  infection,  and  quinine  has  rapidly 
and  promptly  caused  the  disappearance  of  the  parasites  from  the  blood. 

(&)  Pneumonia  and  Acute  Arthritis. — We  have  already  spoken  under 
complications  of  this  association,  which  is  more  frequently  seen  in  children. 

(c)  Pneumonia  and  Tuberculosis. — Many  subjects  of  chronic  pulmonary 
tuberculosis  die  of  an  acute  croupous  pneumonia.  A  point  to  be  specially 
borne  in  mind  is  the  fact  that  acute  tuberculous  pneumonia  may  set  in  with 
all  the  features  and  physical  signs  of  fibrinous  pneumonia  (see  page  175). 

For  the  consideration  of  the  association  of  pneumonia  with  typhoid  fever 
and  influenza,  the  reader  is  referred  to  the  sections  on  those  diseases. 

PosT-oPEKATiON  PNEUMONIA. — Before  the  days  of  anesthesia,  lobar 
pneumonia  was  a  well-recognized  cause  of  death  after  surgical  injuries  and 
operations.  Norman  Cheevers,  in  an  early  number  of  the  Guy's  Hospital 
Reports,  calls  attention  to  it  as  one  of  the  most  frequent  causes  of  death  after 
surgical  procedures,  and  Erichsen  states  that  of  41  deaths  after  surgical  in- 
juries 23  cases  showed  signs  of  pneumonia.  The  lobular  form  is  the  most 
frequent.  I  have  already  referred  to  the  contusion-pneumonia  described  by 
Litten, 

Ether  Pneumonia. — The  question  of  a  direct  relation  between  ether 
narcosis  and  pneumonia  has  been  much  discussed  of  late  years,  having  been 
raised  by  Mr,  Lucas,  of  Guy's  Hospital.  The  statistics  are  by  no  means 
unanimous.  The  London  anaesthetists,  particularly  Hewitt  and  Silk,  seem  to 
have  had  a  fortunate  experience.  Silk  having  found  among  5,000  cases  13  of 
pneumonia;  8  of  these  were  tongue  or  jaw  cases.  The  German  experience 
is  very  different.  Von  Beck  states  that,  owing  to  the  injurious  after-effects 
upon  the  respiratory  tract,  the  use  of  ether  has  been  largely  restricted  in 
Czerny's  clinic.  Gurlt  reports  52,177  cases,  with  30  cases  of  pneumonia  and 
15  deaths.  We  usually  had  three  or  four  cases  each  year  at  the  Johns  Hopkins 
Hospital.  Czerny  suggests  that  the  relation  of  these  ether  pneumonias  to 
abdominal  operations  is  associated  with  the  pain  on  coughing,  which  leads  to 
an  accumulation  of  secretion,  and  through  this  to  retention  or  aspiration  pneu- 
monia. Among  the  various  views  brought  forward  to  account  for  it  are  the 
rapid  evaporation  of  the  ether,  causing  chilling  of  the  pulmonarj'^  tissues,  chill- 
ing of  the  patient  at  the  time  of  operation,  infection  from  the  inhaler,  and 
direct  action  of  the  ether. 

The  probability  is  that  the  prolonged  etherization  lowers  the  vitality  of 
the  tissues  of  the  finer  bronchi  and  permits  the  pathogenic  organisms  (which 
are  almost  always  present)  to  do  their  work.  The  pneumonia  is  more  fre- 
quently lobular  than  lobar.  Neuwerck,  and  subsequently  Whitney,  have  sug- 
gested thorough  disinfection  of  the  mouth  and  throat  before  operation. 

Delayed  Resolution  in  Pneumonia. — The  lung  is  restored  to  its  nor- 
mal state  by  the  liquefaction  and  absorption  of  the  exudate.  There  are 
eases  in  which  resolution  takes  place  rapidly  without  any  increase  in  (or, 
indeed,  without  any)  expectoration;  on  the  other  hand,  during  resolution  it  is 
not  uncommon  to  find  in  the  sputa  the  little  plugs  of  fibrin  and  leucocytes 


186  SPECIFIC  INFECTIOUS  DISEASES. 

which  have  been  loosened  from  the  air-cells  and  expelled  by  coughing,  A 
yariable  time  is  taken  in  the  restoration  of  the  lung.  Sometimes  within  a 
week  or  ten  days  the  dulness  is  greatly  diminished,  the  breath-sounds  become 
clear,  and,  so  far  as  physical  signs  are  any  guide,  the  lung  seems  perfectly 
restored.  It  is  to  be  remembered  that  in  any  case  of  pneumonia  with  extensive 
pleurisy  a  certain  amount  of  dulness  will  persist  for  months,  owing  to  thick- 
ening of  the  pleura. 

Delayed  resolution  is  a  condition  which  causes  much  anxiety  to  the  physi- 
cian. While  it  is  perhaps  more  frequent  in  debilitated  persons,  jet  it  is  met 
with  in  robust,  previously  healthy  individuals,  and  in  cases  which  have  had 
a  very  typical  onset  and  course.  The  condition  is  stated  to  be  most  frequent 
in  apex  pneumonia.  Venesection  has  been  assigned  as  a  cause.  The  solid 
exudate  may  persist  for  weeks  and  yet  the  integrity  of  the  lung  may  ulti- 
mately be  restored.  Grissole  describes  the  lung  from  a  patient  who  died  on 
the  sixtieth  day,  in  which  the  affected  part  showed  a  condition  not  unlike  that 
of  the  acute  stage. 

Clinically,  there  are  several  groups  of  cases :  First,  those  in  which  the 
crisis  occurs  naturally,  the  temperature  falls  and  remains  normal,  but  the 
local  features  persist — ^well-marked  flatness  with  tubular  breathing  and  rales. 
Eesolution  may  occur  very  slowly  and  gradually,  taking  from  two  to  three 
weeks.  In  a  second  group  of  cases  the  temperature  falls  by  lysis,  and  with  the 
persistence  of  the  local  signs  there  is  slight  fever,  sometimes  sweats  and  rapid 
pulse.  The  condition  may  persist  for  three  or  four  weeks,  or,  as  in  one  of  my 
c^ses,  for  eleven  weeks,  and  ultimately  perfect  resolution  occur.  During  all 
this  time  there  may  be  little  or  no  sputum.  The  practitioner  is  naturally 
much  exercised,  and  he  dreads  lest  tuberculosis  should  supervene.  In  a  third 
group  the  crisis  occurs  or  the  fever  falls  by  lysis,  but  the  consolidation  persists 
and  there  may  be  intense  bronchial  breathing,  with  few  or  no  rales,  or  the  fever 
may  recur  and  the  patient  may  die  exhausted.  In  1  of  my  100  autopsies  a 
patient,  aged  fifty-eight,  had  died  on  the  thirty-second  day  from  the  initial 
chill.  The  right  lung  was  solid,  grayish  in  color,  firm,  and  presented  in 
places  a  translucent,  semi-homogeneous  aspect.  In  these  areas  the  alveolar 
walls  were  thickened,  and  the  plugs  filling  the  air-cells  were  undergoing  trans- 
formation into  new  connective  tissue.  This  fibroid  induration  may  proceed 
gradually  and  be  associated  with  shrinkage  of  the  affected  side,  and  the  gradual 
production  of  a  cirrhosis  or  chronic  interstitial  pneumonia. 

Ordinary  fibrinous  pneumonia  never  terminates  in  tuberculosis.  The  in- 
stances of  caseous  pneumonia  and  softening  which  have  followed  an  acute 
pneumonic  process  have  been  from  the  outset  tuberculous. 

Teemixation  in  Abscess.- — This  occurred  in  4  of  my  100  autopsies. 
Usually  the  lung  breaks  down  in  limited  areas  and  the  abscesses  are  not 
large,  but  they  may  fuse  and  involve  a  considerable  proportion  of  a  lobe. 
The  condition  is  recognized  by  the  sputum,  which  is  usually  abundant  and 
contains  pus  and  elastic  tissue,  sometimes  cholesterin  crystals  and  hasma- 
toidin  crystals.  The  cough  is  often  paroxysmal  and  of  great  severity;  usu- 
ally the  fever  is  remittent,  or  in  protracted  cases  intermittent  in  character, 
and  there  may  be  pronounced  hectic  symptoms.  Wlien  a  case  is  seen  for  the 
first  time  it  may  be  difficult  to  determine  whether  it  is  one  of  abscess  of  the 
lung  or  a  local  empyroma  which  has  perforated  the  lung. 


LOBAR  PNEUMONIA.  187 

GrANGKENE. — This  is  most  commonly  seen  in  old  debilitated  persons. 
It  was  present  in  3  of  my  100  autopsies.  It  very  often  occurs  with  abscess. 
The  gangrene  is  associated  with  the  growth  of  the  saproph3^tic  bacteria  on 
a  soil  made  favorable  by  the  presence  of  the  pneumococcus  or  the  strepto- 
coccus. Clinically,  the  gangrene  is  rendered  very  evident  by  the  horribly 
fetid  odor  of  the  expectoration  and  its  characteristic  features.  In  some  in- 
stances the  gangrene  may  be  found  post  mortem  when  clinically  there  has  not 
been  any  evidence  of  its  existence. 

Prognosis, — Pneumonia  is  the  most  fatal  of  all  acute  diseases,  killing  more 
than  diphtheria,  and  outranking  even  consumption  as  a  cause  of  death. 

Hospital  statistics  show  that  the  mortality  ranges  from  30  to  40  per  cent. 
Of  1,012  cases  at  the  Montreal  General  Hospital,  the  mortality  was  30,4  per 
cent.  It  appears  to  be  somewhat  more  fatal  in  southern  climates.  Of  3,969 
cases  treated  at  the  Charity  Hospital,  New  Orleans,  the  death-rate  was  38,01 
per  cent.  The  mortality  at  the  Johns  Hopkins  Hospital  has  been  about  35 
per  cent  in  the  whites  and  30  per  cent  in  the  colored.  In  704  cases  at  the 
Pennsylvania  Hospital  the  mortality  was  29  per  cent.  At  the  Boston  City 
Hospital,  in  1,443  cases  the  mortality  was  29,1  per  cent.  It  has  been  urged 
that  the  mortality  in  this  disease  has  been  steadily  increasing,  and  attempts 
have  been  made  to  connect  this  increase  with  the  expectant  plan  of  treatment 
at  present  in  vogue.  But  the  careful  and  thorough  analysis  by  C.  N".  Townsend 
and  A.  Coolidge,  Jr,,  of  1,000  cases  at  the  Massachusetts  General  Hospital  in- 
dicates clearly  that,  when  all  circumstances  are  taken  into  consideration,  this 
conclusion  is  not  justified. 

According  to  the  analysis  of  708  cases  at  St,  Thomas's  Hospital  by  Had- 
den,  H,  W.  G.  McKenzie,  and  W.  W.  Ord,  the  mortality  progressively  in- 
creases from  the  twentieth  year,  rising  from  3.7  per  cent  under  that  age  to  23 
per  cent  in  the  third  decade,  30.8  per  cent  in  the  fourth,  47  per  cent  in  the 
fifth,  51  per  cent  in  the  sixth,  65  per  cent  in  the  seventh  decade.  Of  465,400 
cases  collected  by  E.  F.  Wells  from  various  sources,  94,836  died,  a  mortality 
of  20.4  per  cent. 

The  mortality  in  private  practice  varies  greatly.  E.  P.  Howard  treated 
170  cases  with  only  6  per  cent  of  deaths.  Fussell  has  recently  reported  134 
cases  with  a  mortality  of  17.9  per  cent.  The  mortality  in  children  is  some- 
times very  low.  Morrill  has  recently  reported  6  deaths  in  123  cases  of  frank 
pneumonia.    On  the  other  hand,  Goodhart  had  25  deaths  in  120  cases. 

The  following  are  among  the  circumstances  which  influence  the  prog- 
nosis : 

Age. — As  Sturges  remarks,  the  old  are  likely  to  die,  the  young  to  recover. 
Under  one  year  it  is  more  fatal  than  between  two  and  five.  Fussell  lost  5  out 
of  8  cases  in  sucklings.  At  about  sixty  the  death-rate  is  very  high,  amounting 
to  60  or  80  per  cent.  From  the  reports  of  its  fatality  in  some  places,  one 
may  say  that  to  die  of  pneumonia  is  almost  the  natural  end  of  old  people. 

As  already  stated,  the  disease  is  more  fatal  in  the  negro  than  in  the 
white  race. 

Previous  habits  of  life  and  the  condition  of  bodily  health  at  the  time  of 
the  attack  form  the  most  important  factors  in  the  prognosis  of  pneumonia. 
In  analyzing  a  series  of  fatal  cases  one  is  very  much  impressed  with  the  num- 
ber of  cases  in  which  the  organs  shown  signs  of  degeneration.    In  25  of  my 


188  SPECIFIC  INFECTIOUS  DISEASES. 

100  antopsies  at  the  Montreal  General  Hospital  the  kidneys  showed  extensive 
interstitial  changes.  Individuals  debilitated  from  sickness  or  poor  food,  hard 
drinkers,  and  that  large  class  of  hospital  patients,  composed  of  robust-looking 
laborers  between  the  ages  of  forty-five  and  sixty,  whose  organs  show  signs  of 
wear  and  tear,  and  who  have  by  excesses  in  alcohol  weakened  the  reserve 
power,  fall  an  easy  prey  to  the  disease.  Very  few  fatal  cases  occur  in  robust, 
healthy  adults.  Some  of  the  statistics  given  by  army  surgeons  show  better 
than  any  others  the  low  mortality  from  pneumonia  in  healthy  picked  men. 
The  death-rate  in  the  German  arm}^  in  over  40,000  cases  was  only  3.6  per  cent. 

Certain  complications  and  terminations  are  particularly  serious.  The 
meningitis  of  pneumonia  is  probably  always  fatal.  Endocarditis  is  extremely 
grave,  much  more  so  than  pericarditis.  Apart  from  these  serious  complica- 
tions, the  fatal  event  in  pneumonia  is  due  either  to  a  gradual  toxsemia  or  to 
mechanical  interference  with  the  respiration  and  circulation. 

Much  stress  has  been  laid  of  late  upon  the  factor  of  leucocytosis  as  an 
element  in  the  prognosis.  A  very  slight  or  complete  absence  of  a  leucocytosis 
is  rightly  regarded  as  very  unfavorable. 

Toxcemia  is  the  important  prognostic  feature  in  the  disease,  to  which  in 
a  majority  of  the  cases  the  degree  of  pyrexia  and  the  extent  of  consolidation 
are  entirely  subsidiary.  It  is  not  at  all  proportionate  to  the  degree  of  lung 
involved.  A  severe  and  fatal  toxaemia  may  occur  with  the  consolidation  of 
only  a  small  part  of  one  lobe.  On  the  other  hand,  a  patient  with  complete 
solidification  of  one  lung  may  have  no  signs  of  a  general  infection.  The 
question  of  individual  resistance  seems  to  be  the  most  important  one,  and 
one  sees  even  most  robust-looking  individuals  fatally  stricken  within  a  few 
days. 

Death  is  rarely  due  to  direct  interference  with  the  function  of  respira- 
tion, even  in  double  pneumonia.  Sometimes  it  seems  to  be  caused  by  the 
extensive  involvement  with  oedema  of  the  other  parts  of  the  lungs,  an 
engorgement  with  progressive  weakness  of  the  right  heart.  But  death  is  most 
frequently  due  to  the  action  of  the  poisons  on  the  vaso-motor  centres,  with 
progressive  lowering  of  the  blood  pressure.  This  is  a  much  more  serious 
factor  than  direct  weakness  of  the  heart  muscle  itself. 

Diagnosis. — ISTo  disease  is  more  readily  recognized  in  a  large  majority  of 
the  cases.  The  external  characters,  the  sputa,  and  the  physical  signs  combine 
to  make  one  of  the  clearest  of  clinical  pictures.  After  a  study  in  the  post- 
mortem room  of  my  own  and  others'  mistakes,  I  think  that  the  ordinary  lobar 
pneumonia  of  adults  is  rarely  overlooked.  Errors  are  particularly  liable  to 
occur  in  the  intercurrent  pneumonias,  in  those  complicating  chronic  affec- 
tions, and  in  the  disease  as  met  with  in  children,  the  aged,  and  drunkards. 
Tuberculo-pneumonic  phthisis  is  frequently  confounded  with  pneumonia. 
Pleurisy  with  effusion  is,  I  believe,  not  often  mistaken  except  in  children. 
The  diagnostic  points  will  be  referred  to  under  pleurisy. 

In  diabetes.  Bright' s  disease,  chronic  heart-disease,  pulmonary  phthisis, 
and  cancer,  an  acute  pneumonia  often  ends  the  scene,  and  is  frequently  over- 
looked. In  these  cases  the  temperature  is  perhaps  the  best  index,  and  should, 
more  particularly  if  cough  occurs,  lead  to  a  careful  examination  of  the  lungs. 
The  absence  of  expectoration  and  of  pulmonary  symptoms  may  nlake  the  diag- 
nosis very  difiicult. 


LOBAR  PNEUMONIA.  189 

In  children  there  are  two  special  sources  of  error;  the  disease  may  be 
entirely  masked  by  the  cerebral  symptoms  and  the  case  mistaken  for  one  of 
meningitis.  It  is  remarkable  in  these  cases  how  few  indications  there  are  of 
pulmonary  trouble.  The  other  condition  is  pleurisy  with  effusion,  which  in 
children  often  has  deceptive  physical  signs.  The  breathing  may  be  intensely 
tubular  and  tactile  fremitus  may  be  present.  The  exploratory  needle  is  some- 
times required  to  decide  the  question.  In  the  old  and  debilitated  a  knowledge 
that  the  onset  of  pneumonia  is  insidious,  and  that  the  symptoms  are  ill- 
defined  and  latent,  should  put  the  practitioner  on  his  guard  and  make  him 
very  careful  in  the  examination  of  the  lungs  in  doubtful  cases.  In  chronic 
alcoholism  the  cerebral  symptoms  may  completely  mask  the  local  process.  As 
mentioned,  the  disease  may  assume  the  form  of  violent  mania,  but  more  com- 
monly the  symptoms  are  those  of  delirium  tremens.  In  any  case,  rapid  pulse, 
rapid  respiration,  and  fever  are  symptoms  which  should  invariably  excite 
suspicion  of  inflammation  of  the  lungs.  Under  cerebro-spinal  meningitis  will 
be  found  the  points  of  differential  diagnosis  between  pneumonia  and  that 
disease. 

Pneumonia  is  rarely  confounded  with  ordinary  consumption,  but  to  differ- 
entiate acute  tuberculo-pneumonic  phthisis  is  often  difficult.  The  case  may 
set  in  with  a  chill.  It  may  be  impossible  to  determine  which  condition  is 
present  until  softening  occurs  and  elastic  tissue  and  tubercle  bacilli  appear 
in  the  sputum.  A  similar  mistake  is  sometimes  made  in  children.  With 
typhoid  fever,  pneumonia  is  not  infrequently  confounded.  There  are  in- 
stances of  pneumonia  with  the  local  signs  well  marked  in  which  the  patient 
rapidly  sinks  into  what  is  known  as  the  typhoid  state,  with  dry  tongue,  rapid 
pulse,  and  diarrhoea.  Unless  the  case  is  seen  from  the  outset  it  may  be  very 
difficult  to  determine  the  true  nature  of  the  malady.  On  the  other  hand, 
there  are  cases  of  typhoid  fever  which  set  in  with  symptoms  of  lobar  pneu- 
monia— the  so-called  pneumo-typhus.  It  may  be  impossible  to  make  a  differ- 
ential diagnosis  in  such  a  case  unless  the  characteristic  eruption  occurs  or  the 
Widal  reaction  be  given. 

Prophylaxis. — We  do  not  know  the  percentage  of  individuals  who  harbor 
the  pneumococcus  normally  in  the  secretions  of  the  mouth  and  throat.  In  a 
great  majority  of  cases  it  is  an  auto-infection,  and  the  lowered  resistance  due 
to  exposure  or  to  alcohol,  or  a  trauma  or  anaesthetization,  simply  furnishes 
conditions  which  favor  the  spread  and  growth  of  a  parasite  already  present. 
Individuals  who  have  already  had  pneumonia  should  be  careful  to  keep  the 
teeth  in  good  condition,  and  the  mouth  and  throat  in  as  healthy  a  state  as  pos- 
sible.    Antiseptic  mouth  washes  may  be  used. 

We  know  practically  nothing  of  the  conditions  under  which  the  pneumo- 
coccus lives  outside  the  body,  or  how  it  gains  entrance  in  healthy  individuals. 
The  sputum  of  each  case  should  be  very  carefully  disinfected.  In  institutions 
the  cases  should  be  isolated. 

Treatment. — Pneumonia  is  a  self-limited  disease,  which  can  neither  be 
aborted  nor  cut  short  by  any  known  means  at  our  command.  Even  under 
the  most  unfavorable  circumstances  it  may  terminate  abruptly  and  naturally. 
A  patient  was  admitted  to  the  Philadelphia  Hospital  on  the  evening  of  the 
seventh  day  after  the  chill,  in  which  he  had  been  seen  by  one  of  my  assistants, 
who  had  ordered  him  to  go  to  a  hospital.    He  remained,  however,  in  his  house 


190  SPECIFIC  INFECTIOUS  DISEASES. 

alone,  without  assistance,  taking  nothing  but  a  little  milk  and  bread  and 
whisky,  and  was  brought  into  the  hospital  by  the  police  in  a  condition  of 
active  delirium.  That  night  his  temperature  was  105°  and  his  pulse  above 
120.  In  his  delirium  he  tried  to  escape  through  the  window  of  the  ward. 
The  following  morning — the  eighth  day — the  crisis  occurred,  and  the  tem- 
perature was  below  98°.  The  entire  lower  lobe  of  the  right  side  was  found 
involved,  and  he  entered  upon  a  rapid  convalescence.  So  also,  under  the 
favoring  circumstances  of  good  nursing  and  careful  diet,  the  experience  of 
many  physicians  in  different  lands  has  shown  that  pneumonia  runs  its  course 
in  a  definite  time,  terminating  sometimes  spontaneously  on  the  third  or  the 
fifth  day,  or  continuing  until  the  tenth  or  twelfth. 

There  is  no  specific  treatment  for  pneumonia.  The  young  practitioner 
should  bear  in  mind  that  patients  are  more  often  damaged  than  helped  by 
the  promiscuous  drugging,  which  is  still  only  too  prevalent. 

1.  General  Managemext  of  a  Case. — The  same  careful  hygiene  of  the 
bed  and  of  the  sick-room  should  be  carried  out  as  in  typhoid  fever.  When 
conditions  are  favorable  the  bed  may  be  wheeled  into  the  open  air.  The 
patient  should  not  be  too  much  bundled  up  with  clothing.  For  the  heavy 
flannel  undershirts  should  be  substituted  a  thin,  light  flannel  jacket,  open 
in  front,  which  enables  the  physician  to  make  his  examinations  without  unnec- 
essarily disturbing  the  patient.  The  room  should  be  bright  and  light,  letting 
in  the  sunshine  if  possible,  and  thoroughly  well  ventilated.  Only  one  or  two 
persons  should  be  allowed  in  the  room  at  a  time.  Even  when  not  called  for 
on  account  of  the  high  fever,  the  patient  should  be  carefully  sponged  each 
day  with  tepid  water.  This  should  be  done  with  as  little  disturbance  as  possi- 
ble.    Special  care  should  be  taken  to  keep  the  mouth  and  gums  cleansed. 

2.  Diet. — Plain  water,  a  pleasant  table  water,  or  lemonade  should  be 
given  freely.  When  the  patient  is  delirious  the  water  should  be  given  at 
fixed  intervals.  The  food  should  be  liquid,  consisting  chiefly  of  milk,  either 
alone  or,  better,  mixed  with  food  prepared  from  some  one  of  the  cereals,  and 
eggs,  either  soft  boiled  or  raw. 

3.  Special  Treatment. — Certain  measures  are  believed  to  have  an  influ- 
ence in  arresting,  controlling,  or  cutting  short  the  disease.  It  is  very  diffi- 
cult for  the  practitioner  to  arrive  at  satisfactory  conclusions  on  this  question 
in  a  disease  so  singularly  variable  in  its  course.  How  natural,  when  on  the 
third  or  fourth  day  the  crisis  occurs  and  convalescence  sets  in,  to  attribute 
the  happy  result  to  the  effect  of  some  special  medication !  How  easy  to  forget 
that  the  same  unexpected  early  recoveries  occur  under  other  conditions !  The 
following  are  among  the  measures  which  may  be  helpful : 

(a)  Bleeding. — The  reproach  of  Van  Helmont,  that  "  a  bloody  Moloch 
presides  in  the  chairs  of  medicine,"  can  not  be  brought  against  this  genera- 
tion of  physicians.  Before  Louis'  iconoclastic  paper  on  bleeding  in  pneu- 
monia it  would  have  been  regarded  as  almost  criminal  to  treat  a  case  without 
venesection.  We  employ  it  nowadays  much  more  than  we  did  a  few  years 
ago,  but  more  often  late  in  the  disease  than  early.  To  bleed  at  the  very  onset 
in  robust,  healthy  individuals  in  whom  the  disease  sets  in  with  great  intensity 
and  high  fever  is,  I  believe,  a  good  practice.  I  have  seen  instances  in  which 
it  was  very  beneficial  in  relieving  the  pain  and  the  dyspnoea,  reducing  the 
temperature,  and  allaying  the  cerebral  symptoms. 


LOBAR  PNEUMONIA.  191 

(&)  Drugs.- — Certain  drugs  are  credited  with  the  power  of  reducing  the 
intensity  and  shortening  the  duration  of  the  attack.  Among  them  veratrum 
viride  still  holds  a  place,  doses  of  TTl  ij-v  of  the  tincture  given  every  two  hours. 
Tartar  emetic — a  remedy  which  had  great  vogue  some  years  ago — is  now 
very  rarely  employed.  To  a  third  drug,  digitalis,  has  been  attributed  of  late 
great  power  in  controlling  the  course  of  the  disease.  Petresco  gives  at  one 
time  as  much  as  from  4  to  12  grammes  of  the  powdered  leaves,  and  claims 
that  these  colossal  doses  are  specially  efficacious  in  shortening  the  course  of 
the  disease  and  diminishing  the  mortality. 

(c)  Antipneumococcic  Serum. — Anders'  recent  analyses  of  the  reported 
cases  do  not  give  a  very  favorable'  impression  of  the  value  of  the  sera  at  present 
in  use.  More  perhaps  may  be  expected  from  the  polyvalent  serum  of  Eomer, 
but  even  with  it  4  of  the  24  cases  treated  in  Curschmann's  clinic  died 
(Passler). 

4,  Symptomatic  Teeatment. — (a)  To  relieve  the  Pain. — The  stitch  in 
the  side  at  onset,  which  is  sometimes  so  agonizing,  is  best  relieved  by  a  hypo- 
dermic injection  of  a  quarter  of  a  grain  of  morphia.  When  the  pain  is  less 
intense  and  diffuse  over  one  side,  the  Paquelin  cautery  applied  lightly  is  very 
efficacious,  or  hot  or  cold  applications  may  be  tried.  When  the  disease  is 
fairly  established  the  pain  is  not,  as  a  rule,  distressing,  except  when  the 
patient  coughs,  and  for  this  the  Dover's  powder  may  be  used  in  5-grain  doses, 
according  to  the  patient's  needs.  Hot  poultices,  formerly  so  much  in  use,  re- 
lieve the  pain,  though  not  more  than  the  cold  applications.  For  children  they 
are  often  preferable. 

(&)  To  combat  the  Toxcemia. — Until  we  have  a  specific,  either  drug  or 
the  product  of  the  bacteriological  laboratory,  which  will  safely  and  surely 
neutralize  the  toxins  of  the  disease,  we  must  be  content  with  measures  which 
promote  the  elimination  of  the  poisons.  Unfortunately,  we  know  very  little 
of  the  channels  by  which  they  are  got  rid  of,  but  on  general  principles  we  may 
suppose  them  to  be  the  skin,  the  kidneys,  and  the  bowels.  By  the  tepid  or 
the  cold  bath  not  only  is  the  action  of  the  skin  promoted,  but  the  vaso-motor 
centres  are  stimulated.  Abundance  of  water  should  be  given  to  promote  the 
flow  of  urine,  and  the  saline  infusion  seems  to  act  helpfully  in  this  way. 
The  bowels  should  be  kept  freely  open  by  saline  laxatives. 

(c)  The  third  and  all-important  indication  in  the  treatment  of  pneu- 
monia is  to  support  the  circulation.  We  can  not  at  present  separate  the  effects 
of  the  fever  from  those  of  the  toxins.  It  is  possible,  indeed,  as  some  suppose, 
that  the  fever  itself  may  be  beneficial.  Undoubtedly,  however,  high  and  pro- 
longed pyrexia  is  dangerous  to  the  heart,  and  should  be  combated.  For  this 
our  most  trusty  weapon  is  hydrotherapy,  which  in  pneumonia  is  used  in  sev- 
eral different  ways.  The  ice-bag  to  the  affected  side  is  one  of  the  most  con- 
venient and  serviceable.  It  allays  the  pain,  reduces  the  fever  slightly,  and, 
as  a  rule,  the  patient  says  he  feels  very  much  more  comfortable.  Broad,  flat 
ice-bags  are  now  easily  obtained  for  the  purpose,  and  if  these  are  not  available 
an  ice  poultice  can  be  readily  made,  and  by  the  use  of  oil-silk  the  clothing 
and  bedding  of  the  patient  can  be  protected  from  the  water.  Cold  sponging  is 
the  best  form  of  hydrotherapy  to  employ  as  a  routine  measure.  When  done 
limb  by  limb  the  patient  is  but  little  disturbed,  and  it  is  refreshing  and  bene- 
ficial.   With  very  pronounced  nervous  symptoms  and  persistent  high  tempera- 


192  SPECIFIC  INFECTIOUS  DISEASES. 

ture,  or  with  hyperpyrexia,  a  cold  bath  of  ten  minutes'  duration  may  be  given. 
Probably  the  very  best  effect  of  the  hydrotherapy  is  in  the  stimulating  effect 
on  the  vaso-motor  centres.  The  dusky  skin,  increasing  cyanosis,  increasing 
shortness  of  breath,  with  signs  of  oedema  of  the  lungs,  and  the  rapid,  small, 
soft  pulse,  tell  of  a  progressive  lowering  of  the  blood  tension.  Digitalin  given 
hypodermically  in  full  doses,  ^V  ~  iV  gr.,  and  strychnine,  ^--g-V  gr.,  are  the 
most  satisfactory  drugs  to  support  the  blood  pressure.  Camphor  and  caffein 
and  musk  are  also  of  value.  The  effect  of  adrenalin,  even  in  intravenous  injec- 
tion, is  too  transitory  to  be  of  any  value.  Alcohol  does  not  seem  to  raise  the 
blood  pressure  in  fever,  and  the  studies  of  Briggs  and  Cook  in  my  wards  would 
indicate  that  it  is  not  of  much  value  in  progressive  vaso-motor  collapse.  This 
does  not  mean,  however,  that  it  may  not  have  a  value  in  the  fever,  and  I 
should  be  sorry  to  give  up  its  use  in  the  severer  forms  of  enteric  and  of  pneu- 
monia. Saline  infusions  promote  elimination  and  may  help  in  tiding  over 
a,  period  of  vascular  depression.  A  litre  may  be  allowed  to  run  by  gravity 
beneath  the  skin,  and  if  necessary  may  be  repeated  two  or  three  times  in  the 
twenty-four  hours. 

Oxygen  Gas. — It  is  doubtful  whether  the  inhalation  of  oxygen  in  pneu- 
monia is  really  beneficial.  The  work  of  Lorrain-Smith  suggests,  indeed, 
that  it  may  under  certain  circumstances  be  positively  harmful.  He  has  shown 
experimentally  that  oxygen  may  be  a  serious  irritant,  actually  producing 
inflammation  of  the  lungs.  If  we  are  justified  in  applying  his  results  to  man, 
there  can  be  but  little  doubt  that  the  administration  of  oxygen  may  not  be 
entirely  "  harmless,"  as  stated  in  previous  editions  of  this  work.  If  the  tension 
of  the  oxygen  breathed  rises  to  80  per  cent  of  an  atmosphere,  which  it  might 
•easily  do  in  certain  methods  of  administration,  it  may  be  injurious.  When 
used  it  should  be  allowed  to  flow  gently  from  the  nozzle  held  at  a  little  dis- 
tance, in  which  way  it  is  freel}"  diluted  with  air. 

Treatment  of  Complications. — If  the  fever  persists  it  is  important  to  look 
out  for  pleurisy,  particularly  for  the  meta-pneumonic  empyema.  The  explora- . 
tory  needle  should  be  used  if  necessary.  A  sero-fibrinous  effusion  should  be 
aspirated,  a  purulent  opened  and  drained.  In  a  complicating  pericarditis  with 
a  large  effusion  aspiration  may  be  necessary.  Delayed  resolution  is  a  difficult 
condition  to  treat.  Fibrotysin,  2.5  cc.  every  other  day,  has  been  used  suc- 
cessfully in  a  few  cases  (Crofton). 


XVI.    DIPHTHERIA. 

Definition. — A  specific  infectious  disease,  characterized  by  a  local  fibrinous 
exudate,  usually  upon  a  mucous  membrane,  and  by  constitutional  symptoms 
due  to  toxins  produced  at  the  site  of  the  lesion.  The  presence  of  the  Klebs- 
Loefiler  bacillus  is  the  etiological  criterion  by  which  true  diphtheria  is  distin- 
guished from  other  forms  of  membranous  inflammation. 

The  clinical  and  bacteriological  conceptions  of  diphtheria  are  at  present 
not  in  full  accord.  On  the  one  hand,  there  are  cases  of  simple  sore  throat 
which  the  bacteriologists,  finding  the  Klebs-Loeffler  bacillus,  call  true  diph- 
theria. On  the  other  hand,  cases  of  membranous,  sloughing  angina,  diag- 
nosed by  the  physician  as  diphtheria,  are  called  by  the  bacteriologists,  in 


DIPHTHERIA.  193 

the  absence  of  the  Klebs-Loeffler  bacilkis,  pseudo-diphtheria  or  diphtheroid 
angina.  The  term  diphtheroid  may  be  used  for  the  present  to  designate  those 
forms  in  which  the  Klebs-Loeffler  bacillus  is  not  present.  Though  usually 
milder,  severe  constitutional  disturbance,  and  even  paralysis,  may  follow  these 
so-called  pseudo-diphtheritic  processes. 

For  an  exhaustive  discussion  on  every  aspect  of  the  disease  the  reader  is 
referred  to  the  splendid  monograph,  edited  by  Nuttall  and  Graham- Smith, 
Cambridge,  1908. 

History. — Known  in  the  East  for  centuries,  and  referred  to  in  the  Baby- 
lonian Talmud,  it  is  not  until  the  first  century  a.d.  that  an  accurate  clinical 
account  appears  in  the  writings  of  Aretseus.  The  paralysis  of  the  palate  was 
recognized  by  ^tius  (sixth  century  a.d.).  Throat  pestilences  are  mentioned 
in  the  Middle  Ages.  Severe  epidemics  occurred  in  Europe  in  the  sixteenth 
and  seventeenth  centuries,  particularly  in  Spain.  In  England  in  the  latter  part 
of  the  eighteenth  century  it  was  described  by  Fothergill  and  Huxham,  and  in 
America  by  Bard.  Washington  died  of  the  disease.  Ballonius  recognized  the 
affection  of  the  larynx  and  trachea  in  1762,  Home  in  Scotland  described  it 
as  croup.  The  modern  description  dates  from  Bretonneau,  of  Tours  (1826), 
who  gave  to  it  the  name  diphtherite.  Throughout  the  nineteenth  century  it 
prevailed  extensively  in  all  known  countries,  and  it  is  at  present  everywhere 
epidemic.  After  innumerable  attempts,  in  which  Klebs  took  a  leading  part, 
the  peculiar  organism  of  the  disease  was  isolated  by  Loeffler.  The  toxin  was 
next  determined  by  the  work  of  Eoux,  Yersin,  and  others,  and  finally  the  anti- 
toxin was  discovered  by  Behring.  As  told  by  Loeffler  in  the  above-mentioned 
volume,  the  story  is  one  of  the  most  brilliant  of  the  achievements  of  scientific 
medicine. 

Etiology. — Everywhere  endemic  in  large  centres  of  population  the  disease 
becomes  at  times  epidemic.  It  is  more  prevalent  on  the  continent  of  Europe 
than  in  Great  Britain,  and  Ireland  has  less  than  other  countries.  The  large 
cities  of  the  United  States  have  been  much  afflicted,  and  wide-spread  epidem- 
ics have  occurred  in  country  districts.  Pandemics  occur  cyclically,  at  irregu- 
lar intervals,  under  conditions  as  yet  imperfectly  known.  Dry  seasons  seem 
to  favor  the  disease,  which,  like  typhoid  fever,  shows  an  autumnal  prevalence. 

Modes  of  Infection. — The  disease  is  highly  contagious.  The  bacilli  may  be 
transmitted  (a)  from  one  person  to  another;  few  diseases  have  proved  more 
fatal  to  physicians  and  nurses.  (&)  Infected  articles  may  convey  the  bacilli, 
which  may  remain  alive  for  many  months;  scores  of  well-attested  instances 
have  been  recorded  of  this  mode  of  transmission,  (c)  Persons  suffering  from 
atypical  forms  of  diphtheria  may  convey  the  disease;  nasal  catarrh,  mem- 
branous rhinitis,  mild  tonsillitis,  otorrhoea  may  be  caused  by  the  diphtheria 
bacilli,  and  from  each  of  these  sources  cases  have  been  traced,  (d)  From  the 
throats  of  healthy  contacts — diphtheria  carriers,  persons  who  present  no  signs 
of  the  disease,  the  bacilli  have  been  obtained  by  culture;  instances  of  this 
method  have  multiplied  of  late  in  the  literature,  and  a  list  is  given  by  Graham- 
Smith,  (e)  Even  healthy  children  without  any  naso-pharyngeal  catarrh, 
who  have  not  been  in  contact  with  the  disease,  may  in  large  cities  harbor 
the  bacilli.  In  1,000  children'  from  the  New  York  tenements  Sholley  found 
18  with  virulent  and  38  with  non-virulent  bacilli.  Long  after  recovery  has 
taken  place  virulent  bacilli  have  been  isolated  from  the  throat.  It  is  impor- 
14 


194  SPECIFIC  INFECTIOUS  DISEASES. 

tant  to  bear  in  mind  under  d  and  e  that  it  is  only  persons  wlio  harbor  the 
virulent  forms  who  are  capable  of  transmitting  the  disease.  In  schools  the 
interchange  of  articles,  such  as  sweets,  pencils,  etc.,  and  the  habit  which 
children  have  of  putting  ever3rthing  into  their  mouths  afford  endless  oppor- 
tunities for  the  transmission  of  the  disease.  As  Westbrook  remarks,  diph- 
theria is  transmitted  usually  by  almost  direct  exchange  of  the  flora  of  the 
nose  and  mouth.  (/)  Numerous  epidemics  have  been  traced  to  milk,  since 
Power  in  1878  determined  this  method  of  spread.  Virulent  bacilli  have  been 
found  in  the  milk,  and  Dean  and  Todd  and  Ashby  have  found  virulent  organ- 
isms in  the  acquired  lesions  on  the  teats  of  cows,  (g)  A  few  instances  of 
accidental  infection  from  cultures  and  through  animals  are  on  record. 

Air  borne  infections,  through  sewer  gas,  soil,  drains,  dust,  etc.,  are  not 
now  held  to  occur.    The  disease  may  be  transmitted  by  direct  inoculation. 

Predisposing  Causes. — Age  is  the  most  important.  Sucklings  are  not  often 
attacked,  but  Jacobi  saw  three  eases  in  the  new-born.  Early  in  the  second 
year  the  disposition  increases  rapidly,  and  continues  at  its  height  until  the 
fifth  year.  At  Baginsky's  clinic,  Berlin,  among  2,711  cases,  1,235  occurred 
from  the  second  to  the  fifth  years  inclusive.  In  ISTew  York  between  1891-1900 
among  the  deaths  80.8  per  cent  occurred  under  five,  17  per  cent  l^etween  five 
and  ten — figures  which  show  the  extraordinary  preponderance  of  the  disease 
among  children.  Girls  are  attacked  in  slightly  larger  numbers  than  boys. 
November,  December,  and  January  are  the  months  of  greatest  prevalence  in 
the  United  States;  in  London  the  months  of  October  and  November. 

Soil  and  altitude  have  little  or  no  influence  on  the  prevalence  of  the  dis- 
ease; nor  does  race  play  an  important  role.  Individiial  susceptibility  is  a 
very  special  factor;  not  only  do  very  many  of  those  exj)Osed  escape,  but  even 
those,  too,  in  whose  throats  virulent  bacilli  lodge  and  grow. 

The  Klebs-Loeffler  bacillus  occurs  in  a  large  number  of  all  suspected  cases 
— 72  per  cent,  based  upon  an  analysis  of  27,000  cases  in  the  literature  by 
Graham  Smith.  It  is  found  chiefly  in  the  false  membrane,  and  does  not 
extend  into  the  subjacent  mucosa.  In  the  majority  of  instances  the  organ- 
isms are  localized,  and  only  a  few  penetrate  into  the  interior.  Post  mortem 
in  many  instances  the  bacilli  are  found  in  the  blood  and  in  the  internal 
organs.  Occasionally  they  are  found  in  the  blood  during  life.  It  may  be  the 
predominating  or  sole  organism  in  the  broncho-pneumonia  so  common  in 
the  disease.  Outside  the  throat,  the  common  site  of  its  morbid  action,  the 
Klebs-Loeffler  bacillus  has  been  found  in  diphtheritic  conjunctivitis,  in  otitis 
media,  sometimes  in  wound  diphtheria,  upon  the  genitals,  in  fibrinous  rhi- 
nitis, and  in  an  attenuated  condition  by  Howard  in  a  case  of  ulcerative 
endocarditis. 

Morphological  Characters. — The  bacillus  is  non-motile,  varies  from 
2.5  to  3  ju,  in  length  and  from  0.5  to  0.8  [x  in  thickness.  In  appearance  it  is 
multiform,  varying  from  short  rather  sharply  pointed  rods  to  irregular  bizarre 
forms,  with  one  or  both  ends  swollen,  and  staining  more  or  less  unevenly 
and  intensely.  Westbrook  recognizes  three  main  types — granular,  barred,  and 
solid  staining.  Branching  forms  are  occasionally  met  with.  The  bacillus 
stains  in  sections  or  on  the  cover-glass  by  the  Gram  method. 

It  grows  best  upon  a  mixture  of  glucose  bouillon  and  blood  serum 
(Loeffler),    forming   moderate-sized,    elevated,    grayish-white    colonies    with 


DIPHTHERIA.  195 

opaque  centres.  It  grows  also  upon  all  the  ordinary  culture  media.  The 
growth  usually  ceases  at  temperatures  below  20°  C. 

The  bacillus  is  very  resistant,  and  cultures  have  been  made  from  a  bit  of 
membrane  preserved  for  five  months  in  a  dry  cloth.  Incorporated  with  dust 
and  kept  moist,  the  bacilli  were  still  cultivable  at  the  end  of  eight  weeks; 
kept  in  a  dried  state  they  no  longer  grew  at  the  end  of  this  period  (Ritter). 

Variation  in  Virulence. — The  Klebs-Loeffler  bacillus  evidently  has  very 
varying  grades  of  virulence  down  even  to  complete  absence  of  pathogenic 
effects.  The  name  pseudo-bacillus  of  diphtheria  should  not  be  given  to 
this  avirulent  organism.  For  testing  the  virulence  the  guinea-pig  is  used, 
being  most  susceptible  to  the  poison.  For  a  gross  test  an  amount  of  a 
forty-eight-hour  bouillon  culture  equalling  one-half  per  cent  of  the  weight 
of  the  animal  is  injected  subcutaneously.  Park  and  Williams  obtained  a 
bacillus  of  such  extraordinary  virulence  that  0.005  cc.  of  a  filtered  bouillon 
culture  killed  a  500  gramme  guinea-pig  in  seventy-two  hours.  "  A  fully 
virulent  culture  is  one  which  causes  the  death  of  a  guinea-pig  within  three 
days  or  less;  a  culture  of  medium  virulence  one  which  causes  the  death  of 
the  animal  in  from  three  to  five  days.  Cultures  which  only  produce  local 
necrosis  and  ulceration  or  death  after  a  greater  number  of  days  may  be  con- 
sidered as  of  slight  virulence"  (J.  H.  Wright).  At  the  seat  of  the  inocula- 
tion there  is  local  necrosis  with  fibrinous  exudate  which  contains  the  bacilli, 
and  there  is  also  a  more  or  less  extensive  cedema  of  the  subcutaneous  tissue. 

The  Presence  of  the  Klees-Loefeler  Bacillus  in  Non-membranous 
Angina  and  in  Healthy  Throats. — The  bacillus  has  been  isolated  from 
cases  which  show  nothing  more  than  a  simple  catarrhal  angina,  of  a  mild  type 
without  any  membrane,  with  diffuse  redness,  and  perhaps  huskiness  and  signs 
of  catarrhal  laryngitis.  In  other  cases  the  anatomical  picture  may  be  that  of 
a  lacunar  tonsillitis. 

The  organisms  may  be  met  with  in  perfectly  healthy  throats,  particularly 
in  persons  in  the  same  house,  or  the  ward  attendants  and  nurses  in  fever 
hospitals. 

Following  an  attack  of  diphtheria  the  bacilli  may  persist  in  the  throat  or 
nose  after  all  the  membrane  has  disappeared  for  weeks  or  months — even  15 
months.  In  explanation  of  this  persistence  Councilman  has  called  attention 
to  the  frequency  with  which  the  antrum  is  affected. 

Toxin  op  the  Klebs-Loeffler  Bacillus. — Roux  and  Yersin  showed 
that  a  fatal  result  following  the  inoculation  with  the  bacillus  was  not  caused 
by  any  extension  of  the  micro-organisms  within  the  body;  and  they  were 
enabled  in  bouillon  cultures  to  separate  the  bacilli  from  the  poison.  The  toxin 
so  separated  killed  with  very  much  the  same  effects  as  those  caused  by  the 
inoculation  of  the  bacilli;  the  pseudo-membrane,  however,  is  not  formed. 
These  results  were  confirmed  by  many  observers,  particularly  by  Sidney  Mar- 
tin, who  separated  a  toxic  albumose.  The  precise  composition  of  the  body 
and  whether  it  is  a  proteid  at  all  is  still  doubtful;  certain  authorities,  how- 
ever, believe  that  it  belongs  to  the  enzymes,  possessing  as  it  does  many  attri- 
butes in  common  with  them. 

Susceptible  animals  may  be  rendered  immune  from  diphtheritic  infection 
by  injecting  weakened  cultures  of  the  bacillus  or,  what  is  better,  suitable  doses 
of  the  diphtheria  toxin.     The  result  of  the  injections  is  a  febrile  reaction 


196  SPECIFIC  INFECTIOUS  DISEASES. 

which  soon  passes  away  and  leaves  the  animal  less  susceptible  to  the  poison  or 
the  living  bacilli.  By  repeating  and  gradually  increasing  the  quantity  of 
poison  injected  a  high  degree  of  immunity  can  be  produced  in  large  animals 
(goat,  horse). 

The  Bacteria  associated  with  the  Diphtheria  Bacillus. — The  most 
common  is  the  streptococcus  pyogenes.  Otliers,  in  addition  to  the  organisms 
constantly  found  in  the  mouth,  are  the  micrococcus  lanceolatus,  the  bacillus 
coli,  and  the  staphylococcus  aureus  and  albus.  Of  these,  probably  the  strepto- 
coccus pyogenes  is  the  most  important,  as  cases  of  general  infection  with  this 
organism  have  been  found  in  diphtheria.  The  suppuration  in  the  lymph- 
glands  and  the  broncho-pneumonia  are  usually  (though  not  always)  caused  by 
this  organism. 

Pseudo-Diphtheeia  Bacillus. — BaciUus  Xerosis. — As  mentioned  above, 
the  Ellebs-Loeffler  bacillus  varies  very  much  in  its  virulence,  and  it  exists  in  a 
form  entirely  devoid  of  pathogenic  properties.  This  organism  should  not, 
however,  be  designated  pseudo-diphtheria  bacillus.  The  name  should  be  con- 
fined to  bacilli,  which,  though  resembling  the  diphtheria  bacillus,  differ  from 
it  not  only  by  absence  of  virulence,  but  also  by  cultured  peculiarities.  A 
similar  bacillus,  showing,  however,  certain  cultural  differences  from  the 
pseudo-diphtheria  bacillus,  has  been  repeatedly  found  in  the  conjunctival  sac 
in  health  and  disease  (B.  xerosis).  Organisms  having  the  morphology  of 
the  dif)htheria  bacillus,  but  devoid  of  virulence,  probably  belonging  to  the 
group  of  pseudo-diphtheria  and  xerosis  bacilli,  have  been  described  in  human 
beings  in  association  with  a  number  of  diseases,  such,  as  Eg}'ptian  dysentery 
(Kruse  and  Pasquale)  ;  they  have  been  demonstrated  upon  the  skin,  in  the 
crusts  of  variola  pustules,  and  in  impetigo,  in  sputum,  in  pneumonia  (Kruse, 
Olilmacher),  in  gangi-ene  of  the  lung  (Babes),  in  ulcerative  endocarditis 
(Howard),  in  ascitic  fluid  (Harris),  in  pus  from  pyuria  (Bergey),  in.  ozsna 
(Wilder),  and  in  tuberculosis  (Schiiltz  and  Ehret).  Other  varieties  of 
pseudo-bacillus,  described  b}'  Euediger  and  Alice  Hamilton,  possess  a  virulence 
sufficient  to  cause  severe  lesions  in  man  and  death  in  inoculated  animals.  In 
such  cases  the  antitoxin  had  no  influence  on  the  infection,  but  animals  recov- 
ered upon  the  injection  of  an  immune  serum  prepared  from  these  bacilli. 

Diphtheroid  Inflammations. — Under  the  term  diphtheroid  may  be  grouped 
those  membranous  inflammations  which  are  not  associated  with  the  Klebs- 
Loeffier  bacillus.  It  is  perhaps  a  more  suitable  designation  than  pseudo-diph- 
theria or  secondary  diphtheria.  As  in  a  great  majorit}''  of  cases  the  strepto- 
coccus pyogenes  is  the  active  organism,  the  term  "  streptococcus  diphtheritis  " 
is  often  employed.  The  name  "  diphtheritis  *'  is  best  used  in  an  anatomical 
sense  to  designate  an  inflammation  of  a  mucous  membrane  or  integumentary 
surface  characterized  by  necrosis  and  a  fibrinous  exudate,  whereas  the  term 
"  diphtheria  "  should  be  limited  to  the  disease  caused  by  the  Klebs-LoeSier 
bacillus.  The  proportion  of  cases  of  diphtheroid  inflammation  varies  greatly 
in  the  different  statistics.  Of  the  large  number  of  observations  made  by  Park 
and  Beebe  (5,611)  in  oSTew  York,  40  per  cent  were  diphtheroid.  Figures  from 
other  sources  do  not  show  so  high  a  percentage. 

It  is  not  to  be  inferred  from  these  statistics  that  any  considerable  number 
of  the  cases  which  present  the  appearances  of  typical  and  characteristic  pri- 
mary diphtheria  are  due  to  other  micro-organisms  than  the  Klebs-Loeffler 


DIPHTHERIA.  197 

bacillus.  Nearly  all  such  cases,  when  carefully  examined  by  a  competent  bac- 
teriologist, are  found  to  be  due  to  the  diphtheria  bacillus.  It  is  the  less  char- 
acteristic cases,  with  more  or  less  suspicion  of  diphtheria,  which  are  most 
likely  to  be  caused  by  other  bacteria  than  the  Klebs-Loeffler  bacillus.  It  is 
also  to  be  remembered  that  in  the  routine  examination  of  a  large  number  of 
cases  for  boards  of  health  and  diphtheria  wards  of  hospitals,  some  cases  of 
genuine  diphtheria  may  escape  recognition  from  lack  of  such  repeated  and 
thorough  bacteriological  tests  as  are  sometimes  required  for  the  detection  of 
cases  presenting  unusual  difficulties. 

Conditions  under  which  the  Diphtheroid  Affection  occurs. — Of 
450  cases  (Park  and  Beebe),  300  occurred  in  the  autumn  months  and  150  in 
the  spring;  198  occurred  in  children  from  the  first  to  the  seventh  year.  In  a 
large  proportion  of  all  the  cases  the  disease  develops  in  children,  and  can  be 
differentiated  from  diphtheria  proper  only  by  the  bacteriological  examination. 
In  many  of  the  cases  it  is  simply  an  acute  catarrhal  angina  with  lacunar  ton- 
sillitis. 

The  diphtheroid  inflammations  are  particularly  prone  to  develop  in  connec- 
tion with  the  acute  fevers. 

(a)  Scarlet  Fever. — In  a  large  proportion  of  the  cases  of  angina  in  scar- 
let fever  the  Klebs-Loeffler  bacillus  is  not  present.  Booker  has  reported  11 
cases  complicating  scarlet  fever,  in  all  of  which  the  streptococci  were  the  pre- 
dominant organisms.  Of  the  450  cases  of  Park  and  Beebe,  43  complicated 
scarlet  fever.  The  angina  of  this  disease  is  not  always,  however,  due  to  the 
streptococcus.  Where  diphtheria  is  prevalent  and  opportunities  are  favorable 
for  exposure,  a  large  proportion  of  the  cases  of  membranous  throats  in  scarlet 
fever  may  be  genuine  diphtheria,  as  is  shown  by  the  statistics  of  Williams  and 
Morse  in  the  Boston  City  Hospital.  Here,  of  97  cases  of  scarlet  fever,  mem- 
branous angina  was  present  in  35 ;  in  12  with  the  Klebs-Loeffler  bacillus,  and 
in  23  with  other  organisms.  Morse  reports  99  cases  of  angina  in  scarlet  fever 
in  which  76  were  diphtheritic.  This  large  proportion  of  cases  in  which  scar- 
let fever  was  associated  with  true  diphtheria  is  attributed  to  local  conditions 
in  the  hospital. 

(&)  Measles. — Membranous  angina  is  much  less  common  in  this  disease. 
It  occurred  in  6  of  the  450  diphtheroid  cases  in  New  York.  Of  4  cases  with 
severe  membranous  angina  at  the  Boston  City  Hospital,  1  only  presented  the 
Klebs-Loeffler  bacillus. 

(c)  Whooping-cough  may  also  be  complicated  with  membranous  angina. 
The  bacteriological  examinations  have  not  been  very  numerous,  Escherich 
gives  4  cases,  in  all  of  which  the  Klebs-Loeffler  bacillus  was  found. 

(d)  Typhoid  Fever. — Membranous  inflammations  in  this  disease  are  not 
very  infrequent;  they  may  occur  in  the  throat,  the  pelvis  of  the  kidney,  the 
bladder,  or  the  intestines.  The  complication  may  be  caused  by  the  Klebs-Loef- 
fler bacillus,  which  was  present  in  4  eases  described  by  Morse.  It  is  frequently, 
however,  a  streptococcus  infection. 

Ernst  Wagner  has  remarked  upon  the  greater  frequency  of  these  mem- 
branous inflammations  in  typhoid  fever  when  diphtheria  is  prevailing. 

Clinical  Features  of  the  Diphtheroid  Affection. — The- cases,  as  a  rule,  are 
milder,  and  the  mortality  is  low,  only  2.5  per  cent  in  the  450  cases  of  Park 
and  Beebe.     The  diphtheroid  inflammations  complicating  the  specific  fevers 


198  SPECIFIC  INFECTIOUS  DISEASES. 

are,  however,  often  very  fatal,  and  a  general  streptococcus  infection  is  by  no 
means  infrequent.  As  in  the  Klebs-Loeffler  angina,  there  may  be  only  a  simple 
catarrhal  process.  In  other  instances  the  tonsils  are  covered  with  a  creamy, 
pultaceous  exudate,  without  any  actual  membrane.  An  important  group  may 
begin  as  a  simple  lacunar  tonsillitis,  while  in  others  the  entire  fauces  and  ton- 
sils are  covered  by  a  continuous  membrane,  and  there  is  a  foul  sloughing 
angina  with  intense  constitutional  disturbance. 

Are  the  diphtheroid  cases  contagious?  General  clinical  experience  war- 
rants the  statement  that  the  membranous  angina  associated  with  the  fevers 
is  rarely  communicated  to  other  patients.  The  health  department  of  New 
York  does  not  keep  the  diphtheroid  cases  under  supervision.  Their  inves- 
tigation of  the  450  diphtheroid  cases  seems  to  justify  this  conclusion.  Park 
and  Beebe  say  that  "  it  did  not  seem  that  the  secondary  cases  were  any  less 
liable  to  occur  when  the  primary  case  was  isolated  than  when  it  was  not.'^ 

SequelcB  of  the  Diphtheroid  Angina. — The  usual  mildness  of  the  disease 
is  in  part,  no  doubt,  due  to  the  less  frequent  systemic  invasion.  Some  of  the 
worst  forms  of  general  streptococcus  infection  are,  however,  seen  in  this  dis- 
ease. There  are  no  peculiarities,  local  or  general,  which  can  be  in  any  way 
regarded  as  distinctive;  and  even  the  most  extensive  paralysis  may  follow  an 
angina  caused  by  it. 

Morbid  Anatomy. — Distribution  op  Membrane. — A  definite  membrane 
was  found  in  127  of  the  220  fatal  Boston  cases,  distributed  as  follows :  tonsils, 
65  cases;  epiglottis,  60;  larynx,  75;  trachea,  66;  pharynx,  51;  mucous  mem- 
brane of  nares,  43;  bronchi,  42;  soft  palate,  including  uvula,  13;  oesophagus, 
12;  tongue,  9;  stomach,  5;  duodenum,  1;  vagina,  2;  vulva,  1;  skin  of  ear,  1; 
conjunctiva,  1.  An  interesting  point  in  the  Boston  investigation  was  the  great 
frequency  with  which  the  accessory  sinuses  of  the  nose  were  found  to  be  in- 
fected. In  the  fatal  cases,  the  exudation  is  very  extensive,  involving  the  uvula, 
the  soft  palate,  the  posterior  nares,  and  the  lateral  and  posterior  walls  of  the 
pharynx.  These  parts  are  covered  with  a  dense  pseudo-membrane,  in  places 
firmly  adherent,  in  others  beginning  to  separate.  In  extreme  cases  the  necro- 
sis is  advanced  and  there  is  a  gangrenous  condition  of  the  parts.  The  mem- 
brane is  of  a  dirty  greenish  or  gray  color,  and  the  tonsils  and  palate  may  be  in 
a  state  of  necrotic  sloughing.  The  erosion  may  be  deep  enough  in  the  tonsils 
to  open  the  carotid  artery,  or  a  false  aneurism  may  be  produced  in  the  deep 
tissues  of  the  neck.  The  nose  may  be  completely  blocked  by  the  false  mem- 
brane, which  may  also  extend  into  the  conjunctivae  and  through  the  Eusta- 
chian tubes  into  the  middle  ear.  In  cases  of  laryngeal  diphtheria  the  exudate 
in  the  pharynx  may  be  extensive.  In  many  cases,  however,  it  is  slight  upon 
the  tonsils  and  fauces  and  abundant  upon  the  epiglottis  and  the  larynx,  which 
may  be  completely  occluded  by  false  membrane.  In  severe  cases  the  exudate 
extends  into  the  trachea  and  to  the  bronchi  of  the  third  or  fourth  dimension. 

In  all  these  situations  the  membrane  varies  very  much  in  consistence, 
depending  greatly  upon  the  stage  at  which  death  has  taken  place.  If  death 
has  occurred  early,  it  is  firm  and  closely  adherent ;  if  late,  it  is  soft,  shreddy, 
and  readily  detached.  When  firmly  adherent  it  is  torn  ofE  with  difficulty  and 
leaves  an  abraded  mucosa.  In  the  most  extreme  cases,  in  which  there  is  exten- 
sive necrosis,  the  parts  look  gangrenous.  In  fatal  cases  the  lymphatic  glands 
of  the  neck  are  enlarged,  and  there  is  a  general  infiltration  of  the  tissues  with 


DIPHTHERIA.  199 

serum;  the  salivary  glands,  too,  may  be  swollen.  In  rare  instances  the  mem- 
brane extends  to  the  gullet  and  stomach. 

On  inspection  of  the  larynx  of  a  child  dead  of  membranous  croup  the  rima 
is  seen  filled  with  mucus  or  with  a  shreddy  material  which,  when  washed  off 
carefully,  leaves  the  mucosa  covered  by  a  thin  grayish-yellow  membrane,  which 
may  be  uniform  or  in  patches.  It  covers  the  ary-epiglottic  folds  and  the  true 
cords,  and  may  be  continued  into  the  ventricles  or  even  into  the  trachea. 
Above,  it  may  involve  the  epiglottis.  It  varies  much  in  consistency.  I  have 
seen  fatal  cases  in  which  the  exudation  was  not  actually  membranous,  but 
rather  friable  and  granular.  It  may  form  a  thick,  even  stratified  membrane, 
which  fills  the  entire  glottis.  The  exudation  may  extend  down  the  trachea 
and  into  the  bronchi,  and  may  pass  beyond  the  epiglottis  to  the  fauces.  Usu- 
ally it  is  readily  stripped  off  from  the  mucous  membrane  of  the  larynx  and 
leaves  exposed  the  swollen  and  injected  mucosa.  On  examination  it  is  seen 
that  the  fibrinous  material  has  involved  chiefly  the  epithelial  lining  and  has  not 
greatly  infiltrated  the  subjacent  tissues. 

We  owe  largely  to  the  labors  of  Wagner,  Weigert,  and  more  particularly  to 
the  splendid  work  of  Oertel,  our  knowledge  of  the  histological  changes  which 
take  place  in  diphtheria.  The  beginning  of  the  lesion  is  due  to  the  toxic  action 
of  the  bacilli  growing  in  the  throat.  The  primary  lesion  is  a  necrosis  and 
degeneration  of  the  epithelial  tissues.  The  organisms  grow,  not  in  the  living, 
but  in  the  necrotic  tissues.  The  first  step  is  necrosis  of  the  epithelium,  often 
preceded  by  active  proliferation  of  the  nuclei  of  the  cells,  which  become 
changed  into  refractive  hyaline  masses.  From  the  structures  below  an  inflam- 
matory exudate  rich  in  fibrin  factors  is  poured  out,  and  fibrin  is  formed  when 
this  comes  in  contact  with  the  necrotic  epithelium. 

The  following  are  the  important  changes  in  the  other  organs : 

Heart. — Fatty  degeneration  is  found  in  a  majority  of  the  cases.  It  may 
precede  the  more  advanced  degeneration,  in  which  tjie  sarcous  elements  become 
swollen  and  converted  into  hyaline  masses.  There  is  a  primary,  acute,  inter- 
stitial myositis,  and  also  a  form  secondary  to  degeneration  of  the  heart  muscle, 
to  which  it  is  possible  that  some  of  the  cases  of  fibrous  myocarditis  are  due. 
Pericarditis  and  endocarditis  are  rare;  endocarditis  was  present  in  7  of  220 
cases  at  the  Boston  City  Hospital.  The  diphtheria  bacilli  have  been  found  in 
the  vegetations. 

The  PULMONARY  COMPLICATIONS  are  the  most  important,  and  death  is  due 
to  them  as  often  as  to  the  throat  lesion.  Broncho-pneumonia,  or,  as  Council- 
man terms  it, 'acinous  pneumonia,  is  the  most  common,  and  was  present  in  131 
of  the  220  Boston  cases.  Acute  lobar  pneumonia  is  rare.  The  pneumococcus 
is  the  principal  agent  in  producing  the  lung  infection.  The  streptococci  and 
the  diphtheria  bacilli  are  frequently  met  with. 

Kidneys. — The  lesions,  which  are  due  to  the  action  of  the  toxins,  not  to 
the  presence  of  bacteria,  vary  from  simple  degeneration  to  an  intense  nephritis. 
There  is  no  specific  type  of  lesion.  Interstitial  and  glomerular  nephritis  are 
most  common  in  the  older  subjects.  Degenerative  changes  are  present  in  a 
large  proportion  of  all  the  fatal  cases. 

The  liver  and  the  spleen  show  the  degenerative  lesions  of  the  acute 
infections. 

General  infection  is  common,  and  is  about  equal  with  the  streptococcus  and 


200  SPECIFIC  INFECTIOUS  DISEASES. 

the  diphtheria  bacillus.  It  occurs  generally  in  the  grave  septic  cases,  in  which 
type  of  cases  the  former  organism  is  more  frequently  met  with. 

Symptoms. — The  period  of  incubation  is  "  from  two  to  seven  days,  often- 
est  two." 

The  initial  symptoms  are  those  of  an  ordinary  febrile  attack — slight  chilli- 
ness, fever,  and  aching  pains  in  the  back  and  limbs.  In  mild  cases  these  symp- 
toms are  trifling,  and  the  child  may  not  feel  ill  enough  to  go  to  bed.  Usually 
the  temperature  rises  within  the  first  twenty-four  hours  to  102.5°  or  103°;  in 
severe  cases  to  101:°.  In  young  children  there  may  be  convulsions  at  the 
outset. 

Phaetxgeal  Diphtheria. — In  a  typical  case  there  is  at  first  redness  of 
the  fauces,  and  the  child  complains  of  slight  difficulty  in  swallowing.  The 
membrane  first  appears  upon  the  tonsils,  and  it  may  be  a  little  difficult  to  dis- 
tinguish a  patchy  diphtheritic  pellicle  from  the  exudate  of  the  tonsillar  crypts. 
The  phar}Tigeal  mucous  membrane  is  reddened,  and  the  tonsils  themselves  are 
swollen.  By  the  third  day  the  membrane  has  covered  the  tonsils,  the  pillars  of 
the  fauces,  and  perhaps  the  uvula,  which  is  thickened  and  oedematous,  and 
may  fill  completely  the  space  between  the  swollen  tonsils.  The  membrane  may 
extend  to  the  posterior  wall  of  the  phar}Tix.  At  first  grajdsh-white  in  color, 
it  changes  to  a  dirty  gray,  often  to  a  yellow-white.  It  is  firmly  adherent,  and 
when  removed  leaves  a  bleeding,  slightly  eroded  surface,  which  is  soon  covered 
by  fresh  exudate.  The  glands  in  the  neck  are  swollen,  and  may  be  tender. 
The  general  condition  of  a  patient  in  a  case  of  moderate  severity  is  usually 
good;  the  temperature  not  very  high,  in  the  absence  of  complications  ranging 
from  102°  to  103°.  The  pulse^range  is  from  100  to  120.  The  local  condition 
of  the  throat  is  not  of  great  severity,  and  the  constitutional  depression  is  slight. 
The  symptoms  gradually  abate,  the  swelling  of  the  neck  diminishes,  the  mem- 
branes separate,  and  from  the  seventh  to  the  tenth  day  the  throat  becomes  clear 
and  convalescence  sets  in. 

Clinically  at^^ical  forms  are  extremely  common,  and  I  follow  here  Koplik's 
division : 

(a)  There  may  be  no  local  manifestation  of  membrane,  but  a  simple  catar- 
rhal angina  associated  sometimes  A^itli  a  croupy  cough.  The  detection  in  these 
cases  of  the  Klebs-Loeffler  bacillus  can  alone  determine  the  diagnosis.  Such 
cases  are  of  great  moment,  inasmuch  as  they  may  communicate  the  severer 
disease  to  other  children. 

(6)  There  are  cases  in  which  the  tonsils  are  covered  by  a  pultaceous  exu- 
date, not  a  consistent  membrane. 

(c)  Cases  presenting  a  punctate  form  of  membrane,  isolated,  and  usually 
on  the  surface  of  the  tonsils. 

(d)  Cases  which  begin  and  often  run  their  entire  course  with  the  local 
picture  of  a  typical  lacunar  amygdalitis.  The}'  may  be  mild,  and  the  local 
exudate  may  not  extend,  but  in  other  cases  there  are  rapid  development  of 
membrane,  and  extension  of  the  disease  to  the  phar}Tix  and  the  nose,  with 
severe  septic  and  constitutional  symptoms. 

(e)  Under  the  term  '^latent  diiDhtheria "  Heubner  has  described  eases, 
usually  secondary,  occurring  chiefly  in  hospital  practice,  in  young  persons  the 
subject  of  wasting  affections,  such  as  rickets  and  tuberculosis.  There  are  fever, 
naso-jDhar^-ngeal  catarrh,  and  gastro-intestinal  disturbances.     Diphtheria  may 


DIPHTHERIA.  201 

not  be  suspected  until  severe  laryngeal  complications  develop,  or  the  condition 
may  not  be  determined  until  autopsy. 

Systemic  Infection. — The  constitutional  disturbance  in  mild  diphtheria 
is  very  slight.  There  are  instances,  too,  of  extensive  local  disease  without 
grave  systemic  symptoms.  As  a  rule,  the  general  features  of  a  case  bear  a 
definite  relation  to  the  severity  of  the  local  disease.  There  are  rare  instances 
in  which  from  the  outset  the  constitutional  prostration  is  extreme,  the  pulse 
frequent  and  small,  the  fever  high,  and  the  nervous  phenomena  are  pro- 
nounced ;  the  patient  may  sink  in  two  or  three  days  overwhelmed  by  the  inten- 
sity of  the  toxaemia.  There  are  cases  of  this  sort  in  which  the  exudate  in  the 
throat  may  be  slight,  but  usually  the  nasal  symptoms  are  pronounced.  The 
temperature  may  be  very  slightly  raised  or  even  subnormal.  More  commonly 
the  severe  systemic  symptoms  appear  at  a  later  date  when  the  pharyngeal  lesion 
is  at  its  height.  They  are  constantly  present  in  extensive  disease,  and  when 
there  is  a  sloughing,  foetid  condition.  The  lymphatic  glands  become  greatly 
enlarged;  the  pallor  is  extreme;  the  face  has  an  ashen-gray  hue;  the  pulse 
is  rapid  and  feeble,  and  the  temperature  sinks  below  normal.  In  the  most 
aggravated  forms  there  are  gangrenous  processes  in  the  throat,  and  in  rare 
instances,  when  life  is  prolonged,  extensive  sloughing  of  the  tissues  of  the  neck. 

Escherich  accounts  for  the  discrepancy  sometimes  observed  between  the 
severity  of  the  constitutional  disturbance  and  the  intensity  of  the  local  process, 
by  assuming  varying  degrees  of  susceptibility  to  the  diphtheria  bacillus  on  the 
one  hand,  and  to  its  poison  on  the  other  hand.  With  high  local  susceptibility 
of  a  part  to  the  action  of  the  bacillus,  with  little  general  susceptibility  to  the 
toxin,  there  is  extensive  local  exudate  with  mild  constitutional  symptoms,  or 
vice  versa,  severe  systemic  disturbance  with  limited  local  inflammation. 

A  leucocytosis  is  present  in  diphtheria.  Morse  does  not  think  it  of  any 
prognostic  value,  since  it  is  present  and  may  be  pronounced  in  mild  cases. 

What  has  been  described  of  late  as  Vincent's  angina  is  an  acute,  febrile, 
pseudo-membranous  inflammation  with  soft,  yellowish-green  exudate,  which 
on  removal  leaves  a  bleeding  ulcer.  The  general  symptoms  may  be  severe,  and 
there  may  be  swelling  of  the  glands  of  the  neck.  A  bacillus  f  usif  ormis  has  been 
described  in  connection  with  it.  There  are  instances  in  which  the  ulceration 
has  been  extensive,  even  proceeding  to  destruction  of  the  uvula  and  of  the  soft 
palate. 

Nasal  Diphtheria. — In  cases  of  pharyngeal  diphtheria  the  Klebs-Loef- 
fler  bacillus  is  found  on  the  mucous  membrane  of  the  nose  and  in  the  secre- 
tions, even  when  no  membrane  is  present,  but  it  may  apparently  produce  two 
affections  similar  enough  locally  but  widely  differing  in  their  general  features. 

In  membranous  or  fibrinous  rJiinitis,  a  very  remarkable  affection  seen  usu- 
ally in  children,  the  nares  are  occupied  by  thick  membranes,  but  there  is  an 
entire  absence  of  any  constitutional  disturbance.  The  condition  has  been  stud- 
ied very  carefully  by  Park,  Abbott,  Gerber  and  Podack,  and  others.  Eavenel 
has  collected  77  cases,  in  41  of  which  a  bacteriological  examination  was  made, 
in  33  the  Klebs-Loeffler  bacillus  being  present.  All  the  cases  ran  a  benign 
course,  and  in  all  but  a  few  the  membrane  was  limited  to  the  nose,  and  the 
constitutional  symptoms  were  either  absent  or  very  slight.  Eemarkable  and 
puzzling  features  are  that  the  disease  runs  a  benign  course,  and  that  infection 
of  other  children  in  the  family  is  extremely  rare. 
15 


202  SPECIFIC  INFECTIOUS  DISEASES. 

On  the  other  hand,  nasal  diphtheria  is  apt  to  present  a  most  malignant 
type  of  the  disease.  The  infection  may  be  primary  in  the  nose,  and  in  a  case 
in  my  wards  there  was  otitis  media,  and  the  Klebs-Loeffler  bacillus  was  sepa- 
rated from  the  discharge  before  the  condition  of  nasal  diphtheria  was  sus- 
pected. While  some  cases  are  of  mild  character,  others  are  very  intense,  and 
the  constitutional  symptoms  most  profound.  The  glandular  inflammation  is 
usually  very  intense,  owing,  as  Jacobi  points  out,  to  the  great  richness  of  the 
nasal  mucosa  in  lymphatics.  From  the  nose  the  inflammation  may  extend 
through  the  tear-ducts  to  the  conjunctivae  and  into  the  antra. 

Laryngeal  Diphtheria. — Membranous  Group. — ^With  a  very  large  pro- 
portion of  all  the  cases  of  membranous  laryngitis  the  Klebs-Loeffler  bacillus  is 
associated ;  in  a  much  smaller  number  other  organisms,  particularly  the  strep- 
tococcus, are  found.  Membranous  croup,  then,  may  be  said  to  be  either  genu- 
ine diphtheria  or  diphtheroid  in  character.  Of  286  cases  in  which  the  disease 
was  confined  to  the  larynx  or  bronchi,  in  229  the  Klebs-Loeffler  bacilli  were 
found.  In  57  they  were  not  present,  but  17  of  these  cultures  were  unsatis- 
factory (Park  and  Beebe).  The  streptococcus  cases  are  more  likely  to  be  sec- 
ondary to  other  acute  diseases. 

Symptoms. — Naturally,  the  clinical  symptoms  are  almost  identical  in  the 
non-specific  and  specific  forms  of  membranous  larjTigitis. 

The  affection  begins  like  an  acute  laryngitis  with  slight  hoarseness  and 
rough  cough,  to  which  the  term  croupy  has  been  applied.  After  these  symp- 
toms have  lasted  for  a  day  or  two  with  varying  intensity,  the  child  suddenly 
becomes  worse,  usually  at  night,  and  there  are  signs  of  impeded  respiration. 
At  first  the  difficulty  in  breathing  is  paroxysmal,  due  probably  to  more  or  less 
spasm  of  the  muscles  of  the  glottis.  Soon  the  dyspncea  becomes  continuous, 
inspiration  and  expiration  become  difficult,  particularly  the  latter,  and  with 
the  inspiratory  movements  the  epigastrium  and  lower  intercostal  spaces  are 
retracted.  The  voice  is  husky  and  may  be  reduced  to  a  whisper.  The  color 
gradually  changes  and  the  imperfect  aeration  of  the  blood  is  shown  in  the 
lividity  of  the  lips  and  finger-tips.  Restlessness  comes  on  and  the  child  tosses 
from  side  to  side,  vainly  trying  to  get  breath.  Occasionally,  in  a  severer  par- 
oxysm, portions  of  membrane  are  coughed  out.  The  fever  in  membranous 
laryngitis  is  rarely  very  high  and  the  condition  of  the  child  is  usually  very 
good  at  the  time  of  the  onset.  The  pulse  is  always  increased  in  frequency  and 
if  cyanosis  be  present  is  small.  In  favorable  cases  the  dyspnoea  is  not  very 
urgent,  the  color  of  the  face  remains  good,  and  after  one  or  two  paroxysms  the 
child  goes  to  sleep  and  wakes  in  the  morning,  perhaps  without  fever  and  feel- 
ing comfortable.  The  attack  may  recur  the  following  night  with  greater 
severity.  In  unfavorable  cases  the  dyspnoea  becomes  more  and  more  urgent, 
the  cyanosis  deepens,  the  child,  after  a  period  of  intense  restlessness,  sinks  into 
a  semi-comatose  state,  and  death  finally  occurs  from  poisoning  of  the  nerve 
centres  by  carbon  dioxide.  In  other  cases  the  onset  is  less  sudden  and  is  pre- 
ceded by  a  longer  period  of  indisposition.  As  a  rule,  there  are  pharyngeal 
symptoms.  The  constitutional  disturbance  may  be  more  severe,  the  fever 
higher,  and  there  may  be  swelling  of  the  glands  of  the  neck.  Inspection  of 
the  fauces  may  show  the  presence  of  false  membranes  on  the  pillars  or  on  the 
tonsils.  Bacteriological  examination  can  alone  determine  whether  these  are 
due  to  the  Klebs-Loeffler  bacillus  or  to  the  streptococcus.    Fagge  held  that  non- 


DIPHTHERIA.  203 

contagious  membranous  croup  may  spread  upward  from  the  larynx  just  as 
diphtheritic  inflammation  is  in  the  habit  of  spreading  downward  from  the 
fauces.  Ware,  of  Boston,  whose  essay  on  croup  is  perhaps  the  most  solid  con- 
tribution to  the  subject  made  in  this  country,  reported  the  presence  of  exudate 
in  the  fauces  in  74  out  of  75  cases  of  croup.  These  observations  were  made 
prior  to  1840,  during  periods  in  which  diphtheria  was  not  epidemic  to  any 
extent  in  Boston.  In  protracted  cases  pulmonary  symptoms  may  occur,  which 
are  sometimes  due  to  the  difficulty  in  expelling  the  muco-pus  from  the  tubes ; 
in  others,  the  false  membrane  extends  into  the  trachea  and  even  into  the 
bronchial  tubes.  During  the  paroxysm  the  vesicular  murmur  is  scarcely  audi- 
ble, but  the  laryngeal  stridor  may  be  loudly  communicated  along  the  bronchial 
tubes. 

DiPHTHKRiA  OF  Other  Parts. — Primary  diphtheria  occurs  occasionally 
in  the  conjunctiva.  It  follows  in  some  instances  the  affection  of  the  nasal 
mucous  membrane.  Some  of  the  cases  are  severe  and  serious,  but  it  has  been 
shown  by  C.  Frankel  and  others  that  the  diphtheria  bacilli  may  be  present  in 
a  conjunctivitis  catarrhal  in  character,  or  associated  with  only  slight  croupous 
deposits. 

Diphtheria  of  the  external  auditory  meatus  is  seen  in  rare  instances  in 
which  a  diphtheritic  otitis  media  has  extended  through  the  tympanic  mem- 
brane. 

Diphtheria  of  the  shin  is  most  frequently  seen  in  the  severer  forms  of 
pharyngeal  diphtheria,  in  which  the  membrane  extends  to  the  mouth  and 
lips,  and  invades  the  adjacent  portions  of  the  skin  of  the  face.  The  skin  about 
the  anus  and  genitals  may  also  be  attacked.  Pseudo-membranous  inflamma- 
tion is  not  uncommon  on  ulcerated  surfaces  and  wounds.  In  very  many 
of  these  cases  it  is  a  streptococcus  infection,  but  in  a  majority,  perhaps, 
in  which  the  patient  is  suffering  with  diphtheria,  the  Klebs-Loeflier  bacil- 
lus will  be  found  in  the  fibrinous  exudate.  As  proposed  by  Welch,  the  term 
"wound  diphtheria"  should  be  limited  to  infection  of  a  wound  by  the 
Klebs-Loeffler  bacillus.  This  "  may  manifest  itself  as  a  simple  inflamma- 
tion, or  inflammation  with  superficial  necrosis,  or  inflammation  with  more  or 
less  adherent  pseudo-membrane.  The  conditions  as  regards  varying  intensity 
and  character  of  the  infection,  association  with  other  bacteria,  particularly 
streptococci,  and  the  necessity  of  a  bacteriological  examination  to  establish 
the  diagnosis,  are  in  no  way  different  in  the  diphtheria  of  wounds  from  those 
in  diphtheria  of  mucous  membranes.  Wound  diphtheria  may  occur  without 
demonstrable  connection  with  cases  of  diphtheria  and  without  affection  of  the 
throat  in  the  individual  attacked,  but  such  occurrences  are  rare"  (Welch). 
Paralysis  may  follow  wound  diphtheria.  Pseudo-membranous  inflammations 
of  wounds  are  caused  more  frequently  by  other  micro-organisms,  particularly 
the  streptococcus  pyogenes,  than  by  the  Klebs-Loefller  bacillus.  The  fibrinous 
membrane  so  common  in  the  neighborhood  of  the  tracheotomy  wound  in  diph- 
theria is  rarely  associated  with  the  Klebs-Loeffler  bacillus.  Diphtheria  of  the 
genitals  is  occasionally  seen. 

Complications  and  Sequelae. — Of  local  complications,  hsemorrhage  from 
the  nose  or  throat  may  occur  in  the  severe  ulcerative  cases.  Skin  rashes  are 
not  infrequent,  particularly  the  diffuse  erythema.  Occasionally  there  is  urti- 
caria and  in  the  severe  cases  purpura.     Fatal  cases  almost  invariably  show 


204  SPECIFIC  INFECTIOUS  DISEASES. 

capillary  bronchitis  with  broncho-pnemnonia  and  large  patches  of  collapse,  or 
the  septic  particles  may  reach  the  bronchi  and  excite  gangrenous  processes 
which  may  lead  to  severe  and  fatal  hemorrhage.  Jaundice,  usually  a  feature 
of  the  toxsemia  is  rarely  of  serious  import. 

Albuminuria,  present  in  all  severe  cases,  is  alarming  only  when  the  albu- 
min is  in  considerable  quantity  and  associated  with  epithelial  or  blood  casts. 
Kepliritis  may  appear  quite  early  in  the  disease,  setting  in  occasionally  with 
complete  suppression  of  the  urine.  In  comparison  with  scarlet  fever  the  renal 
changes  lead  less  frequently  to  general  dropsy.  In  rare  instances  there  may 
be  coma,  and  even  convulsions,  without  albumin  in  the  urine,  and  without 
dropsy. 

Of  the  sequelse,  paralysis  is  by  far  the  most  important.  It  can  be  experi- 
mentally produced  in  animals  by  the  inoculation  of  the  toxins.  The  disease  is 
a  toxic  neuritis,  due  to  the  absorption  of  the  poison.  The  proportion  of  the 
cases  in  which  it  occurs  ranges  from  10  to  15  and  even  to  20  per  cent.  It  is 
strictly  a  sequel,  coming  on  usually  in  the  second  or  third  week  of  convales- 
cence. It  may  follow  very  mild  cases ;  indeed,  the  local  lesion  may  be  so  trifling 
that  the  onset  of  the  paralysis  alone  calls  attention  to  the  true  nature  of  the 
trouble.  It  is  proportionately  less  frequent  in  children  than  in  adults.  L.  W. 
Eolleston's  recent  study  of  the  subject  indicates  that  the  early  use  of  anti- 
toxin diminishes  the  liability  to  paralysis.  In  494  cases  collected  by  Wood- 
head,  the  palate  was  involved  in  155,  the  ocular  muscles  in  197,  in  10  other 
muscles.     Ninety-one  of  the  patients  died. 

Of  the  local  paralyses  the  most  common  is  that  which  affects  the  palate. 
This  gives  a  nasal  character  to  the  voice,  and,  owing  to  a  return  of  liquids 
through  the  nose,  causes  a  difficulty  in  swallowing.  The  palate  is  seen  to  be 
relaxed  and  motionless,  and  the  sensation  in  it  is  also  much  impaired.  The 
affection  may  extend  to  the  constrictors  of  the  pharynx,  and  deglutition  become 
embarrassed.  Within  two  or  three  weeks  or  even  a  shorter  time  the  paralysis 
disappears.  In  many  cases  the  affection  of  the  palate  is  only  part  of  a  general 
neuritis.  Of  other  local  forms  perhaps  the  most  common  are  paralyses  of  the 
eye-muscles,  intrinsic  and  extrinsic.  There  may  be  strabismus,  ptosis,  and 
loss  of  power  of  accommodation.  Facial  paralysis  is  rare.  The  neuritis  may 
be  confined  to  the  nerves  of  one  limb,  though  more  commonly  the  legs  or  the 
arms  are  affected  together.  Very  often  with  the  palatal  parah^sis  is  associated 
a  weakness  of  the  legs  without  definite  palsy  but  with  loss  of  the  knee-jerk. 

The  multiple  form  of  diphtheritic  neuritis  may  begin  with  the  palatal 
affection,  or  with  loss  of  power  of  accommodation  and  loss  of  the  tendon 
reflexes.  This  last  is  an  important  sign,  which,  as  Bernhardt,  Buzzard,  and 
E.  L.  MacDonnell  have  sho^vn,  may  occur  early,  but  is  not  necessarily  fol- 
lowed by  other  symptoms  of  neuritis.  There  is  paraplegia,  which  may  be 
complete  or  involve  only  the  extensors  of  the  feet.  The  paralysis  may  extend 
and  involve  the  arms  and  face  and  render  the  patient  entirely  helpless.  The 
muscles  of  respiration  may  be  spared. 

Heart. — Irregularity  of  the  heart  is  common.  It  was  present  in  60  per  cent 
of  the  Boston  cases  of  White  and  Smith.  A  murmur  at  the  apex  or  base  of 
the  heart  is  present  in  94  per  cent  of  all  cases.  This  means  of  course  that  a 
majority  of  all  young  children  with  fever  have  a  heart  murmur.  Only  a  few 
cases  of  diphtheria  have  serious  heart  symptoms,  36  out  of  the  946  cases  spe- 


DIPHTHERIA.  205 

ciall}^  studied.  Eaj^id  action  of  the  heart  with  gallop  rhythm  and  epigastric 
pain  and  tenderness  are  the  most  serious  symptoms.  The  cases  in  which  the 
pulse  drops  from  110  to  40  or  30  are  usually  very  serious.  The  heart  symp- 
toms are  more  common  in  the  second  or  third  week  of  the  disease,  and  fatal 
dilatation  of  the  heart  may  come  on  as  late  as  the  sixth  or  seventh  week.  It 
seems  probable  that  the  heart  weakness  is  due  to  granular  and  fatty  degen- 
eration of  the  muscle  substance.  Possibly  in  some  of  the  cases  there  is  degen- 
eration of  the  vagus,  a  view  which  is  supported  by  the  frequency  of  paralysis 
of  the  palate  with  vomiting  and  epigastric  pain  and  tenderness. 

Serum  Sickness. — Strictly  an  effect  of  the  treatment,  "  Die  Serumkrank- 
heit "  may  be  considered  among  the  complications.  In  from  eight  to  ten  days 
after  the  inoculation  there  appears  at  the  site  an  erythema  or  urticaria, 
which  spreads  rapidly  over  the  body.  There  is  usually  oedema,  local  glandular 
enlargements,  and  in  some  cases  albuminuria.  There  are  pains  and  slight 
swelling  in  the  joints,  and  moderate  fever.  The  oedema  and  the  morbilli- 
form and  exudative  rashes  are  the  most  striking  features.  Convalescence 
occurs  on  the  third  or  fourth  day.  These  symptoms  have  been  shown  to  be 
due  to  the  toxic  effects  of  the  horse  serum. 

Sudden  death  has  occurred  in  about  20  cases  after  the  serum  injections 
(Eosenau  and  Anderson).  The  serious  symptoms  come  on  within  five  or  ten 
minutes  of  the  injection  with  collapse,  unconsciousness,  and  convulsions  and 
death.  The  toxic  effect  is  due  to  the  alien  serum,  from  which  it  is  quite 
possible  that  before  long  the  dangerous  elements  may  be  removed. 

Diagnosis. — The  presence  of  the  Klebs-Loeffler  bacillus  is  regarded  by  bac- 
teriologists as  the  sole  criterion  of  true  diphtheria,  and  as  this  organism  may 
be  associated  with  all  grades  of  throat  affections,  from  a  simple  catarrh  to  a 
sloughing,  gangrenous  process,  it  is  evident  that  in  many  instances  there  will 
be  a  striking  discrepancy  between  the  clinical  and  the  bacteriological  diagnosis. 

The  bacteriological  diagnosis  is  simple.  The  plan  adopted  by  the  New 
York  Health  Department  is  a  model  which  may  be  followed  with  advantage  in 
other  cities.  Outfits  for  making  cultures,  consisting  of  a  box  containing  a 
tube  of  blood-serum  and  a  sterilized  swab  in  a  test-tube,  are  distributed  to 
about  forty  stations  at  convenient  points  in  the  city.  A  list .  of  these  places 
is  published,  and  a  physician  can  obtain  the  outfit  free  of  cost.  The  direc- 
tions are  as  follows :  "  The  patient  should  be  placed  in  a  good  light,  and,  if 
a  child,  properly  held.  In  cases  where  it  is  possible  to  get  a  good  view  of  the 
throat,  depress  the  tongue  and  ^ub  the  cotton  swab  gently  but  freely  against 
any  visible  exudate.  In  other  cases,  including  those  in  which  the  exudate  is 
confined  to  the  larynx,  avoiding  the  tongue,  pass  the  swab  far  back  and  rub 
it  freely  against  the  mucous  membrane  of  the  pharynx  and  tonsils.  Without 
laying  the  swab  down,  withdraw  the  cotton  plug  from  the  culture-tube,  insert 
the  swab,  and  rub  that  portion  of  it  which  has  touched  the  exudate  gently  but 
thoroughly  all  over  the  surface  of  the  blood-serum.  Do  not  push  the  swab 
into  the  blood-serum,  nor  break  the  surface  in  any  way.  Then  replace  the 
swab  in  its  own  tube,  plug  both  tubes,  put  them  in  the  box,  and  return  the 
culture  outfit  at  once  to  the  station  from  which  it  was  obtained."  The  culture- 
tubes  which  have  been  inoculated  are  kept  in  an  incubator  at  37°  C.  for  twelve 
hours  and  are  then  ready  for  examination.  Some  prefer  a  method  by  which 
the  material  from  the  throat  collected  on  a  sterile  swab,  or,  as  recommended 


206  SPECIFIC  INFECTIOUS  DISEASES. 

by  von  Esmarcli,  on  small  pieces  of  sterilized  sponge,  is  sent  to  the  laborator}^ 
where  the  cultures  and  microscopical  examination  are  made  b}'^  a  bacteriologist. 

An  immediate  diagnosis  "without  the  use  of  cultures  is  often  possible  by 
making  a  smear  preparation  of  the  exudate  from  the  throat.  The  Klebs-Loef- 
fler  bacilli  may  be  present  in  sufficient  numbers,  and  may  be  quite  character- 
istic to  an  expert.  In  this  connection  may  be  given  the  following  statement 
by  Park,  who  has  had  such  an  exceptional  experience :  "  The  examination  by 
a  competent  bacteriologist  of  the  bacterial  growth  in  a  blood-serum  tube  which 
has  been  properly  inoculated  and  kept  for  fourteen  hours  at  the  body  tem- 
perature can  be  thorouglily  relied  upon  in  eases  where  there  is  visible  mem- 
brane in  the  throat,  if  the  culture  is  made  during  the  period  in  which  the 
membrane  is  forming,  and  no  antiseptic,  especially  no  mercurial  solution,  has 
lately  been  applied.  In  cases  in  which  the  disease  is  confined  to  the  larynx  or 
bronchi,  surprisingly  accurate  results  can  be  obtained  from  cultures,  but  in  a 
certain  proportion  of  cases  no  diphtheria  bacilli  will  be  found  in  the  first 
culture,  and  yet  will  be  abundantly  present  in  later  cultures.  "We  believe, 
therefore,  that  absolute  reliance  for  a  diagnosis  can  not  be  placed  upon  a  single 
culture  from  the  pharynx  in  purely  laryngeal  cases.'' 

Where  a  bacteriological  examination  can  not  he  made,  the  practitioner  must 
regard  as  suspicious  all  forms  of  throat  affections  in  children,  and  carry  out 
measures  of  isolation  and  disinfection.  In  this  way  alone  can  serious  errors 
be  avoided.  It  is  not,  of  course,  in  the  severer  forms  of  membranous  angina 
that  mistake  is  likely  to  occur,  but  in  the  various  lighter  forms,  many  of  which 
are  in  reality  due  to  the  Klebs-Loeffler  bacillus. 

A  large  proportion  of  the  cases  of  diphtheroid  inflammation  of  the  throat 
are  due  to  the  streptococcus  pyogenes.  They  are  usually  milder,  and  the  lia- 
bility to  general  infection  is  less  intense;  still,  in  scarlet  fever  and  other  spe- 
cific fevers  some  of  the  most  virulent  cases  of  throat  disease  which  we  see, 
with  intense  systemic  infection,  are  caused  by  this  micro-organism.  These 
streptococcus  cases  are  probably  much  less  numerous  than  the  figures  wliich 
I  have  given  woidd  indicate.  The  more  careful  examinations  in  the  diphtheria 
pavilions  of  hospitals,  particularly  in  Europe,  have  shown  that  in  the  large 
majority  of  cases  admitted  the  Klebs-Loeffier  bacillus  is .  present.  I  have 
already  referred,  under  the  section  on  scarlet  fever,  to  the  question  of  the 
diagnosis  between  scarlet  fever  with  severe  angina  and  diphtheria. 

Prognosis. — In  hospital  practice  the  mortality  was  formerly  from  30  to 
50  per  cent.  In  the  Boston  City  Hospital  the  death-rate  between  1888  and 
189-4  was  only  once  below  40  per  cent,  and  in  1892  and  1893  rose  to  nearly 
50  per  cent.  Following  the  introduction  of  antitoxin  from  1895  to  1903  the 
death-rate  has  not  once  been  above  15  per  cent,  and  of  late  years  has  been 
about  10  or  13  per  cent  (McCollom).  In  country  places  the  disease  may  dis- 
play an  appalling  virulence.  In  cases  of  ordinary  severity  the  outlook  is  usu- 
ally good.  Death  results  from  involvement  of  the  larjmx,  septic  infection, 
sudden  heart-failure,  diphtheritic  paralysis,  occasionally  from  uraemia,  and 
sometimes  from  broncho-pneumonia  occurring  during  convalescence.  In 
England  and  "Wales  in  1903  there  were  6,077  deaths,  compared  with  9,130,  the 
average  number  in  the  previous  decennium  (Tatham).  Of  late  years  the  mor- 
tality has  been  steadily  falling.  In  Boston  during  the  ten  years  ending  1903 
the  mortality  per  10,000  of  the  living  has  ranged  from  30.65  to  88.73.     The 


DIPHTHERIA.  207 

mortality  has  greatly  decreased,  from  18.03  per  10,000  living  in  1894  to  3.51 
in  1903  (McCollom). 

Prophylaxis. — Isolation  of  the  sick,  disinfection  of  the  clothing  and  of 
everything  that  has  come  in  contact  with  the  patient,  careful  scrutiny  of  the 
milder  cases  of  throat  disorder,  and  more  stringent  surveillance  in  the  period 
of  convalescence  are  the  essential  measures  to  prevent  the  spread  of  the  dis- 
ease. Suspected  cases  in  families  or  schools  should  be  at  once  isolated  or  re- 
moved to  a  hospital  for  infectious  disorders.  When  a  death  has  occurred  from 
diphtheria,  the  body  should  be  wrapped  in  a  sheet  which  has  been  soaked  in 
a  corrosive-sublimate  solution  (1  to  3,000),  and  placed  in  a  closely  sealed 
coffin.     The  funeral  should  always  be  private. 

In  cases  of  well-marked  diphtheria  these  precautions  are  usually  carried 
out,  but  the  chief  danger  is  from  the  milder  cases,  particularly  the  ambulatory 
form,  in  which  the  disease  has  perhaps  not  been  suspected.  But  from  such 
patients  mingling  with  susceptible  children  the  disease  is  often  conveyed.  The 
healthy  children  in  a  family  in  which  diphtheria  exists  may  carry  the  disease 
to  their  school-fellows.  The  question  of  the  influence  of  isolation  hospitals 
on  the  spread  of  the  disease  has,  I  think,  been  solved  in  Boston,  a  city  which 
has  suffered  terribly  from  diphtheria.  The  ratio  of  mortality  per  10,000  living 
in  1893  was  11-|-,  and  in  1894  it  was  19-}-.  In  1895  the  infectious  pavilion 
was  opened.  Prior  to  that  year  only  about  10  per  cent  of  the  reported  cases 
were  treated  in  hospital ;  in  succeeding  years  50  per  cent  were  treated  in  hos- 
pital. In  1898  the  mortality  per  10,000  had  fallen  to  3,  and  in  1899  it 
was  4.9. 

A  very  important  matter  in  the  prophylaxis  relates  to  the  period  of  con- 
valescence. It  has  been  shown  by  numerous  observations  that,  after  all  the 
membrane  has  cleared  away,  virulent  bacilli  may  persist  in  the  throat  from 
periods  ranging  from  six  weeks  to  six  months,  or  even  longer.  There  is  evi- 
dence to  show  that  the  disease  may  be  communicated  by  such  patients,  so  that 
isolation  should  be  continued  in  any  given  case  until"the  bacteriological  exami- 
nation shows  that  the  throat  is  free. 

It  can  not  be  too  strongly  emphasized  that  the  important  elements  in  the 
prophylaxis  of  diphtheria  are  the  rigid  scrutiny  of  the  milder  types  of  throat 
affection,  and  the  thorough  isolation  and  disinfection  of  the  individual 
patients. 

Careful  attention  should  be  given  to  the  throats  and  mouths  of  children, 
particularly  to  the  teeth  and  tonsils,  as  Caille  has  urged.  Swollen  and  enlarged 
tonsils  should  be  removed.  In  persons  exposed,  the  antiseptic  mouth  washes, 
such  as  corrosive  sublimate  (1  to  10,000),  chlorine  water  (1  to  1,100),  or  swab- 
bing the  throat  with  a  diluted  Loeffier's  solution,  should  be  employed. 

Treatment. — The  important  points  are  hygienic  measures  to  prevent  the 
spread  of  the  malady,  local  treatment  of  the  throat  to  destroy  the  bacilli,  medi- 
cation, general  or  specific,  to  counteract  the  effects  of  the  toxins,  and,  lastly, 
to  meet  the  complications  and  sequelae. 

(a)  Hygienic  Measures. — The  patient  should  be  in  a  room  from  which 
the  carpets,  curtains,  and  superfluous  furniture  have  been  removed.  The  tem- 
perature should  be  about  68°,  and  thorough  ventilation  should  be  secured. 
The  air  may  be  kept  moist  by  a  kettle  or  a  steam-atomizer.  If  possible,  only 
the  nurse,  the  child's  mother,  and  the  doctor  should  come  in  contact  with  the 


208  SPECIFIC  INFECTIOUS  DISEASES. 

patient.  During  the  visit  the  physician  should  wear  a  linen  overall,  and  on 
leaving  the  room  he  should  thoroughly  wash  his  hands  and  face  in  a  corrosive- 
suhlimate  solution.  The  strictest  quarantine  should  be  employed  against  other 
members  in  the  house. 

(b)  Local  Treatment. — In  mild  cases  the  throat  symptoms  are  alone 
prominent.  Vigorous  local  treatment  from  the  outset  should  be  carried  out, 
taking  especial  care  in  all  instances  to  avoid  mechanical  injury  to  the  tissues. 
A  very  large  number  of  solutions  have  been  recommended.  They  are  best 
employed  with  a  swab  of  cotton-wool  or  a  soft  sponge,  or  irrigation  with  hot 
antiseptic  solutions  may  be  used.  The  direct  application  with  a  swab  of  cot- 
ton-wool or  sponge  is,  as  a  rule,  effective.  In  many  young  children  it  is  really 
a  most  trying  procedure  to  carry  out  the  treatment,  and  sometimes  one  is 
compelled  to  desist.  The  nurse  should  hold  the  child  on  her  knees,  well 
wrapped  in  a  shawl,  with  its  head  resting  on  her  shoulder.  The  nose  is  then 
held,  and  so  soon  as  the  child  opens  its  mouth  a  cork  should  be  placed  between 
the  molar  teeth.  The  local  application  can  then  be  made,  or  thorough  irriga- 
tion carried  out.  In  infants  the  disinfecting  fluids  are  sometimes  better 
applied  through  the  nostrils.    The  following  solutions  may  be  employed : 

Loeffler's  solution:  Menthol,  10  grammes  dissolved  in  toluol  to  36  cc. 
Liq.  Ferri  sesquiclilorati,  4  cc. ;  alcohol  absol.,  60  cc. 

Corrosive  sublimate,  1  to  1,000,  either  alone  or  with  tartaric  acid,  5 
grammes  to  the  litre. 

Carbolic  acid,  3  per  cent  in  30  per  cent  alcohol  solution,  is  much  employed; 
some  prefer  to  touch  the  small  spots  of  exudate  with  pure  carbolic  acid. 

Another  solution  is:  The  tincture  of  the  perchloride  of  iron,  a  drachm 
and  a  half,  in  glycerine,  one  ounce,  water,  one  ounce,  with  from  15  to  20 
minims  of  carbolic  acid.  Chlorine  water,  boric  acid,  peroxide  of  hydrogen, 
iodoform,  lactic  acid,  trypsin,  and  papain  are  also  recommended. 

LoefBer's  solution,  which  has  been  given  a  very  thorough  trial,  is  j)erhaps 
the  most  satisfactory. 

Nasal  diphtheria  requires  prompt  and  thorough  disinfection  of  the  pas- 
sages. Jacobi  recommends  chloride  of  sodium,  saturated  boric  acid,  or  1 
part  of  bichloride  of  mercury,  35  of  chloride  of  sodium,  and  1,000  of  water, 
or  the  1-per-cent  solution  of  carbolic  acid.  Loeffler's  solution  may  be  diluted 
and  applied  with  a  syringe  or  a  spray.  To  be  effectual  the  injection  must  be 
properly  given.  The  nurse  should  be  instructed  to  pass  the  nozzle  of  the 
s}Tinge  horizontally,  not  vertically;  otherwise  the  fluid  vnll  return  through 
the  same  nostril. 

When  the  larynx  becomes  involved,  a  steam  tent  may  be  arranged  upon 
the  bed,  so  that  the  child  may  breathe  an  atmosphere  saturated  with  moisture. 
If  the  dyspnoea  becomes  urgent,  an  emetic  of  sulphate  of  zinc  or  ipecacuanha 
may  be  given.  When  the  signs  of  obstruction  are  marked  there  should  be  no 
delay  in  the  performance  of  intubation  or  tracheotomy. 

Hot  applications  to  the  neck  are  usually  very  grateful,  particularly  to 
young  children,  though  in  the  case  of  older  children  and  adults  the  ice  poul- 
tices are  to  be  j)referred. 

(c)  General  Measures. — The  food  should  be  liquid — milk,  beef  juices, 
barley  water,  albumen  water,  and  soups.  The  child  should  be  encouraged  to 
drink  water  freely.    When  the  phar^mgeal  involvement  is  very  great  and  swal- 


DIPHTHERIA.  209 

lowing  painful,  nutritive  enemata  should  be  used.  In  cases  with  severe  con- 
stitutional symptoms  stimulants  should  be  given  early. 

Medicines  given  internally  are  of  very  little  avail  in  the  disease.  There 
is  still  a  widespread  belief  in  the  profession  that  forms  of  mercury  are  bene- 
ficial. The  tincture  of  the  perchloride  of  iron  is  also  very  warmly  recom- 
mended. We  are  still,  however,  without  drugs  which  can  directly  counteract 
the  toz-albumins  of  this  disease,  and  we  must  rely  on  general  measures  of  feed- 
ing and  stimulants  to  support  the  strength. 

The  convalescence  of  the  disease  is  not  without  its  dangers,  and  patients 
should  be  very  carefully  watched,  particularly  if  there  are  signs  of  heart 
weakness. 

The  diphtheritic  paralysis  requires  rest  in  bed,  and  in  those  cases  in  which 
the  heart  rhythm  is  disturbed  the  avoidance  of  sudden  exertion.  In  the 
chronic  forms  with  wasting,  massage,  electricity,  and  strychnine  are  invaluable 
aids.  If  swallowing  becomes  very  difficult,  the  patient  must  be  fed  with  the 
stomach-tube,  which  is  very  much  preferable  to  feeding  per  rectum. 

(d)  Antitoxin  Treatment. — As  the  years  go  on  additional  experience 
has  shown  that,  thoroughly  carried  out,  this  method  of  treatment  is  both  safe 
and  efficacious.  There  are  no  reasonable  grounds  for  skepticism  on  the  part  of 
intelligent  practitioners,  and  still  less  on  the  part  of  those  in  charge  of  the 
hospitals  for  infectious  diseases. 

The  principle  of  action  depends  on  the  circumstance  that  the  blood-serum 
of  an  animal  rendered  immune,  when  introduced  into  another  animal,  protects 
it  from  infection  with  the  diphtheria  bacilli,  and  has  also  an  important  cura- 
tive influence  upon  diphtheria,  whether  artificially  given  to  animals,  or  spon- 
taneously acquired  by  man.  In  the  preparation  of  the  blood-serum  a  uniform 
standard  strength  is  procured.  The  antitoxin  unit  is  the  amount  of  antitoxin 
which,  injected  into  a  guinea-pig  of  250  grammes  in  weight,  neutralizes  100 
times  the  minimum  fatal  dose  of  toxin  of  standard  strength. 

Dosage. — This  is  one  of  the  most  important  questions  relating  to  the  use 
of  the  antitoxin.  J.  H.  McCollom,  of  the  Boston  City  Hospital,  who  has  prob- 
ably had  a  richer  experience  with  the  disease  than  any  man  in  the  United 
States,  insists  that  the  guiding  practice  in  the  use  of  the  antitoxin  is  to  give  it 
until  the  characteristic  ejffects  are  produced,  whether  4,000  or  70,000  units  be 
required  for  this  result.  He  very  rightly  remarks  that  in  the  case  of  a  patient 
ill  with  diphtheria  there  is  no  way  of  estimating  the  quantity  of  toxin  gener- 
ated by  the  membrane,  and  therefore  one  must  administer  the  agent  until  the 
characteristic  effect  is  produced — viz.,  the  shriveling  of  the  membrane,  the 
diminution  of  the  nasal  discharge,  the  correction  of  the  fetid  odor,  and  a  gen- 
eral improvement  in  the  condition  of  the  patient.  'No  case,  he  says,  in  the 
acute  stage  should  be  considered  hopeless.  "  When  one  sees  a  patient  with 
membrane  covering  the  tonsils  and  uvula,  profuse  sanious  discharge  from  the 
nose,  spots  of  ecchymosis  on  the  body  and  extremities,  cold,  clammy  hands 
and  feet,  a  feeble  pulse,  and  the  nauseous  odor  of  diphtheria,  and  finds  that 
after  the  administration  of  10,000  units  of  antitoxin  in  two  doses  the  condi- 
tion of  the  patient  improves  slightly;  that  after  10,000  units  more  have  been 
given  there  is  a  marked  abatement  in  the  severity  of  the  symptoms ;  that  when 
an  additional  10,000  units  have  been  given  the  patient  is  apparently  out  of 
danger,  and  eventually  recovers — one  must  believe  in  the  curative  power  of 


210  SPECIFIC  INFECTIOUS  DISEASES. 

antitoxin,  ^^^len  one  sees  a  patient  in  vliom  the  intubation  tube  lias  been 
repeatedly  clogged,  when  the  hopeless  condition  of  the  patient  changes  for  the 
better  after  the  administration  of  50.000  units,  one  can  not  help  but  be  con- 
vinced of  the  importance  of  giving  large  doses  of  antitoxin  in  the  ver}-  severe 
and  apparently  hopeless  cases.  In  the  majority  of  instances  these  large  doses 
are  not  required,  particularly  if  the  patients  are  seen  early  in  the  attack,  4,000 
to  6,000  units  being  enough  to  produce  the  characteristic  efEect  on  the  mem- 
brane.*' 

Favorable  effects  are  seen  in  improvement  in  both  the  local  and  general 
condition.  The  swelling  of  the  fauces  subsides,  the  membrane  begins  to  dis- 
appear, the  temperature  falls,  and  the  pulse  becomes  slower. 

Untoward  Effects. — Of  these  the  most' common  are  urticaria  and  arthral- 
gia, but  they  are  trifling  and  imimportant.     Abscess  is  rare. 

Results. — Of  183,256  cases  treated  in  150  cities  previous  to  the  serum 
period,  the  mortality  was  38.4  per  cent.  Since  the  introduction  of  serum 
132,5-18  cases  have  been  treated,  "with  a  mortality  of  14.6  per  cent.  Leaving 
out  those  not  treated  with  the  serum,  the  mortality  was  9.8  per  cent  (Edwin 
Eosenthal).  The  figures  of  the  Boston  City  Hospital  have  already  been  given 
and  are  of  special  value,  as  the  number  of  cases  is  large,  the  character  severe, 
and  the  Director  of  the  South  Department,  Dr.  McCollom,  has  had  faith  in 
the  treatment  and  courage  in  carrying  it  out. 

In  Chicago,  from  1888  to  1895,  the  total  number  of  deaths  from  diph- 
theria was  11,488.  From  1896  to  1903,  the  period  during  the  use  of  anti- 
toxin, the  deaths  were  6,088,  a  decrease  of  47  per  cent.  Of  586  cases  treated 
on  the  first  day  of  the  disease  there  were  only  2  deaths ;  of  936  cases  treated 
later  than  the  fourth  day  there  were  216  deaths  (A.  E.  Ee}Tiolds). 

Immunization  for  the  Prevention  of  Diphtheria. — Persons  exposed  to  diph- 
theria may  be  protected  by  a  sufficient  dose  of  the  antitoxin.  Children,  par- 
ticularly, should  receive  an  immunizing  injection  at  once.  The  minimum  dose 
should  be  500  units  for  a  child  under  two  years  of  age;  for  older  children  and 
adults  larger  doses  (500  to  1,000)  are  employed,  which  may  be  repeated  in  a 
few  days  if  necessary.  In  New  York  (city)  since  January,  1895,  13,000  per- 
sons have  been  so  treated^  of  whom  only  40  contracted  the  disease  and  only 
one  died. 

XVII.     ERYSIPELAS. 

Definition. — An  acute,  contagious  disease,  characterized  by  a  special  in- 
flammation of  the  skin  caused  by  streptococcus  erysipelatos  seu  p3"ogenes. 

Etiology. — Erysipelas  is  a  widespread  affection,  endemic  in  most  com- 
munities, and  at  certain  seasons  epidemic.  TVe  are  as  yet  ignorant  of  the 
atmospheric  or  telluric  influences  which  favor  the  diffusion  of  the  poison. 

It  is  particularly  prevalent  in  the  spring  of  the  vear.  Of  2,012  cases  col- 
lected by  Anders,  1,214  occurred  during  the  first  five  months  of  the  year. 
April  had  the  largest  number  of  cases.  The  affection  prevails  extensiveh''  in 
old.  ill-ventilated  hospitals  and  institutions  in  which  the  sanitary  conditions 
are  defective.  With  tlie  improved  sanitation  of  late  years  the  number  of  cases 
has  materially  diminished.  It  has  been  observed,  however,  to  break  out  in  new 
institutions  under  the  most  favorable  hygienic  circumstances.     Erysipelas  is 


ERYSIPELAS.  211 

both  contagious  and  inoculable;  but,  except  under  special  conditions,  the  poi- 
son is  not  very  virulent  and  does  not  seem  to  act  at  any  great  distance.  It 
can  be  conveyed  by  a  third  person.  The  poison  certainly  attaches  itself  to  the 
furniture,  bedding,  and  walls  of  rooms  in  which  patients  have  been  confined. 

The  disposition  to  the  disease  is  widespread,  but  the  susceptibility  is 
specially  marked  in  the  case  of  individuals  with  wounds  or  abrasions  of  any 
sort.  Eecently  delivered  women  and  persons  who  have  been  the  subjects  of 
surgical  operations  are  particularly  prone  to  it.  A  wound,  however,  is  not 
necessary,  and  in  the  so-called  idiopathic  form,  although  it  may  be  difficult  to 
say  that  there  was  not  a  slight  abrasion  about  the  nose  or  lips,  in  very  many 
cases  there  certainly  is  no  observable  external  lesion. 

Chronic  alcoholism,  debility,  and  Bright's  disease  are  predisposing  agents. 
Certain  persons  show  a  special  susceptibility  to  erysipelas,  and  it  may  recur 
in  them  repeatedly.     There  are  instances,  too,  of  a  family  predisposition. 

The  specific  agent  of  the  disease  is  a  streptococcus  growing  in  long  chains, 
which  is  included  under  the  group  name  Streptococcus  pyogenes,  with  which 
Streptococcus  erysipelatos  appears  to  be  identical.  The  fever  and  constitu- 
tional symptoms  are  due  in  great  part  to  the  toxins ;  the  more  serious  visceral 
complications  are  the  result  of  secondary  metastatic  infection. 

Immunity. — Susceptible  animals  can  be  rendered  immune  to  virulent 
streptococci  by  repeated  non-lethal  injections  of  cultures.  Marmorek's  pro- 
tective serum,  prepared  by  inoculating  the  horse  and  other  animals  with  cul- 
tures of  intensified  virulence,  belongs  to  the  bactericidal  and  not  to  the  anti- 
toxic sera.  Notwithstanding  some  apparently  favorable  results,  its  value  in 
the  treatment  of  human  infections  has  not  been  demonstrated. 

Morbid  Anatomy  .-^Erysipelas  is  a  simple  inflammation.  In  its  uncom- 
plicated forms  there  is  seen,  post  mortem,  little  else  than  inflammatory  oedema. 
Investigations  have  shown  that  the  cocci  are  found  chiefly  in  the  l}Tnph-spaces 
and  most  abundantly  in  the  zone  of  spreading  inflammation.  In  the  unin- 
volved  tissue  beyond  the  inflamed  margin  they  are  to  be  found  in  the  lymph- 
vessels,  and  it  is  here,  according  to  Metschnikoff  and  others,  that  an  active 
warfare  goes  on  between  the  leucocytes  and  the  cocci  (phagocytosis).  In  more 
extensive  and  virulent  forms  of  the  disease  there  is  usuall}^  suppuration. 

Infarcts  occur  in  the  lungs,  spleen,  and  kidneys,  and  there  may  be  the  gen- 
eral evidences  of  pysemic  infection.  Some  of  the  worst  cases  of  malignant 
endocarditis  are  secondary  to  erysipelas ;  thus,  of  23  cases,  3  occurred  in  con- 
nection with  this  disease.  Septic  pericarditis  and  pleuritis  also  occur.  As 
just  mentioned,  the  disease  may  in  rare  cases  extend  to  and  involve  the 
meninges.  Pneumonia  is  not  a  very  common  complication.  Acute  nephritis 
is  also  met  with ;  it  is  often  ingrafted  upon  an  old  chronic  trouble. 

Symptoms. — Tlie  following  description  applies  specially  to  erysipelas  of  the 
face  and  head,  the  form  of  the  disease  which  the  physician  is  most  commonly 
called  upon  to  treat. 

The  incuhation  is  variable,  probably  from  three  to  seven  days. 

The  stage  of  invasion  is  often  marked  by  a  rigor,  and  followed  by  a  rapid 
rise  in  the  temperature  and  other  characteristics  of  an  acute  fever.  When 
there  is  a  local  abrasion,  the  spot  is  slightly  reddened;  but  if  the  disease  is 
idiopathic,  there  is  seen  within  a  few  hours  slight  redness  over  the  bridge  of 
the  nose  and  on  the  cheeks.    The  swelling;  and  tension  of  the  skin  increase  and 


212  SPECIFIC  INFECTIOUS  DISEASES. 

■within  twenty-four  hours  the  external  symptoms  are  well  marked.  The  skin 
is  smooth,  tense,  and  oedematous.  It  looks  red,  feels  hot,  and  the  superficial 
layers  of  the  epidermis  may  be  lifted  as  small  blebs.  The  patient  complains  of 
an  unpleasant  feeling  of  tension  in  the  skin;  the  swelling  rapidly  increases; 
and  during  the  second  day  the  eyes  are  usually  closed.  The  first-affected  parts 
gradually  become  pale  and  less  swollen  as  the  disease  extends  at  the  periphery. 
When  it  reaches  the  forehead  it  progresses  as  an  advancing  ridge,  perfectly  well 
defined  and  raised;  and  often,  on  palpation,  hardened  extensions  can  be  felt 
beneath  the  skin  which  is  not  3^et  reddened.  Even  in  a  case  of  moderate  sever- 
ity, the  face  is  enormously  swollen,  the  eyes  are  closed,  the  lips  greatly  oedema- 
tous, the  ears  thickened,  the  scalp  is  swollen,  and  the  patient's  features  are 
quite  unrecognizable.  The  formation  of  blebs  is  common  on  the  eyelids,  ears, 
and  forehead.  The  cervical  lymph-glands  are  swollen,  but  are  usually  masked 
in  the  oedema  of  the  neck.  The  temperature  keeps  high  without  marked  remis- 
sions for  four  or  five  days  and  then  defervescence  takes  place  by  crisis.  Leu- 
cocytosis  is  present.  Kirkbride  has  noted  the  presence  in  one  case  of  leucin 
and  t}Tosin  in  the  urine.  The  general  condition  of  the  patient  varies  much 
with  his  previous  state  of  health.  In  old  and  debilitated  persons,  particularly 
in  those  addicted  to  alcohol,  the  constitutional  depression  from  the  outset  may 
be  very  great.  Delirium  is  present,  the  tongue  becomes  dry,  the  pulse  feeble, 
and  there  is  marked  tendency  to  death  from  toxemia.  In  the  majority  of 
cases,  however,  even  with  extensive  lesions,  the  constitutional  disturbance,  con- 
sidering the  height  of  the  fever  range,  is  slight.  The  mucous  membrane  of  the 
mouth  and  throat  may  be  swollen  and  reddened.  The  erysipelatous  inflamma- 
tion may  extend  to  the  lar}Tix,  but  the  severe  oedema  of  this  part  occasionally 
met  with  is  commonly  due  to  the  extension  of  the  inflammation  from  without 
inward. 

There  are  cases  in  which  the  inflammation  extends  from  the  face  to  the 
neck,  and  over  the  chest,  and  may  gradually  migrate  or  wander  over  the  greater 
part  of  the  body  (E.  migrans). 

The  close  relation  between  the  erysipelas  coccus  and  the  pus  organisms  is 
shown  by  the  frequency  vdth  which  suppuration  occurs  in  facial  erysipelas. 
Small  cutaneous  abscesses  are  common  about  the  cheeks  and  forehead  and 
neck,  and  beneath  the  scalp  large  collections  of  pus  may  accumulate.  Sup- 
puration seems  to  occur  more  frequently  in  some  epidemics  than  in  others,  and 
at  the  Philadelphia  Hospital  one  year  nearly  all  the  cases  in  the  erysipelas 
wards  presented  local  abscesses. 

Complications. — Meningitis  is  rare.  The  cases  in  which  death  occurs  with 
marked  brain  symptoms  do  not  usually  show,  post  mortem,  meningeal 
affection. 

Pneumonia  is  an  occasional  complication.  Ulcerative  endocarditis  and 
septicsemia  are  more  common.  Albuminuria  is  almost  constant,  particularly 
in  persons  over  fiftv.  True  nephritis  is  occasionally  seen.  Da  Costa  has 
called  attention  to  curious  irregular  returns  of  the  fever  which  occur  during 
convalescence  without  any  aggravation  of  the  local  condition. 

The  diagnosis  rarely  presents  any  difficulty.  The  mode  of  onset,  the  rapid 
rise  in  fever,  and  the  characters  of  the  local  disease  are  quite  distinctive. 

Prognosis. — Healthy  adults  rarely  die.  The  general  mortality  in  hospitals 
is  about  7  per  cent,  in  private  practice  about  4  per  cent  (Anders).     In  the 


SEPTICAEMIA  AND  PYEMIA.  213 

new-born,  when  the  disease  attacks  the  navel,  it  is  almost  always  fatal.  In 
drunkards  and  in  the  aged  erysipelas  is  a  serious  affection,  and  death  may 
result  either  from  the  intensity  of  the  fever  or,  more  commonly,  from  toxaemia. 
The  wandering  or  ambulatory  erysipelas,  which  has  a  more  protracted  course, 
may  cause  death  from  exhaustion. 

Treatment. — Isolation  should  be  strictly  carried  out,  particularly  in  hos- 
pitals. A  practitioner  in  attendance  upon  a  case  of  erysipelas  should  not 
attend  cases  of  confinement. 

The  disease  is  self-limited  and  a  large  majority  of  the  cases  get  well  with- 
out any  internal  medication.  I  can  speak  definitely  on  this  point,  having,  at 
the  Philadelphia  Hospital,  treated  many  cases  in  this  way.  The  diet  should 
be  nutritious  and  light.  Stimulants  are  not  required  except  in  the  old  and 
feeble.  For  the  restlessness,  delirium,  and  insomnia,  chloral  or  the  bromides 
may  be  given;  or,  if  these  fail,  opium.  When  the  fever  is  high  the  patient 
may  be  bathed  or  sponged,  or,  in  private  practice,  if  there  is  an  objection  to 
this,  antipyrin  or  antifebrin  may  be  given. 

Of  internal  remedies  believed  to  influence  the  disease,  the  tincture  of  the 
perchloride  of  iron  has  been  highly  recommended.  At  the  Montreal  General 
Hospital  this  was  the  routine  treatment,  and  doses  of  half  a  drachm  to  a 
drachm  were  given  eyevj  three  or  four  hours.  I  am  by  no  means  convinced 
that  it  has  any  special  action ;  nor,  so  far  as  I  know,  has  any  medicine,  given 
internally,  a  definite  control  over  the  course  of  the  disease. 

Of  local  treatment,  the  injection  of  antiseptic  solutions  at  the  margin  of 
the  spreading  areas  has  been  much  practised.  Two-per-cent  solutions  of  car- 
bolic acid,  the  corrosive  sublimate  and  the  biniodide  of  mercury  have  been 
much  used.  The  injection  should  be  made  not  into  but  just  a  little  beyond 
the  border  of  the  inflamed  patch.  F.  P.  Henry  has  treated  a  large  number 
of  cases  at  the  Philadelphia  Hospital  with  the  last-mentioned  drug,  and  this 
mode  of  practice  is  certainly  most  rational. 

Of  local  applications,  ichthyol  is  at  present  much  used.  The  inflamed 
region  may  be  covered  with  salicylate  of  starch.  Perhaps  as  good  an  appli- 
cation as  any  is  cold  water,  which  was  highly  recommended  by  Hippocrates, 


XVIII.     SEPTIC-ffiMIA   AND    PY-ffiMIA. 

Certain  terms  must  first  be  defined. 

An  infection  is  the  morbid  process  induced  by  the  invasion  and  growth  in 
the  body  of  pathogenic  micro-organisms.  An  infection  may  be  local,  as  in 
a  boil,  or  general,  as  in  some  cases  of  anthrax. 

An  intoxication  is  the  morbid  condition  caused  by  the  absorption  of  toxins, 
in  large  part  derived  from  pathogenic  organisms.  The  term  saprcemia  is  the 
equivalent  of  septic  intoxication. 

A  hard-and-fast  line  can  not  be  drawn  between  an  infection  and  an  intoxi- 
cation, but  agents  of  infection  alone  are  capable  of  reproduction,  whereas  those 
of  intoxication  are  chemical  poisons,  some  of  which  are  produced  by  the  agency 
of  bacteria,  or  by  vegetable  and  animal  cells.  Infectious  diseases  which  are 
communicated  directly  from  one  person  to  another  are  termed  contagious,  and 
the  infecting  agent  is  sometimes  spoken  of  as  a  contagium.    "  Whether  or  not 


214  SPECIFIC  INFECTIOUS  DISEASES. 

an  infectious  disease  is  contagious  in  the  ordinary  sense  depends  upon  the 
nature  of  the  infectious  agent,  and  especially  upon  the  manner  of  its  elimina- 
tion from  and  reception  by  the  body.  Most  but  not  all  contagious  diseases  are 
infectious.  Scabies  is  a  contagious  disease,  but  it  is  not  infectious  "  (Welch), 
There  are  three  chief  clinical  types  of  infection. 

1.  Local  Iis^pections  with  the  Development  of  Toxins. 

This  is  the  common  mode  of  invasion  of  many  of  the  diseases  which  we 
have  already  considered.  Tetanus,  diphtheria,  erysipelas,  and  pneumonia  are 
diseases  which  have  sites  of  local  infection  in  which  the  pathogenic  organisms 
develop ;  but  the  constitutional  efEects  are  caused  by  the  absorption  of  the  poi- 
sonous products.  The  diphtheria  toxin  produces  all  the  general  symptoms,  the 
tetanus  toxin  every  feature,  of  the  disease  without  the  presence  of  their  re- 
spective bacilli.  Certain  of  the  symptoms  following  the  absorption  of  the  tox- 
ins are  general  to  all ;  others  are  special  and  peculiar,  according  to  the  organ- 
ism which  produces  them.  A  chill,  fever,  general  malaise,  prostration,  rapid 
pulse,  restlessness,  and  headache  are  the  most  frequent.  With  but  few  excep- 
tions the  febrile  disturbance  is  the  most  common  feature.  The  most  serious 
effects  are  seen  upon  the  nervous  system  and  upon  the  heart,  and  the  gravity 
of  the  symptoms  on  the  part  of  these  organs  is  to  some  extent  a  measure  of  the 
intensity  of  the  intoxication.  The  organisms  of  certain  local  infections  pro- 
duce poisons  which  have  special  actions;  thus  the  diphtheria  toxin,  besides 
having  the  effects  already  referred  to,  is  especially  prone  to  attack  the  nervous 
system  and  to  cause  peripheral  neuritis.  The  tetanus  toxin  has  a  specific 
action  on  the  motor  neurones. 

2.  Septicemia. 

Formerly,  and  in  a  surgical  sense,  the  term  ''  septicaemia "  was  used  to 
designate  the  invasion  of  the  blood  and  tissues  of  the  body  by  the  organisms 
of  suppuration,  but  in  the  medical  sense  the  term  may  be  applied  to  any  con- 
dition in  which,  with  or  without  a  local  site  of  infection,  there  is  microbic 
invasion  of  the  blood  and  tissues,  but  without  metastatic  foci  of  suppuration. 
Owing  to  the  great  development  of  bacteria  in  the  blood,  and  in  order  to  sepa- 
rate it  sharply  from  local  infectious  processes  with  toxic  invasion  of  the  body, 
it  is  proposed  to  call  this  condition  bactersemia;  toxaemia  denotes  the  latter 
state. 

(a)  Progeessive  Septicemia  eeom  Local  Infection. — The  common 
streptococcus  and  staphylococcus  infection  is  as  a  rule  first  local,  and  the  tox- 
ins alone  pass  into  the  blood.  In  other  instances  the  cocci  appear  in  the  blood 
and  throughout  the  tissues,  causing  a  septicaemia  which  intensifies  greatly  the 
severity  of  the  case.  Other  infections  in  which  the  bacterial  invasion,  local  at 
first,  may  become  general  are  pneumonia,  typhoid  fever,  anthrax,  gonorrhoea, 
and  puerperal  fever. 

The  clinical  features  of  this  form  are  well  seen  in  the  cases  of  puerperal 
septicaemia  or  in  dissection  wounds,  in  which  the  course  of  the  infection  may 
be  traced  along  the  lymphatics.  The  svmptoms  usually  set  in  within  twenty- 
four  hours,  and  rarely  later  than  the  third  or  fourth  day.  There  is  a  chill 
or  chilliness^  with  moderate  fever  at  firstj  which  gradually  rises  and  is  marked 


SEPTICEMIA  AND  PYAEMIA.  215 

by  daily  remissions  and  even  intermissions.  The  pulse  is  small  and  com- 
pressible, and  may  reach  120  or  higher.  Gastro-intestinal  disturbances  are 
common,  the  tongue  is  red  at  the  margin,  and  the  dorsum  is  dry  and  dark. 
There  may  be  early  delirium  or  marked  mental  prostration  and  apathy.  As 
the  disease  progresses  there  may  be  pallor  of  the  face  or  a  yellowish  tint. 
Capillary  haemorrhages  are  not  uncommon. 

In  streptococcus  cases  we  are  beginning  to  recognize  the  fact  that  these 
infections  are  not  always  so  serious  as  we  thought.  Death  may  occur  within 
twenty-four  hours  or  be  delayed  for  several  days,  even  for  weeks,  and  recovery 
may  occur.  One  case  recently  showed  streptococci  in  the  blood  for  six  weeks, 
but  ultimately  recovered  (Cole).  On  post-mortem  examination  there  may  be 
no  gross  focal  lesions  in  the  viscera,  and  the  seat  of  infection  may  present  only 
slight  changes.  The  spleen  is  enlarged  and  soft,  the  blood  may  be  extremely 
dark  in  color,  and  haemorrhages  are  common,  particularly  on  the  serous  sur- 
faces. Neither  thrombi  nor  emboli  are  found.  Certain  clinical  features  sepa- 
rate the  streptococcus  frohi  the  staphylococcus  infection,  chiefly  in  the  absence 
of  delirium,  a  rather  abnormal  mental  acuteness,  and  in  the  presence  of  a 
greater  degree  of  anaemia. 

Many  instances  of  septicaemia  are  combined  infections ;  thus  in  diphtheria 
streptococcus  septicaemia  is  a  common,  and  the  most  serious,  event.  The  local 
disease  and  the  symptoms  produced  by  absorption  of  the  toxins  dominate  the 
clinical  picture ;  but  the  features  are  usually  much  aggravated  by  the  systemic 
invasion.  A  similar  infection  may  occur  in  typhoid  fever  and  in  tuberculosis, 
and  may  obscure  the  typical  picture.  These  secondary  septicaemias  are  caused 
most  fre(|uently  by  the  streptococcus,  but  may  result  from  the  invasion  of 
other  bacteria. 

(&)  General  Septicemia  without  Eecognizable  Local  Infection. — - 
Crypto  genetic  Septiccemias. — This  is  a  group  of  very  great  interest  to  the 
physician,  the  full  importance  of  which  we  are  only  now  beginning  to  recog- 
nize. 

The  subjects  when  attacked  may  be  in  perfect  health ;  more  commonly  they 
are  already  weakened  by  acute  or  chronic  illness.  The  pathogenic  organisms 
are  varied.  Streptococcus  pyogenes  is  the  most  common;  the  forms  of 
staphylococcus  more  rare.  Other  occasional  causal  agents  are  Micrococcus 
lanceolatus  (pneumococcus).  Bacillus  proteus,  and  Bacillus  pyocyaneus.  Be- 
tween May  1,  1892,  and  June  1,  1895,  there  were  examined  in  the  post-mortem 
room  from  my  wards  21  cases  of  general  infection,  of  which  13  were  due  to 
Streptococcus  pyogenes,  2  to  Staphylococcus  pyogenes,  and  6  to  the  pneumo- 
coccus. In  19  of  these  cases  the  patients  were  already  the  subjects  of  some 
other  malady,  which  was  aggravated,  or  in  most  instances  terminated,  by  the 
general  septicemia.  The  symptoms  vary  somewhat  with  the  character  of  the 
micro-organisms.  In  the  streptococcus  cases  there  may  be  chills  with  high, 
irregular  fever,  and  a  more  characteristic  septic  state  than  in  the  pneumo- 
coccus infection. 

Most  of  these  cases  come  correctly  under  the  term  "  cryptogenetic  septi- 
caemia" as  employed  by  Leube,  inasmuch  as  the  local  focus  of  infection  is 
not  evident  during  life,  and  may  not  be  found  after  death.  Although  most 
of  these  cases  are  terminal  infections,  yet  it  is  well  to  bear  in  mind  that  there 
are  instances  of  this  type  of  affection  coming  on  in  apparently  healthy  persons. 


216  SPECIFIC  INFECTIOUS  DISEASES. 

The  fever  may  be  extremely  irregular,  characteristically  septic,  and  persist 
for  many  weeks.  Foci  of  suppuration  may  not  develop,  and  may  not  be  found 
even  at  autopsy.  I  have  on  several  occasions  met  with  cases  of  an  intermit- 
tent pyrexia  persisting  for  weeks,  in  which  it  seemed  impossible  to  give  any 
explanation  of  the  phenomena,  and  some  which  ultimately  recovered,  and  in 
which  tuberculosis  and  malaria  could  be  almost  positively  excluded.  These 
cases  require  to  be  carefully  studied  bacteriologically.  Dreschfeld  has  de- 
scribed them  as  idiopathic  intermittent  fever  of  pysemic  character.  Local 
symptoms  may  be  absent,  though  in  three  of  his  cases  there  was  enlargement 
of  the  liver,  and  in  two  the  condition  was  a  diffuse  suppurative  hepatitis.  The 
pyocyanic  disease,  or  cyano-pyfemia,  is  an  extremely  interesting  form  of  infec- 
tion with  Bacillus  pyocyaneus,  of  which  a  larger  number  of  cases  have  been 
reported  of  late  years.  (See  Wollstein's  paper.  Archives  of  Pediatrics,  Octo- 
ber, 1897,  and  Barker,  Jour.  Am.  Med.  Assoc,  1897.) 

3.  Septico-py^mia, 

The  pathogenic  micro-organisms  which  invade  the  blood  and  tissues  may 
settle  in  certain  foci  and  there  cause  suppuration.  When  multiple  abscesses 
are  thus  produced  in  connection  with  a  general  infection,  the  condition  is 
known  as  pyramia  or,  perhaps  better,  septico-pyaemia.  There  are  no  specific 
organisms  of  suppuration,  and  the  condition  of  pysemia  may  be  produced  by 
organisms  other  than  the  streptococci  and  staphylococci,  though  these  are  the 
most  common.  Other  forms  which  may  invade  the  system  and  cause  foci  of 
suppuration  are  Micrococcus  lanceolatus,  the  gonococcus.  Bacillus  coli,  Bacillus 
typhosus,  Bacillus  prateus,  Bacillus  pyocyaneus,  Bacillus  influenzce,  and  very 
probably  the  anaerobic  bacteria  of  Veillon  and  Zuber.  In  a  large  proportion  of 
all  cases  of  pyaemia  there  is  a  focus  of  infection,  either  a  suppurating  exter- 
nal wound,  an  osteomyelitis,  a  gonorrhoea,  an  otitis  media,  an  empyema,  or  an 
area  of  suppuration  in  a  lymph-gland  or  about  the  appendix.  In  a  large 
majority  of  all  these  cases  the  common  pus  cocci  are  present. 

In  a  suppurating  wound,  for  example,  the  pus  organisms  induce  hyaline 
necrosis  in  the  smaller  vessels  with  the  production  of  thrombi  and  purulent 
phlebitis.  The  entrance  of  pus  organisms  in  small  numbers  into  the  blood 
does  not  necessarily  produce  pyaemia.  Commonly  the  transmission  to  various 
parts  from  the  local  focus  takes  place  by  the  fragments  of  thrombi  which  pass 
as  emboli  to  different  parts,  where,  if  the  conditions  are  favorable,  the  pus 
organisms  excite  suppuration.  A  thrombus  which  is  not  septic  or  contami- 
nated, when  dislodged  and  impacted  in  a  distant  vessel,  produces  at  most  only 
a  simple  infarction;  but,  coming  from  an  infected  source  and  containing  pus 
microbes,  an  independent  centre  of  infection  is  established  wherever  the  em- 
bolus may  lodge.  These  independent  suppurative  centres  in  pyaemia,  known  as 
embolic  or  metastatic  abscesses,  have  the  following  distribution: 

(a)  In  external  wounds,  in  osteo-myelitis,  and  in  acute  phlegmon  of  the 
skin,  the  embolic  particles  very  frequently  excite  suppuration  in  the  lungs, 
producing  the  well-known  wedge-shaped  pyaemic  infarcts ;  from  these,  or  rarely 
by  paradoxical  embolism,  or  direct  passage  of  bacteria  or  minute  emboli 
through  the  pulmonary  capillaries,  metastatic  foci  of  inflammation  may  occur 
in  other  parts. 

(6)  Suppurative  foci  in  the  territory  of  the  portal  system,  particularly  in 


SEPTICEMIA  AND  PYJEMIA.  217 

the  intestines,  produce  metastatic  abscesses  in  the  liver  with  or  without  sup- 
purative pylephlebitis. 

Endocarditis  is  an  event  which  is  very  liable  to  occur  in  all  forms  of  sep- 
ticasmia,  and  modifies  materially  the  character  of  the  clinical  features.  Strep- 
tococci and  staphylococci  are  the  most  common  organisms  present  in  the  vege- 
tations, but  the  pneumococci,  gonococci,  tubercle  bacilli,  typhoid  bacilli, 
anthrax  bacilli,  and  other  forms  have  been  isolated.  The  vegetations  which 
grow  at  the  site  of  the  valve  lesion  become  covered  with  thrombi,  particles 
of  which  may  be  dislodged  and  carried  as  emboli  to  different  parts  of  the  body, 
causing  multiple  abscesses  or  infarcts. 

Symptoms  of  Septico-pysemia. — In  a  case  of  wound  infection,  prior  to  the 
onset  of  the  characteristic  symptoms,  there  may  be  signs  of  local  trouble,  and 
in  the  case  of  a  discharging  wound  the  pus  may  change  in  character.  The 
onset  of  the  disease  is  marked  by  a  severe  rigor,  during  which  the  temperature 
rises  to  103°  or  104°  and  is  followed  by  a  profuse  sweat.  These  chills  are 
repeated  at  intervals,  either  daily,  or  every  other  day.  In  the  intervals  there 
may  be  slight  pyrexia.  The  constitutional  disturbance  is  marked  and  there 
are  loss  of  appetite,  nausea,  and  vomiting,  and,  as  the  disease  progresses,  rapid 
emaciation.  Transient  erythema  is  not  uncommon.  Local  symptoms  usually 
occur.  If  the  lungs  become  involved  there  are  dyspnoea  and  cough.  The 
physical  signs  may  be  slight.  Involvement  of  the  pleura  and  pericardium  is 
common.  The  anasmia,  often  profound,  causes  great  pallor  of  the  skin,  which 
later  may  be  bile-tinged.  The  spleen  is  enlarged,  and  there  may  be  intense 
pain  in  the  side,  pointing  to  perisplenitis  from  embolism.  Usually  in  the 
rapid  cases  a  typhoid  state  supervenes,  and  the  patient  dies  comatose. 

In  the  chronic  cases  the  disease  may  be  prolonged  for  months;  the  chills 
recur  at  long  intervals,  the  temperature  is  irregular,  and  the  condition  of  the 
patient  varies  from  month  to  month.  The  course  is  usually  slow  and  progress- 
ively downward. 

Diagnosis. — Pyaemia  is  a  disease  frequently  overlooked  and  often  mistaken 
for  other  affections. 

Cases  following  a  wound,  an  operation,  or  parturition  are  readily  recog- 
nized.    On  the  other  hand,  the  following  conditions  may  be  overlooked: 

Osteo-myelitis. — Here  the  lesion  may  be  limited,  the  constitutional  symp- 
toms severe,  and  the  course  of  the  disease  very  rapid.  The  cause  of  the  trouble 
may  be  discovered  only  post  mortem. 

So,  too,  acute  septico-pysemia  may  follow  gonorrhoea  or  a  prostatic  abscess. 

Cases  are  sometimes  confounded  with  typhoid  fever,  particularly  the  more 
chronic  instances,  in  which  there  are  diarrhoea,  great  prostration,  delirium, 
and  irregular  fever.  The  spleen,  too,  is  often  enlarged.  The  marked  leuco- 
cytosis  is  an  important  differential  point. 

In  some  of  the  instances  of  ulcerative  endocarditis  the  diagnosis  is  very 
difficult,  particularly  in  what  is  known  as  the  typhoid,  in  contradistinction 
to  the  septic,  type  of  this  disease.  In  acute  miliary  tuberculosis  the  symp- 
toms occasionally  resemble  those  of  septicaemia,  more  commonly  those  of 
typhoid  fever. 

The  post-fehrile  artliritides,  such  as  occur  after  scarlet  fever  and  gonor- 
rhoea, are  really  instances  of  mild  septic  infection.  The  joints  may  some- 
times suppurate  and  pyemia  develop.     So,  also,  in  tuberculosis  of  the  kidneys 


218  SPECIFIC  INFECTIOUS  DISEASES. 

and  calculous  pyelitis  recurring  rigors  and  sweats  due  to  septic  infection  are 
common.  In  some  latitudes  septic  and  pysemic  processes  are  too  often  con- 
founded with  malaria.  In  early  tuberculosis,  or  even  when  signs  of  excava- 
tion are  present  in  the  lungs,  and  in  cases  of  suppuration  in  various  parts, 
particularly  empyema  and  abscess  of  the  liver,  the  diagnosis  of  malaria  is 
made.  The  practitioner  may  take  it  as  a  safe  rule,  to  which  he  will  find  very 
few  eseeptions,  that  an  intermittent  fever  which  resists  quinine  is  not  malaria. 

Other  conditions  associated  with  chills  which  may  be  mistaken  for  pygemia 
are  profound  ana?mia,  certain  cases  of  Hodgkin's  disease,  the  hepatic  inter- 
mittent fever  associated  with  the  lodgment  of  gall-stones  at  the  orifice  of  the 
common  duct,  rare  cases  of  essential  fever  in  nervous  women,  and  the  inter- 
mittent fever  sometimes  seen  in  rapidly  growing  cancer. 

Treatment. —  (a)  Surgical. — In  pyaemia,  where  the  pus  is  accessible,  free 
evacuation  and  drainage  is  often  the  only  treatment  required.  In  a  case  of 
empygema  with  weeks  of  high  and  irregular  fever  the  day  after  operation  the 
temperature  is  normal,  and  may  remain  so.  In  some  cases  with  a  local  infec- 
tion Bier's  method  of  Iwpersmia  has  been  used  with  success,  but  where  the 
focus  of  manufacture  of  the  poison  is  accessible  the  knife  should  be  used. 
Unfortunately,  in  only  too  many  cases  the  focus  of  infection  is  not  accessible; 
it  then  is  a  septicsemia,  and  for  such  cases  the  bacteriologists  have  intro- 
duced the  treatment  with  vaccines. 

(h)  Vaccine  Treatment. — By  blood  cultures  or  by  cultures  from  the  focus 
of  infection  the  organism  is  isolated,  then  a  vaccine  is  prepared,  and,  if 
Wright's  method  is  followed,  the  use  and  dose  are  regulated  by  the  opsonic 
index  of  the  patient.  In  many  cases  where  the  germ  can  not  be  isolated  and 
the  condition  is  one  of  septic  fever  the  ordinary  antistreptococcus  serum  is 
used,  or  one  of  the  polyvalent  sera.  Good  results  are  obtained  in  a  few  cases, 
and  we  are  working  in  the  right  direction,  but  the  method  is  as  yet  only  in  the 
experimental  stage. 

(c)  Drugs. — There  are  none  which  control  septic  fever.  The  coal-tar 
products  are  of  doubtful  service.  Quinine  may  be  used.  Cold  bathing  is 
much  the  best  measure  to  control  the  fever. 

4.  Terminal  Infections. 

There  is  truth  in  the  paradoxical  statement  that  persons  rarely  die  of  the 
disease  with  which  they  sufi'er.  Secondary,  terminal,  infections  carry  ofE  many 
of  the  incurable  cases.  Flexner  analyzed  255  cases  of  chronic  renal  and  cardiac 
disease  in  which  complete  bacteriological  examinations  were  made  at.  autopsy. 
Excluding  tuberculous  infection,  213  gave  positive  and  42  negative  results. 
The  infections  may  be  local  or  general.  The  former  are  extremely  common, 
and  are  found  in  a  large  proportion  of  all  cases  of  Bright's  disease,  arterio- 
sclerosis, heart  disease,  cirrhosis  of  the  liver,  and  other  chronic  disorders. 
Affections  of  the  serous  membranes  (acute  pleurisy,  pericarditis,  or  perito- 
nitis), meningitis,  and  endocarditis  are  the  most  frequent  lesions.  It  is  per- 
haps safe  to  say  that  the  majority  of  cases  of  advanced  arterio-sclerosis  and 
of  Bright's  disease  succumb  to  these  intercurrent  infections.  The  infective 
agents  are  very  varied.  The  streptococcus  is  the  most  common,  but  the  pneu- 
mococcus,  staphylococcus  and  gonococcus,  and  the  proteus,  pyocyaneus,  and 


RHEUMATIC  FEVER-  219 

gas  bacilli  are  also  met  with.  It  is  surprising  in  how  many  instances  of 
arterio-sclerosis,  of  chronic  heart  disease,  of  Bright's  disease,  and  particularly 
of  cirrhosis  of  the  liver  in  Flexner's  series  the  fatal  event  was  determined  by 
an  acute  tuberculosis  of  the  peritonseum  or  pleura. 

The  general  terminal  infections  are  somewhat  less  common.  Of  85  eases 
of  chronic  renal  disease  in  which  Flexner  found  micro-organisms  at  autopsy, 
38  exhibited  general  infections;  of  48  cases  of  chronic  cardiac  disease,  in  14 
the  distribution  of  bacteria  was  general.  The  blood-serum  of  persons  suffer- 
ing from  advanced  chronic  disease  was  found  by  him  to  be  less  destructive  to 
the  staphylococcus  aureus  than  normal  human  serum.  Other  diseases  in  which 
general  terminal  infection  may  occur  are  Hodgkin's  disease,  leukaemia,  and 
chronic  tuberculosis. 

And,  lastly,  probably  of  the  same  nature  is  the  terminal  entero-colitis  so 
frequently  met  with  in  chronic  disorders. 


XIX.     RHEUMATIC    FEVER. 

Definition. — An  acute,  non-contagious  fever,  dependent  upon  an  unknown 
infective  agent,  and  characterized  by  multiple  arthritis  and  a  marked  tendency 
to  inflammation  of  the  fibrous  tissues. 

Etiology. — Distribution  and  Prevalence. — It  prevails  in  temperate 
and  humid  climates.  Church  has  collected  interesting  statistics  on  this  point. 
Oddly  enough,  the  two  countries  with  the  highest  admission  in  the  British 
army  per  thousand  of  strength — Egypt,  7.03,  and  Canada,  6.26 — ^have  climates 
the  most  diverse.  In  1903  in  England  and  Wales  1,812  deaths  were  due  to 
rheumatic  fever  (Tatham).  The  disease  prevails  more  in  the  northern  lati- 
tudes. In  the  Montreal  General  Hospital  there  were  for  the  twelve  years 
ending  1903,  2  deaths  in  482  cases  among  12,044  admissions;  at  the  Eoyal 
Victoria  Hospital,  Montreal,  for  ten  years  ending  1903,  3  deaths  in  285  cases 
among  9,286  admissions  (John  McCrae).  At  the  Johns  Hopkins  Hospital 
for  the  fifteen  years  ending  1904,  there  were  360  admissions  (330  patients) 
and  9  deaths  (T.  McCrae).  The  general  impression  is  that  the  disease  pre- 
vails more  in  the  British  Isles  than  elsewhere;  but,  as  Church  remarks,  the 
returns  are  very  imperfect  (this  holds  good  everywhere).  In  Norway,  where 
cases  of  rheumatic  fever  are  notified,  there  were  for  the  four  years  1888-92 
13,654  cases,  with  250  deaths. 

Season. — In  London  the  cases  reach  the  maximum  in  the  months  of  Sep- 
tember and  October.  In  the  Montreal  General  Hospital  Bell's  statistics  of 
456  cases  show  that  the  largest  number  was  admitted  in  February,  March, 
and  April.  And  the  same  is  true  in  Baltimore,  55  per  cent  of  our  cases  were 
admitted  in  the  first  four  months  of  the  year  (McCrae).  The  disease  prevails 
most  in  the  dry  years  or  a  succession  of  such,  and  is  specially  prevalent  when 
the  subsoil  water  is  abnormally  low  and  the  temperature  of  the  earth  high 
(Newsholme). 

Age. — Young  adults  are  most  frequently  affected,  but  the  disease  is  by  no 
means  uncommon  in  children  between  the  ages  of  ten  and  fifteen  years.  Suck- 
lings are  rarely  attacked.  Milton  Miller  has  analyzed  19  undoubted  cases. 
The  eases  have  to  be  distinguished  from  a  totally  different  affection,  the  pyo- 


220  SPECIFIC  INFECTIOUS  DISEASES. 

genie  arthritis  of  infants.  Of  456  cases  admitted  to  the  Montreal  General 
Hospital  there  were,  under  fifteen  years,  4.38  per  cent;  from  fifteen  to  twent}'-- 
five  years,  48.68  per  cent;  from  twenty-five  to  thirty- five  years,  25.87  per  cent; 
from  thirty-five  to  forty- five  years,  13.6  per  cent;  above  forty-five  years,  7.4 
per  cent.  Of  our  360  admissions,  110  were  in  the  third  decade  and  65  per 
cent  below  the  thirtieth  year  of  age  (McCrae).  Ten  per  cent  of  the  cases 
had  the  first  attack  in  the  first  decade.  Of  the  655  cases  analj^zed  by  Whip- 
ham  for  the  Collective  Investigation  Committee  of  the  British  Medical  Asso- 
ciation, only  32  cases  occurred  under  the  tenth  3^ear  and  80  per  cent  between 
the  twentieth  and  fortieth  years.  These  figures  do  not  give  the  ratio  of  cases 
in  children,  in  whom  the  milder  types  of  arthritis  are  very  common. 

Sex. — If  all  ages  are  taken,  males  are  affected  oftener  than  females.  Of 
our  patients,  239  were  males,  91  females.  In  the  Collective  Investigation  Ee- 
port  there  were  375  males  and  279  females.  Up  to  the  age  of  twenty,  how- 
ever, females  predominate.  Between  the  ages  of  ten  and  fifteen  girls  are  more 
prone  to  the  disease. 

Heredity. — It  is  a  deeply  groimded  belief  with  the  public  and  the  pro- 
fession that  rheumatism  is  a  family  disease,  but  Church  thinks  the  evidence 
is  still  imperfect.  In  25  per  cent  of  our  cases  there  was  a  history  of  the  dis- 
ease in  the  family.  The  not  rare  occurrence  in  several  members  of  the  same 
family  is  used  by  those  who  believe  in  the  infectious  origin  as  an  argument 
in  favor  of  its  being  a  house  disease. 

Occupations  which  necessitate  exposure  to  cold  and  great  changes  of  tem- 
perature predispose  strongly,  and  the  disease  is  met  with  oftenest  in  drivers, 
servants,  bakers,  sailors,  and  laborers. 

Chill. — Exposure  to  cold,  a  wetting,  or  a  sudden  change  of  temperature 
are  among  the  factors  in  determining  the  onset  of  an  attack,  but  they  were 
present  in  only  12  per  cent  of  our  cases. 

Xot  only  does  an  attack  not  confer  immunity,  but  as  in  pneumonia  pre- 
disposes the  subject  to  the  disease. 

Rheumatic  Fever  as  an  Acute  Infectious  Disease. — (a)  General  Evi- 
dence.— Eheumatic  fever,  as  Xewsholme  has  shown,  occurs  in  epidemics  with- 
out regular  periodicity,  recurring  at  intervals  of  three,  four,  or  six  years,  and 
varying  much  in  intensity.  A  severe  epidemic  is  apt  to  be  followed  by  two 
or  three  mild  outbreaks.  "  The  curves  of  the  mortality  statistics  ,  .  .  approx- 
imate very  closely  to  those  of  pyemia,  puerperal  fever,  and  erysipelas,  dis- 
eases which  are  certainly  associated  with  specific  micro-organisms"  (Church). 
The  constancy  also  of  the  seasonal  variations  is  an  additional  support  to 
this  view. 

(6)  Clinical  Features. — Physicians  have  long  been  impressed  with  the 
striking  similarity  of  the  s}Tnptoms  to  those  of  septic  infection.  In  the  char- 
acter of  the  fever,  the  mode  of  involvement  of  the  joints,  the  tendency  to  re- 
lapse, the  sweats,  the  anaemia,  the  leucocytosis,  and,  above  all,  the  great  liabil- 
ity to  endocarditis  and  involvement  of  the  serous  membranes,  the  disease 
resembles  pyaemia  very  closely,  and  may,  indeed,  be  taken  as  the  very  type  of  an 
acute  infection.  But,  as  Stephen  Mackenzie  remarks,  acute  rheumatism  should 
be  considered  not  simply  from  the  point  of  view  of  the  rheumatic  polyarthritis 
of  the  adult,  but  as  a  whole  in  its  manifestations  at  difEerent  periods  of  life; 
yet  even  from  this  standpoint  the  multiform  manifestations  of  the  rheumatic 


RHEUMATIC  FEVER.  221 

j^oison  in  childhood  and  young  adults  may  very  reasonably  be  referred  to  the 
effect  of  the  toxins  of  micro-organisms. 

(c)  Special  Evidence. — The  bacteriology  of  the  disease  is  still  under  dis- 
cussion. Many  organisms  have  been  described,  a  special  bacillus  by  Achalme, 
forms  of  streptococci,  and  a  diplococcus  by  Wasserman,  which  is  probably  the 
same  as  that  described  in  England  by  Poynton  and  Payne,  Ainley  Walker, 
Shaw  and  Beattie.  This  latter,  which  has  been  called  the  Micrococcus  rlieu- 
maticus,  has  been  isolated  from  the  throat,  joints,  and  exudates  in  persons 
suffering  with  rheumatic  fever.  Poynton,  Payne,  and  others  have  produced 
with  this  organism,  injected  into  rabbits,  endocarditis,  arthritis,  and  subcu- 
taneous nodules.  In  a  series  of  cases  in  my  clinic  Cole  could  not  confirm  these 
results,  studying  blood  cultures  and  the  effusion  into  the  joints.  On  the  other 
hand,  he  was  able  with  strains  of  streptococci  from  various  sources  to  produce 
experimentally  endocarditis  and  arthritis.  A  view  very  commonly  held  is  that 
the  organism  producing  the  disease  is  an  attenuated  streptococcus.  Beattie, 
in  a  recent  paper,  claims  that  the  results  obtained  by  injecting  streptococci  are 
different  from  those  produced  by  Micrococcus  rheumaticus.  A  point  of  great 
interest  is  that  Ainley  Walker  has  obtained  formic  acid  from  the  cultures  of 
this  germ.  The  problem  is  one  of  great  difficulty  and  of  the  first  importance, 
in  view  of  the  suffering  and  incapacity  caused  by  rheumatic  fever. 

There  is  considerable  evidence  against  the  view  that  it  is  simply  a  mild 
pyogenic  infection.  Salicylates  have  no  effect  on  the  ordinary  streptococcus 
infections,  and  the  clinical  course  in  the  streptococcus  arthritis  is  very  differ- 
ent; moreover,  rheumatic  joints  never  suppurate.  The  isolation  of  strepto- 
cocci may  simply  indicate  the  presence  of  secondary  streptococcus  invaders 
such  as  occur  in  scarlet  fever  and  small-pox. 

Other  views  as  to  the  nature  of  rheumatism  are  the  metabolic  or  chemical: 
that  it  depends  upon  a  morbid  material  produced  within  the  system  in  de- 
fective processes  of  assimilation.  It  has  been  suggested  that  this  material  is 
lactic  acid  (Prout)   or  certain  combinations  with  lactic  acid   (Latham). 

A  nervous  theory  of  acute  rheumatism  was  advocated  by  the  late  J.  K. 
Mitchell,  of  Philadelphia,  who  believed  that  the  nerve  centres  were  primarily 
affected  by  cold  and  that  the  local  lesions  were  really  trophic  in  character. 

Morbid  Anatomy. — There  are  no  changes  characteristic  of  the  disease. 
The  affected  joints  show  hyperemia  and  swelling  of  the  synovial  membranes 
and  of  the  ligamentous  tissues.  There  may  be  slight  erosion  of  the  cartilage. 
The  fluid  in  the  joint  is  turbid,  albuminous  in  character,  and  contains  leuco- 
cytes and  a  few  fibrin  flakes.  Pus  is  very  rare  in  uncomplicated  cases.  Eheu- 
matic  fever  rarely  proves  fatal,  except  when  there  are  serious  complications, 
such  as  pericarditis,  endocarditis,  myocarditis,  pleurisy,  or  pneumonia.  The 
conditions  found  show  nothing  peculiar,  nothing  to  distinguish  them  from 
other  forms  of  inflammation.  In  death  from  hyperpyrexia  no  special  changes 
are  found.  The  blood  usually  contains  an  excessive  amount  of  fibrin.  In  the 
secondary  rheumatic  inflammations,  as  pleurisy  and  pericarditis,  various  pus 
organisms  have  been  found,  possibly  the  result  of  a  mixed  infection. 

Symptoms. — As  a  rule,  the  disease  sets  in  abruptly,  but  it  may  be  preceded 
by  irregular  pains  in  the  joints,  slight  malaise,  sore  throat,  and  particularly  by 
tonsillitis.  A  definite  rigor  is  uncommon;  more  often  there  is  slight  chilli- 
ness.   The  fever  rises  quickly,  and  with  it  one  or  more  of  the  joints  become 


222  SPECIFIC  INFECTIOUS  DISEASES. 

painful.  Within  twenty-four  hours  from  the  onset,  the  disease  is  fully  mani- 
fest. The  temperature  range  is  from  102°  to  104°.  The  pulse  is  frequent,  soft, 
and  usually  above  100.  The  tongue  is  moist,  and  rapidly  becomes  covered  with 
a  white  fur.  There  are  the  ordinary  symptoms  associated  with  an  acute  fever, 
such  as  loss  of  appetite,  thirst,  constipation,  and  a  scanty,  highly  acid,  highly 
colored  urine.  In  a  majority  of  the  cases  there  are  profuse,  very  acid  sweats, 
of  a  peculiar  sour  odor.  Sudaminal  and  miliary  vesicles  are  abundant,  the 
latter  usually  surrounded  by  a  minute  ring  of  hypersemia.  The  mind  is  clear, 
except  in  the  cases  with  hyperpyrexia.  The  affected  joints  are  painful  to  move, 
soon  become  swollen  and  hot,  and  present  a  reddish  flush.  The  order  of  fre- 
quency of  involvement  of  the  joints  in  our  series  was  knee,  ankle,  shoulder, 
wrist,  elbow,  hip,  hand,  foot.  The  joints  are  not  attacked  together,  but  suc- 
cessively. For  example,  if  the  knee  is  first  affected,  the  redness  may  disappear 
from  it  as  the  wrists  become  painful  and  hot.  The  disease  is  seldom  limited  to 
a  single  articulation.  The  amount  of  swelling  is  variable.  Extensive  effusion 
into  a  joint  is  rare,  and  much  of  the  enlargement  is  due  to  the  infiltration  of 
the  periarticular  tissues  with  serum.  The  swelling  may  be  limited  to  the  joint 
proper,  but  in  the  wrists  and  ankles  it  sometimes  involves  the  sheaths  of  the 
tendons  and  produces  great  enlargement  of  the  hands  and  feet.  Correspond- 
ing joints  are  often  affected.  In  attacks  of  great  severity  every  one  of  the 
larger  joints  may  be  involved.  The  vertebral,  sterno-clavicular,  and  phalan- 
geal articulations  are  less  often  inflamed  in  acute  than  in  gonorrhoeal  rheuma- 
tism. Perhaps  no  disease  is  more  painful  than  acute  polyarthritis.  The  ina- 
bility to  change  the  posture  without  agonizing  pain,  the  drenching  sweats,  the 
prostration  and  utter  helplessness,  combine  to  make  it  one  of  the  most  distress- 
ing of  febrile  affections.  A  special  feature  of  the  disease  is  the  tendency  of 
the  inflammation  to  subside  in  one  joint  while  increasing  with  great  intensity 
in  another. 

The  temperature  range  in  an  ordinary  attack  is  between  102°  and  104°. 
In  only  18  of  our  cases  did  the  temperature  rise  above  104°.  In  100  it  reached 
103°  or  over.  It  is  peculiarly  irregular,  with  marked  remissions  and  exacerba- 
tions, depending  very  much  upon  the  intensity  and  extent  of  the  articular  in- 
flammation. Defervescence  is  usually  gradual.  The  profuse  sweats  materially 
influence  the  temperature  curve.  If  a  two-hourly  chart  is  made  and  observa- 
tions upon  the  sweats  are  noted,  the  remissions  will  usually  be  found  coinci- 
dent with  the  sweats.  The  perspiration  is  sour-smelling  and  acid  at  first;  but, 
when  persistent,  becomes  neutral  or  even  alkaline. 

The  blood  is  profoundly  altered  in  acute  rheumatism.  There  is,  indeed, 
no  acute  febrile  disease  in  which  an  auEemia  occurs  with  greater  rapidity. 
The  average  leucocyte  count  in  our  cases  was  about  12,000  per  c.mm. 

With  the  high  fever  a  murmur  may  often  be  heard  at  the  apex  region. 
Endocarditis  is  also  a  common  cause  of  an  apex  'bruit.  The  heart  should  be 
carefully  examined  at  the  first  visit  and  subsequently  each  day. 

The  urine  is,  as  a  rule,  reduced  in  amount,  of  high  density  and  high  color. 
It  is  very  acid,  and,  on  cooling,  deposits  urates.  The  chlorides  may  be  greatly 
diminished  or  even  absent.  Formic  acid  is  present  (Walker).  Febrile  albu- 
minuria is  not  uncommon. 

The  saliva  may  become  acid  in  reaction  and  is  said  to  contain  an  excess 
of  sulphocyanides. 


RHEUMATIC  FEVER.  223 

Subacute  Rheumatism. — This  represents  a  milder  form  of  the  disease,  in 
which  all  the  symptoms  are  less  pronounced.  The  fever  rarely  rises  above 
101°;  fewer  joints  are  involved;  and  the  arthritis  is  less  intense.  The  cases 
may  drag  on  for  weeks  or  months,  and  the  disease  may  finally  become  chronic. 
It  should  not  be  forgotten  that  in  children  this  mild  or  subacute  form  may  be 
associated  with  endocarditis  or  pericarditis. 

Complications. — These  are  important  and  serious. 

(1)  Hypekpyeexia. — The  temperature  may  rise  rapidly  a  few  days  after 
the  onset,  and  be  associated  with  delirium;  but  not  necessarily,  for  the  tem- 
perature may  rise  to  108°  or,  as  in  one  of  Da  Costa's  cases,  110°,  without  cere- 
bral symptoms.  Hyperpyrexia  is  most  common  in  first  attacks,  57  of  107  eases 
(Church).  It  is  most  apt  to  occur  during  the  second  week.  Delirium  may 
precede  or  follow  its  onset.  As  a  rule,  with  the  high  fever,  the  pulse  is  feeble 
and  frequent,  the  prostration  is  extreme,  and  finally  stupor  supervenes.  In 
our  series  there  was  no  instance  of  hyperpyrexia,  which  seems  rare  in  the 
United  States. 

(3)  Cardiac  Affection's. —  (a)  Endocarditis,  the  most  frequent  and  seri- 
ous complication,  occurs  in  a  considerable  percentage  of  all  cases.  Of  889 
cases,  494  had  signs  of  old  or  recent  endocarditis  (Church).  The  liability  to 
endocarditis  diminishes  as  age  advances.  The  incidence  of  organic  disease  in 
our  cases  was  more  than  double  in  patients  who  had  had  their  first  attack  below 
the  age  of  twenty  years,  compared  with  those  with  the  first  attack  over  twenty 
years  of  age.  It  increases  directly  with  the  number  of  attacks.  Of  116  cases, 
in  the  first  attack  58.1  per  cent  had  endocarditis,  63  per  cent  in  the  second 
attack,  and  71  per  cent  in  the  third  attack  (Stephen  Mackenzie).  Thirty-five 
per  cent  of  our  cases  showed  organic  valve  lesions,  in  96  per  cent  the  mitral 
was  involved,  in  27  per  cent  the  aortic,  and  in  33  per  cent  both  the  lesions 
were  combined.  The  mitral  segments  are  most  frequently  involved  and  the 
affection  is  usually  of  the  simple,  verrucose  variety.  Ulcerative  endocarditis  is 
very  rare.  Of  209  cases  of  this  disease  which  I  analyzed,  in  only  24  did  the 
symptoms  of  a  severe  endocarditis  arise  during  the  progress  of  acute  or  sub- 
acute rheumatism.  The  valvulitis  in  itself  is  rarely  dangerous,  producing  few 
symptoms,  and  is  usu.ally  overlooked.  Unhappily,  though  the  valve  at  the  time 
may  not  be  seriously  damaged,  the  inflammation  starts  changes  which  lead  to 
sclerosis  and  retraction  of  the  segments,  and  so  to  chronic  valvular  disease. 
Yenous  thrombosis  is  an  occasional  complication. 

{h)  Pericarditis  may  occur  independently  of  or  together  with  endocarditis. 
It  may  be  simple  fibrinous,  sero-fibrinous,  or  in  children  purulent.  Clinically 
we  meet  it  more  frequently  in  connection  with  this  disease  than  in  any  other 
acute  affection.  It  w^as  present  in  20  cases  of  our  series — 6  per  cent — in 
only  four  of  which  did  effusion  occur.  The  physical  signs  are  very  charac- 
teristic. The  condition  will  be  fully  described  under  its  appropriate  section. 
A  peculiar  form  of  delirium  may  develop  during  the  progress  of  rheumatic 
pericarditis. 

(c)  Myocarditis  is  most  frequent  in  connection  with  endo-pericardial 
changes.  As  Sturges  insisted,  the  term  carditis  is  applicable  to  many  cases. 
The  anatomical  condition  is  a  granular  or  fatty  degeneration  of  the  heart- 
muscle,  which  leads  to  weakening  of  the  walls  and  to  dilatation.  It  is  not, 
I  think,  nearly  so  common  as  the  other  cardiac  aflEections.     S.  West  has  re- 


224  SPECIFIC  INFECTIOUS  DISEASES. 

ported  instances  of  acute  dilatation  of  the  heart  in  rheumatic  fever,  in  one 
of  which  marked  fatty  changes  were  found  in  the  heart-fibres. 

(3)  Pulmonary  Affections. — Pneumonia  and  pleurisy  occurred  in  9.9-i 
per  cent  of  3,433  cases  (Stephen  Mackenzie).  They  frequently  accompany 
the  cases  of  endo-pericarditis.  According  to  Howard's  analysis  of  a  large 
number  of  cases,  there  were  pulmonary  complications  in  only  10.5  per  cent 
of  cases  of  rheumatic  endocarditis ;  in  58  per  cent  of  eases  of  pericarditis ;  and 
in  71  per  cent  of  cases  of  endo-pericarditis.  Congestion  of  the  lung  is  occa- 
sionally found,  and  in  several  cases  has  proved  rapidly  fatal. 

(4)  Nervous  Complications. — These  are  due,  in  part,  to  the  hyper- 
pyrexia and  in  part  to  the  special  action  upon  the  brain  of  the  toxic  agent 
of  the  disease.  They  may  be  grouped  as  follows :  (a)  Delirium,  associated 
with  the  h}^erpyrexia  or  the  toxaemia,  may  be  active  and  noisy  in  character; 
more  rarely  a  low  muttering  delirium,  passing  into  stupor  and  coma.  It  was 
present  in  only  five  of  our  307  cases,  and  in  four  of  these  we  thought  the  sal- 
icylates at  fault.  A  peculiar  delirium  occurs  in  connection  with  rheumatic 
pericarditis.  It  may  be  excited  by  the  salicylate  of  soda,  either  shortly  after 
its  administration,  or  more  commonly  a  few  days  later,  (h)  Coma,  which  is 
more  serious,  may  occur  without  preliminary  delirium  or  convulsions,  and 
may  prove  rapidly  fatal.  Certain  of  these  cases  are  associated  with  hyper- 
pyrexia; but  Southey  has  reported  the  case  of  a  girl  who,  without  previous 
delirium  or  high  fever,  became  comatose,  and  died  in  less  than  an  hour.  A 
certain  number  of  such  cases,  as  those  reported  by  Da  Costa,  have  been  asso- 
ciated with  marked  renal  changes  and  were  evidently  ursemic.  The  coma  may 
supervene  during  the  attack,  or  after  convalescence  has  set  in.  (c)  Convul- 
sions are  less  common,  though  they  may  precede  the  coma.  Of  127  observa- 
tions cited  by  Besnier,  there  were  37  of  delirirmi,  only  7  of  convulsions,  17  of 
coma  and  convulsions,  54  of  delirium,  coma,  and  convulsions,  and  3  of  other 
varieties  (Howard),  [d)  Chorea.  The  relations  of  this  disease  and  rheu- 
matism will  be  subsequently  discussed.  It  is  sufficient  here  to  say  that  in  only 
88  out  of  554  cases  which  I  have  anah^zed  from  the  Infirmary  for  Diseases  of 
the  JSTervous  System,  Philadelphia,  were  chorea  and  rheumatism  associated. 
It  is  most  apt  to  develop  in  the  slighter  attacks  in  childhood,  (e)  Meningitis 
is  extremely  rare,  though  undoubtedly  it  does  occur.  It  must  not  be  forgot- 
ten that  in  ulcerative  endocarditis,  which  is  occasionally  associated  with  acute 
rheumatism,  meningitis  is  frequent.  (/)  Polyneuritis  has  been  described.  I 
saw  a  remarkable  case  which  followed  hyperpyrexia.  Free  venesection  saved 
the  patient's  life.  After  many  months  the  patient  recovered,  but  with  a 
remarkable  ataxia. 

(5)  Cutaneous  Affections. — Sweat- vesicles  have  already  been  men- 
tioned as  extremely  common.  A  red  miliary  rash  may  also  develop.  Scarla- 
tiniform  eruptions  are  occasionally  seen.  Purpura,  with  or  without  urticaria, 
may  occur,  and  various  forms  of  erythema.  It  is  doubtful  whether  the  cases 
of  extensive  purpura  with  urticaria  and  arthritis — ^peliosis  rheumatica — 
belong  truly  to  acute  rheumatism. 

(6)  Eheumatic  Nodules. — These  curious  structures,  described  originally 
by  Meynet,  occur  in  the  form  of  small  subcutaneous  nodules  attached  to  the 
tendons  and  fasciae.  Barlow  and  Warner,  in  England,  and  T.  B.  Futcher,  in 
the  United  States,  have  paid  special  attention  to  their  varieties  and  impor- 


RHEUMATIC  FEVER.  225 

tance.  They  vary  in  size  from  a  small  shot  to  a  large  pea,  and  are  most 
numerous  on  the  fingers,  hands,  and  wrists.  They  also  occur  about  the  elbows, 
knees,  the  spines  of  the  vertebrae,  and  the  scapula.  They  are  not  often  tender. 
They  are  more  common  after  the  decline  of  the  fever  and  in  the  children  with 
mitral  valve  disease.  In  only  5  of  our  patients  were  they  present  during  the 
acute  attack.  The  nodules  may  grow  with  great  rapidity  and  usually  last  for 
weeks  or  months.  They  are  more  common  in  children  than  in  adults,  and  in 
the  former  their  presence  may  be  regarded  as  a  positive  indication  of  rheuma- 
tism. They  have  been  noted  particularly  in  association  with  chronic  rheumatic 
endocarditis.  Subcutaneous  nodules  occur  also  in  migraine,  gout,  and  arthri- 
tis deformans.  Histologically  they  are  made  up  of  round  and  spindle-shaped 
cells.  In  addition  to  these  firm,  hard  nodules,  there  occur  in  rheumatism  and 
in  chronic  vegetative  endocarditis  remarkable  bodies,  which  have  been  called 
by  Fereol  "  nodosites  cutanees  ephemeres."  In  a  case  of  chronic  vegetative 
endocarditis  (without  arthritis),  which  I  saw  with  Dr.  J.  K.  Mitchell,  there 
were,  in  addition  to  occasional  elevated  spots  resembling  urticaria,  areas  of 
infiltration  in  the  skin,  from  two  to  three  lines  in  diameter,  not  elevated,  but 
pale  pink,  and  exquisitely  tender  and  painful  even  without  being  touched. 

The  course  of  acute  rheumatism  is  extremely  variable.  It  is,  as  Austin 
Flint  first  showed,  a  self-limited  disease,  and  it  is  not  probable  that  medi- 
cines have  any  special  influence  upon  its  duration  or  course.  Gull  and  Sutton, 
who  likewise  studied  a  series  of  63  cases  without  special  treatment,  arrived  at 
the  same  conclusion. 

Prognosis. — Rheumatic  fever  is  the  most  serious  of  all  diseases  with  a  low 
death-rate.  The  mortality  is  rarely  above  3_.oi  3  per  cent.  Only  9  of  our  330 
patients  died,  2.7  per  cent,  all  with  endocarditis  and  6  with  pericarditis. 

Sudden  death  in  rheumatic  fever  is  due  most  frequently  to  myocarditis. 
Herringham  has  reported  a  case  in  which  on  the  fourteenth  day  there  was 
fatty  degeneration  and  acute  inflammation  of  the  myocardium.  In  a  few  rare 
cases  it  results  from  embolism.  I  saw  one  case  at  the  Montreal  General  Hos- 
pital in  which  we  thought  possibly  the  sudden  death  was  due  to  Fuller's  alka- 
line treatment,  which  had  been  kept  up  by  mistake.  There  was  slight  endo- 
carditis but  no  myocardial  changes.  Alarming  symptoms  of  depression 
sometimes  follow  excessive  doses  of  the  salicylate  of  soda. 

Diagnosis. — Practically,  the  recognition  of  acute  rheumatism  is  very  easy; 
but  there  are  several  affections  which,  in  some  particulars,  closely  resemble  it. 

(1)  Multiple  Secondary  Arthritis. — ^Under  this  term  may  be  em- 
braced the  various  forms  of  arthritis  which  come  on  or  follow  in  the  course  of 
the  infective  diseases,  such  as  gonorrhoea,  scarlet  fever,  dysentery,  and  cerebro- 
spinal meningitis.  Of  these  the  gonorrhoea!  form  will  receive  special  consid- 
eration and  is  the  type  of  the  entire  group. 

(3)  Septic  Arthritis,  which  occurs  in  the  course  of  pyaemia  from  any 
cause,  and  particularly  in  puerperal  fever.  No  hard  and  fast  line  can  be 
drawn  between  these  and  the  cases  in  the  first  group ;  but  the  inflammation 
rapidly  passes  on  to  suppuration  and  there  is  more  or  less  destruction  of  the 
joints.  The  conditions  under  which  the  arthritis  occurs  give  a  clew  at  once 
to  the  nature  of  the  case.    Under  this  section  may  also  be  mentioned : 

(a)  Acute  necrosis  or  acuie  osteo-myelitis,  occurring  in  the  lower  end  of 
the  femur,  or  in  the  tibia,  and  which  may  be  mistaken  for  acute  rheumatism. 
16 


226  SPECIFIC  INFECTIOUS  DISEASES. 

Sometimes,  too,  it  is  multiple.  The  greater  intensity  of  the  local  symptoms, 
the  involvement  of  the  epiphyses  rather  than  the  joints,  and  the  more 
serious  constitutional  disturbances  are  points  to  be  considered.  The  con- 
dition is  unfortunately  often  mistaken  for  acute  arthritis,  and,  as  the  treat- 
ment is  essentially  surgical,  the  error  is  one  which  may  cost  the  life  of  the 
patient. 

(b)  The  acute  artliritis  of  infants  must  be  distinguished  from  rheuma- 
tism. It  is  a  disease  which  is  usually  confined  to  one  joint  (the  hip  or  knee), 
the  effusion  in  which  rapidly  becomes  purulent.  The  affection  is  most  com- 
mon in  sucklings  and  is  undoubtedly  pygemic  in  character.  It  may  also  occur 
in  the  gonorrhoeal  ophthalmia  or  vaginitis  of  the  new-born,  as  pointed  out  by 
Clement  Lucas. 

(3)  Gout. — While  the  localization  in  a  single,  usually  a  small,  joint,  the 
age,  the  history,  and  the  mode  of  onset  are  features  which  enable  us  to  recog- 
nize acute  gout,  there  are  everywhere  many  cases  of  acute  arthritis,  called 
rheumatic  fever,  which  are  in  reality  gout.  The  involvement  of  several  of 
the  larger  joints  is  not  so  infrequent  in  gout,  and  unless  tophi  are  present, 
or  unless  a  very  accurate  analysis  of  the  urine  is  made,  the  diagnosis  may  be 
difficult. 

(4)  Acute  Arthritis  Deformans. — In  several  cases  I  have  mistaken 
this  form  for  rheumatic  fever.  It  may  come  on  with  fever  and  multiple  arthri- 
tis, and  for  weeks  there  may  be  no  suspicion  of  the  true  nature  of  the  disease. 
Gradually  the  fever  subsides,  but  the  periarticular  thickening  persists.  As  a 
rule,  however,  in  the  acute  febrile  cases  the  involvement  of  the  smaller  joints, 
the  persistence;  and  the  early  changes  in  the  articulations  suggest  arthritis 
deformans. 

Treatment. — The  bed  should  have  a  smooth,  soft,  3'et  elastic  mattress. 
The  patient  shoidd  wear  a  flannel  night-gown,  which  may  be  opened  all  the 
way  down  the  front  and  slit  along  the  outer  margin  of  the  sleeves.  Three 
or  four  of  these  should  be  made,  so  as  to  facilitate  the  frequent  changes  re- 
quired after  the  sweats.  He  may  wear  also  a  light  flannel  cape  about  the 
shoulders.  He  should  sleep  in  blankets,  not  in  sheets,  so  as  to  reduce  the  liabil- 
ity to  catch  cold  and  obviate  the  unpleasant  clamminess  consequent  upon  heavy 
sweating.  Chambers  insisted  that  the  liability  to  endocarditis  and  pericarditis 
was  much  reduced  when  the  patients  were  in  blankets. 

Milk  is  the  most  suitable  diet.  It  may  be  diluted  with  alkaline  mineral 
waters.  Lemonade  and  oatmeal  or  barley  water  should  be  freely  given.  The 
thirst  is  usually  great  and  may  be  fully  satisfied.  There  is  no  objection  to 
broths  and  soups  if  the  milk  is  not  well  borne.  The  food  should  be  given  at 
short  and  stated  intervals.  As  convalescence  is  established  a  fuller  diet  may 
be  allowed,  but  meat  should  be  used  sparingly. 

The  local  treatment  is  of  the  greatest  importance.  It  often  suffices  to 
wrap  the  affected  joints  in  cotton.  If  the  paui  is  severe,  hot  cloths  may  be 
applied,  saturated  with  Fullers  lotion  (carbonate  of  soda,  6  drachms;  lauda- 
num, 1  oz. ;  glycerine,  2  oz. ;  and  water,  9  oz.) .  Tincture  of  aconite  or' chloral 
may  be  employed  in  an  alkaline  solution.  Chloroform  liniment  is  also  a  good 
application.  Fixation  of  the  joints  is  of  great  service  in  alla}dng  the  pain. 
I  have  seen,  in  a  German  hospital,  the  joints  enclosed  in  plaster  of  Paris, 
apparently  with  great  relief.     Splints,  padded  and  bandaged  with  moderate 


RHEUMATIC  FEVER.  22,1 

firmness,  will  often  be  found  to  relieve  pain.  Friction  is  rarely  well  borne  in 
an  acutely  inflamed  joint.  Cold  compresses  are  much  used  in  Germany.  The 
application  of  blisters  above  and  below  the  joint  often  relieves  the  pain.  This 
method,  which  was  used  so  much  a  few  years  ago,  is  not  to  be  compared  with 
the  light  application  of  the  Paquelin  thermo-cautery. 

The  drug  treatment  of  acute  rheumatism  is  still  far  from  satisfactory, 
though  the  introduction  of  the  salicyl  compounds  has  been  a  great  boon. 
Pribram's  exhaustive  consideration  of  the  question,  extending  over  some  67 
pages  (Nothnagel's  Handbuch,  Bd.  v),  in  which  he  discusses  some  75  drugs 
and  measures,  indicates  perhaps  better  than  anything  else  that  the  therapeu- 
tics of  the  disease  are  still  far  from  satisfactory. 

Treatment  with  the  Salicyl  Compounds. — Salicin,  introduced  in 
1876  by  Maclagan,  may  be  used  in  doses  of  20  grains  every  hour  or  two  until 
the  pain  is  relieved.  It  has  the  advantage  of  being  less  depressing  than  the 
salicylate  of  soda.  It  is  also  perhaps  the  best  drug  to  use  for  children.  Sali- 
cylic acid,  15  to  20  grains,  may  be  given  every  two  hours  in  acute  cases  until 
the  pain  is  relieved.  It  is  best  given  in  capsules.  Salicylate  of  soda,  20-grain 
doses  every  two  hours,  is  perhaps  the  best  of  the  drugs  for  general  use  in  the 
acute  rheumatism  of  adults.  After  the  pain  has  been  relieved,  the  drug  should 
be  given  every  four  or  five  hours  until  the  temperature  begins  to  fall.  The 
potassium  bicarbonate  may  be  given  with  it.  Oil  of  wintergreen,  20  minims 
every  two  hours  in  milk,  may  be  used  if  the  salicylate  of  soda  disagrees.  There 
are  many  other  salicyl  compounds  introdiiced  of  late,  but  the  best  results  are  h 
obtained  from  the  use  of  one  or  other  of  the  above-named  preparations.  There 
can  be  no  question  as  to  their  efficacy  in  relieving  the  pain  in  the  disease.  A 
majority  of  observers  agree  that  they  also  protect  the  heart,  shorten  the  course, 
and  render  relapse  less  likely. 

The  Alkaline  Treatment. — Potassium  bicarbonate  may  be  given  in 
half-drachm  doses  every  three  hours  with  the  salicylic  acid  or  salicin.  Fuller's 
plan  was  to  give  a  drachm  and  a  half  of  the  sodium  bicarbonate  with  half  a 
drachm  of  potassium  acetate  in  three  ounces  of  water,  rendered  effervescent  at 
the  time  of  administration  by  half  a  drachm  of  citric  acid  or  an  ounce  of 
lemon-juice.    When  the  urine  is  alkaline  the  amount  may  be  reduced. 

The  heart  should  be  watched  carefully  during  the  administration  of  full 
doses  of  the  alkalies. 

A  wide-spread  popular  belief  attributes  marvellous  efficacy  to  bee-stings 
in  all  sorts  of  rheumatism,  and  a  formic-acid  treatment  has  been  introduced. 
A  2|  per  cent  solution  is  injected  in  the  neighborhood  of  the  painful  joints. 
Ainley  Walker  has  collected  (B.  M.  J.,  October  10,  1908)  an  interesting  lit- 
erature on  the  subject. 

To  allay  the  pain  opium  may  be  given  in  the  form  of  Dover's  powder, 
or  morphia  hypodermically.  Antipyrin,  antifebrin,  and  phenacetin  are  useful 
sometimes  for  the  purpose.  During  convalescence  iron  is  indicated  in  full 
doses,  and  quinine  is  a  useful  tonic.  Of  the  complications,  hyperpyrexia 
should  be  treated  by  the  cold  bath  or  the  cold  pack.  The  treatment  of  endo- 
carditis and  pericarditis  and  the  pulmonary  complications  will  be  considered 
under  their  respective  sections. 

To  prevent  and  arrest  endocarditis  Caton  urges  the  use  of  a  series  of  small 
blisters  along  the  course  of  the  third,  fourth,  fifth,  and  sixth  intercostal  nerves 


228  SPECIFIC  INFECTIOUS  DISEASES. 

of  the  left  side,  applied  one  at  a  time  and  repeated  at  different  points.  Potas- 
sium or  sodium  iodide  is  given  in  addition  to  the  salicylates.  The  patients 
are  kept  in  bed  for  about  six  weeks. 

XX.     CHOLERA  ASIATICA. 

Definition.— A  specific,  infectious  disease,  caused  by  the  comma  bacillus  of 
Koch,  and  characterized  clinically  by  violent  purging  and  rapid  collapse. 

Historical  Summary. — Cholera  has  been  endemic  in  India  from  a  remote 
period,  but  only  within  the  last  century  did  it  make  inroads  into  Europe  and 
America.  An  extensive  epidemic  occurred  in  1832,  in  which  year  it  was 
brought  in  immigrant  ships  from  Great  Britain  to  Quebec.  It  travelled  along 
the  lines  of  traffic  up  the  Great  Lakes,  and  finally  reached  as  far  west  as  the 
military  posts  of  the  upper  Mississippi.  In  the  same  year  it  entered  the  United 
States  by  way  of  New  York.  There  were  recurrences  of  the  disease  in 
1835-36.  In  1848  it  entered  the  country  through  I^ew  Orleans,  and  spread 
widely  up  the 'Mississippi  Valley  and  across  the  continent  to  California.  In 
18-49  it  again  appeared.  In  1854  it  was  introduced  by  immigrant  ships  into 
New  York  and  prevailed  widely  throughout  the  country.  In  1866  and  in  1867 
there  were  less  serious  epidemics.  In  1873  it  again  appeared  in  the  United 
States,  but  did  not  prevail  widely.  In  1884  there  was  an  outbreak  in  Europe, 
and  again  in  1892  and  1893.  Although  occasional  cases  have  been  brought  by 
ship  to  the  quarantine  stations  in  this  country,  the  disease  has  not  gained  a 
foothold  here  since  1873.  It  has  prevailed  in  the  Philippines,  but  is  now,  1904, 
well  under  control. 

Etiology. — In  1884  Koch  announced  the  discovery  of  the  specific  organ- 
ism of  this  disease.  Subsequent  observations  have  confirmed  his  statement 
that  the  comma  bacillus,  as  it  is  termed,  occurs  constantly  in  the  true  cholera, 
and  in  no  other  disease.  It  has  the  form  of  a  slightly  bent  rod,  which  is 
thicker,  but  not  more  than  about  half  the  length  of  the  tubercle  bacillus,  and 
sometimes  occurs  in  corkscrew-like  or  S  forms.  It  is  not  a  true  bacillus,  but 
really  a  spirochaete.  The  organisms  grow  upon  a  great  variety  of  media  and 
display  distinctive  and  characteristic  appearances.  Koch  found  them  in  the 
water-tanks  in  India,  and  they  were  isolated  from  the  Elbe  water  during  the 
Hamburg  epidemic  of  1892.  During  epidemics  virulent  bacilli  may  be  found 
in  the  faeces  of  healthy  persons.  The  bacilli  are  found  in  the  intestine,  in  the 
stools  from  the  earliest  period  of  the  disease,  and  very  abundantly  in  the  char- 
acteristic rice-water  evacuations,  in  which  they  may  be  seen  as  an  almost  pure 
culture.  They  very  rarely  occur  in  the  vomit.  Post  mortem,  they  are  foimd 
in  enormous  numbers  in  the  intestine.  In  acutely  fatal  cases  they  do  not  seem 
to  invade  the  intestinal  wall,  but  in  those  with  a  more  protracted  course  they 
are  found  in  the  depths  of  the  glands  and  in  the  still  deeper  tissues.  Experi- 
mental animals  are  not  susceptible  to  cholera  germs  administered  per  os.  But 
if  introduced  after  neutralization  of  the  gastric  contents,  and  if  kept  in  con- 
tact with  the  intestinal  mucosa  by  controlling  peristalsis  with  opium,  guinea- 
pigs  succumb  after  showing  cholera-like  S}Tnptoms.  The  intestines  are  filled 
with  thin,  watery  contents,  containing  comma  bacilli  in  almost  pure  culture. 

Cholera  ToxI^^— Koch  in  his  studies  of  cholera  failed  to  find  the  spirilla 
in  the  internal  organs.     He  concluded  that  the  constitutional  symptoms  of 


CHOLERA   ASIATICA.  229 

the  disease  resulted  from  the  absorption  of  toxic  bodies  from  the  intestine. 
In  old  cholera  cultures  ptomaines  are  contained ;  these  probably  have  nothing 
to  do  with  the  intoxication  of  human  cholera.  R.  Pfeiffer  has  shown  that  the 
cholera  toxin  is  intimately  associated  with  the  proteid  of  the  bacterial  cells, 
and,  being  of  a  very  labile  nature,  can  not  be  separated.  Dead  cultures  are 
toxic;  and  the  symptoms  produced  by  the  introduction  of  even  minimal 
amounts  are  often  comparable  with  those  of  the  algid  stage  of  cholera  asiatica. 
The  symptoms  occur  very  rapidly,  and  death  often  results  in  eight  to  twelve 
hours ;  in  non-fatal  cases  recovery  is  often  equally  as  rapid.  The  intracellular 
cholera  toxin  is  poisonous  to  animals  if  introduced  into  the  blood,  peritoneal 
cavity,  or  subcutaneous  tissues.  No  absorption  takes  place  from  the  intestine 
unless  the  epithelial  layer  has  been  injured. 

Immunity. — From  a  recent  careful  study  (1904)  of  the  question  of  pro- 
tective inoculation,  E.  P.  Strong  concludes  that  there  is  as  yet  no  satisfactory 
form  of  human  protective  inoculation,  though  the  methods  employed  by  Haff- 
kine  and  Kolle  promise  good  results. 

Modes  of  Infection. — As  in  other  diseases,  individual  peculiarities  count 
for  much,  and  during  epidemics  virulent  cholera  bacilli  have  been  isolated 
from  the  normal  stools  of  healthy  men.  Cholera  cultures  have  also  been  swal- 
lowed with  impunity. 

The  disease  is  not  highly  contagious;  physicians,  nurses,  and  others  in 
close  contact  with  patients  are  not  often  affected.  On  the  other  hand,  wash- 
erwomen and  those  who  are  brought  into  very  close  contact  with  the  linen  of 
the  cholera  patients,  or  with  their  stools,  are  particularly  prone  to  catch  the 
disease.  There  have  been  several  instances  of  so-called  "  laboratory  cholera," 
in  which  students,  having  been  accidentally  infected  while  working  with  the 
cultures,  have  taken  the  disease,  and  at  least  one  death  has  resulted  from  this 
cause. 

Vegetables  which  have  been  washed  in  the  infected  water,  particularly  let- 
tuces and  cresses,  may  convey  the  disease.  Milk  may  also  be  contaminated. 
The  bacilli  live  on  fresh  bread,  butter,  and  meat,  for  from  six  to  eight  days. 
In  regions  in  which  the  disease  prevails  the  possibility  of  the  infection  of  food 
by  flies  should  be  borne  in  mind,  since  it  has  been  shown  that  the  bacilli  may 
live  for  at  least  three  days  in  their  intestines. 

Infection  through  the  air  is  not  to  be  much  dreaded,  since  the  germs  when 
dried  die  rapidly. 

The  disease  is  propagated  chiefly  by  contaminated  water  used  for  drink- 
ing, cooking,  and  washing.  The  virulence  of  an  epidemic  in  any  region  is  in 
direct  proportion  to  the  imperfection  of  its  water-supply.  In  India  the  demon- 
stration of  the  connection  between  drinking-water  and  cholera  infection  is 
complete.  The  Hamburg  epidemic  is  a  most  remarkable  illustration.  The 
unfiltered  water  of  the  Elbe  was  the  chief  supply,  although  taken  from  the 
river  in  such  a  situation  that  it  was  of  necessity  directly  contaminated  by 
sewage.  It  is  not  known  accurately  from  what  source  the  contagion  came, 
whether  from  Russia  or  from  France,  but  in  August,  1893,  there  was  a  sud- 
den explosive  epidemic,  and  within  three  months  nearly  18,000  persons  were 
attacked,  with  a  mortality  of  43.3  per  cent.  The  neighboring  city  of  Altona, 
which  also  took  its  water  from  the  Elbe,  but  which  had  a  thoroughly  well- 
equipped  modern  filtration  system,  had  in  the  same  period  only  516  cases. 


230  SPECIFIC  INFECTIOUS  DISEASES. 

Two  main  ij^es  of  epidemics  of  cholera  are  recognized :  the  first,  in  which 
many  individuals  are  attacked  simultaneoiislv,  as  in  the  Hamburg  outbreak, 
and  in  which  no  direct  connection  can  be  traced  between  the  individual  cases. 
In  this  type  there  is  widespread  contamination  of  the  drinking-water.  In  the 
other  the  cases  occur  in  groups,  so-called  cholera  nests;  individuals  are  not 
attacked  simultaneously  but  successively.  A  direct  connection  between  the 
cases  may  be  very  difficult  to  trace.  Again,  both  these  t}-pes  may  be  com- 
bined, and  in  an  epidemic  which  has  started  in  a  widespread  infection  through 
water,  there  may  be  other  outbreaks,  which  are  examples  of  the  second  or 
chain-like  t}'pe. 

Pettenkofer,  on  the  other  hand,  denies  the  truth  of  this  drinking-water 
theory,  and  maintains  that  the  conditions  of  the  soil  are  of  the  greatest  impor- 
tance ;  particularly  a  certain  porosity,  combined  with  moisture  and  contamina- 
tion with  organic  matter,  such  as  sewage.  He  holds  that  germs  develop  in 
the  subsoil  moisture  during  the  warm  months,  and  that  they  rise  into  the 
atmosphere  as  a  miasm. 

The  disease  always  follows  the  lines  of  human  travel.  In  India  it  has, 
in  many  notable  cases,  been  widely  spread  by  pilgrims.  It  is  carried  also  by 
caravans  and  in  ships.     It  is  not  conveyed  through  the  atmosphere. 

Places  situated  at  the  sea-level  are  more  prone  to  the  disease  than  inland 
tovras.  In  high  altitudes  the  disease  does  not  prevail  so  extensively.  A  high 
temperature  favors  the  development  of  cholera,  but  in  Europe  and  America 
the  epidemics  have  been  chiefly  in  the  late  summer  and  in  the  autumn. 

The  disease  affects  persons  of  all  ages.  It  is  particularly  prone  to  attack 
the  intemperate  and  those  debilitated  by  want  of  food  and  by  bad  surroimd- 
ings.  Depressing  emotions,  such  as  fear,  undoubtedly  have  a  marked  influence. 
It  is  doubtful  whether  an  attack  furnishes  immunitv"  against  a  second  one. 

Morbid  Anatomy. — A  post-mortem  diagnosis  of  the  nature  of  the  disease 
could  be  made  by  any  competent  bacteriologist,  as  the  micro-organisms  are 
specific  and  distinctive.  The  body  has  the  appearances  associated  with  pro- 
found collapse.  There  is  often  marked  post-mortem  elevation  of  temperature. 
The  rigor  mortis  sets  in  early  and  may  produce  displacement  of  the  limbs. 
The  lower  jaw  has  been  seen  to  move  and  the  eyes  to  rotate.  Various  move- 
ments of  the  arms  and  legs  have  also  been  noted.  The  blood  is  thick  and 
dark,  and  there  is  a  remarkable  diminution  in  the  amount  of  its  water  and 
salts.  The  peritongeum  is  sticky,  and  the  coils  of  intestines  are  congested  and 
look  thin  and  shrunken.  The  small  intestine  usually  contains  a  turbid  serum, 
similar  in  appearance  to  that  which  was  passed  in  the  stools.  The  mucosa  is, 
as  a  rule,  swollen,  and  in  very  acute  cases  slightly  h}-perffimic ;  later  the  con- 
gestion, which  is  not  uniform,  is  more  marked,  especially  about  the  Peyer's 
patches.  Post  mortem  the  epithelial  lining  is  sometimes  denuded,  but  this 
is  probably  not  a  change  which  takes  place  freely  during  life.  In  the  stools, 
however,  large  numbers  of  columnar  epithelial  cells  have  been  described  by 
Horner  and  others.  The  bacilli  are  found  in  the  contents  of  the  intestine 
and  in  the  mucous  membrane.  The  spleen  is  usually  small.  The  liver  and 
kidneys  show  cloudy  swelling,  and  the  latter  extensive  coagulation-necrosis  and 
destruction  of  the  epithelial  cells. 

Symptoms. — A  period  of  incubation  of  uncertain  length,  probably  not  more 
than  from  two  to  five  days,  precedes  the  onset  of  the  sj^nptoms. 


CHOLERA  ASIATICA.  231 

Three  stages  may  be  recognized  in  the  attack:  the  preliminary  diarrhoea, 
the  collapse  stage,  and  the  period  of  reaction. 

(a)  The  preliminary  diarrhcea  may  set  in  abruptly  without  any  pre- 
vious indications.  More  commonly  there  are,  for  one  or  two  days,  colicky 
pains  in  the  abdomen,  with  looseness  of  the  bowels,  perhaps  vomiting,  with 
headache  and  depression  of  spirits.     There  may  be  no  fever. 

(6)  Collapse  Stage. — The  diarrhcea  increases,  or,  without  any  of  the 
preliminary  symptoms,  sets  in  with  the  greatest  intensity,  and  profuse  liquid 
evacuations  succeed  each  other  rapidly.  There  are  in  some  instances  griping 
pains  and  tenesmus.  More  commonly  there  is  a  sense  of  exhaustion  and  col- 
lapse. The  thirst  becomes  extreme,  the  tongue  is  white;  cramps  of  great 
severity  occur  in  the  legs  and  feet.  Within  a  few  hours  vomiting  sets  in  and 
becomes  incessant.  The  patient  rapidly  sinks  into  a  condition  of  collapse, 
the  features  are  shrunken,  the  skin  has  an  ashy  gray  hue,  the  eyeballs  sink 
in  the  sockets,  the  nose  is  pinched,  the  cheeks  are  hollow,  the  voice  becomes 
husky,  the  extremities  are  cyanosed,  and  the  skin  is  shrivelled,  wrinkled,  and 
covered  with  a  clammy  perspiration.  The  temperature  sinks.  In  the  axilla 
or  in  the  mouth  it  may  be  from  five  to  ten  degrees  below  normal,  but  in  the 
rectum  and  in  the  internal  parts  it  may  be  103°  or  104°,  The  pulse  becomes 
extremely  feeble  and  flickering,  and  the  patient  gradually  passes  into  a  condi- 
tion of  coma,  though  consciousness  is  often  retained  until  near  the  end. 

The  fseces  are  at  first  yellowish  in  color,  from  the  bile  pigment,  but  soon 
they  become  grayish- white  and  look  like  turbid  whey  or  rice-water;  whence 
the  term  "  rice-water  stools."  There  are  found  in  them  numerous  small  flakes 
of  mucus  and  granular  matter,  and  at  times  blood.  The  reaction  is  usually 
alkaline.  The  fluid  contains  albumin  and  the  chief  mineral  ingredient  is  chlo- 
ride of  sodium.  Microscopically,  mucus  and  epithelial  cells  and  innumerable 
bacteria  are  seen,  the  majority  of  the  latter  being  the  comma  bacilli. 

The  condition  of  the  patient  is  largely  the  result  of  the  concentration  of 
the  blood  consequent  upon  the  loss  of  serum  in  the  stools.  There  is  almost 
complete  arrest  of  secretion,  particularly  of  the  saliva  and  the  urine.  On  the 
other  hand,  the  sweat-glands  increase  in  activity,  and  in  nursing  women  it 
has  been  stated  that  the  lacteal  flow  is  unaffected.  This  stage  sometimes  lasts 
not  more  than  two  or  three  hours,  but  more  commonly  from  twelve  to  twenty- 
four.  There  are  instances  in  which  the  patient  dies  before  purging  begins — 
the  so-called  cholera  sicca. 

(c)  Eeaction  Stage. — When  the  patient  survives  the  collapse,  the  cyano- 
sis gradually  disappears,  the  warmth  returns  to  the  skin,  which  may  have  for 
a  time  a  mottled  color  or  present  a  definite  erythematous  rash.  The  heart's 
action  becomes  stronger,  the  urine  increases  in  quantity,  the  irritability  of  the 
stomach  disappears,  the  stools  are  at  longer  intervals,  and  there  is  no  abdom- 
inal pain.  In  the  reaction  the  temperature  may  not  rise  above  normal.  Not 
infrequently  this  favorable  condition  is  interrupted  by  a  recurrence  of  severe 
diarrhcea  and  the  patient  is  carried  off  in  a  relapse.  Other  cases  pass  into 
the  condition  of  what  has  been  called  cliolera-typlwid,  a  state  in  which  the 
patient  is  delirious,  the  pulse  rapid  and  feeble,  and  the  tongue  dry.  Death 
finally  occurs  with  coma.     These  symptoms  have  been  attributed  to  uremia. 

During  epidemics  attacks  are  found  of  all  grades  of  severity.  There  are 
cases  of  diarrhoea  with  griping  pains,  liquid,  copious  stools,  vomiting,  and 


232  SPECIFIC  INFECTIOUS  DISEASES. 

cramps,  with  slight  collapse.  To  these  the  term  cholerine  has  been  applied. 
They  resemble  the  milder  cases  of  cholera  nostras.  At  the  opposite  end  of  the 
series  there  are  the  instances  of  cholera  sicca,  in. which  death  may  occur  in 
a  few  hours  after  the  onset,  without  diarrha?a.  There  are  also  cases  in  which 
the  patients  are  overwhelmed  with  the  poison  and  die  comatose,  without  the 
preliminary  stage  of  collapse. 

Complications  and  Sequelae.— The  t>T3hoid  condition  has  already  been  re- 
ferred to.  The  consecutive  nephritis  rarely  induces  dropsy.  Diphtheritic 
colitis  has  been  described.  There  is  a  special  tendency  to  diphtheritic  inflam- 
mation of  the  mucous  membranes,  particularly  of  the  throat  and  genitals. 
Pneumonia  and  pleurisy  may  follow,  and  destructive  abscesses  may  occur  in 
different  parts.  Suppurative  parotitis  is  not  very  uncommon.  In  rare  in- 
stances local  gangrene  may  occur.  A  troublesome  sjinptom  of  convalescence 
is  cramps  in  the  muscles  of  the  arms  and  legs. 

Dia^osis. — The  only  affection  with  which  Asiatic  cholera  could  be  con- 
founded is  the  cholera  nostras,  the  severe  choleraic  diarrhoea  which  occurs 
during  the  summer  months  in  temperate  climates.  The  clinical  picture  of  the 
two  affections  is  identical.  The  extreme  collapse,  vomiting,  and  rice-water 
stools,  the  cramps,  the  cyanosed  appearance,  are  all  seen  in  the  worst  forms  of 
cholera  nostras.  In  enfeebled  persons  death  may  occur  vrithin  twelve  hours. 
It  is  of  course  extremely  important  to  be  able  to  diagnose  between  the  two 
affections.  This  can  only  be  done  by  one  thoroughly  versed  in  bacteriological 
methods,  and  conversant  with  the  diversified  flora  of  the  intestines. 

Attacks  very  similar  to  Asiatic  cholera  are  produced  in  poisoning  by 
arsenic,  corrosive  sublimate,  and  certain  fungi;  but  a  difficulty  in  diagnosis 
could  scarcely  arise. 

The  prognosis  is  always  uncertain,  as  the  mortality  ranges  in  different 
epidemics  from  .30  to  80  per  cent.  Intemperance,  debility,  and  old  age  are 
unfavorable  conditions.  The  more  rapidly  the  collapse  sets  in,  the  greater  is 
the  danger,  and  as  Andral  truly  says  of  the  malignant  form,  "  It  begins  where 
other  diseases  end — in  death.'"'*  Cases  vrith  marked  cyanosis  and  very  low  tem- 
perature rarely  recover. 

Prophylaxis. — Preventive  measures  are  all-important,  and  isolation  of  the 
sick  and  thorough  disinfection  have  effectually  prevented  the  disease  entering 
England  or  the  TTnited  States  since  1873.  On  several  occasions  since  that 
date  cholera  has  been  brought  to  various  ports  in  America,  but  has  been 
checked  at  quarantine.  During  epidemics  the  greatest  care  should  be  exer- 
cised in  the  disinfection  of  the  stools  and  linen  of  the  patients.  When  an 
epidemic  prevails,  persons  should  be  warned  not  to  drink  water  unless  pre- 
viously boiled.  Errors  in  diet  should  be  avoided.  As  the  disease  is  not  more 
contagious  than  t^-phoid  fever,  the  chance  of  a  person  passing  safely  through 
an  epidemic  depends  very  much  upon  how  far  he  is  able  to  carry  out  thor- 
oughly prophylactic  measures.  ,  Digestive  disturbances  are  to  be  treated 
prompth',  and  particularly  the  diarrhcea,  which  so  often  is  a  preliminary  s}anp- 
tom.  For  this,  opium  and  acetate  of  lead  and  large  doses  of  bismuth  should 
be  given. 

Medicinal  Treatment. — During  the  initial  stage,  when  the  diarrhoea  is 
not  excessive  but  the  abdominal  pain  is  marked,  opium  is  the  most  efficient 
remedy,  and  it  should  be  given  hypodermically  as  morphia.     It  is  advisable 


YELLOW  FEVER.  233 

to  give  at  once  a  full  dose,  which  may  be  repeated  on  the  return  of  the  pain. 
It  is  best  not  to  attempt  to  give  remedies  by  the  mouth,  as  they  disturb  the 
stomach.  Ice  should  be  given,  and  brandy  or  hot  coffee.  In  the  collapse  stage, 
writers  speak  strongly  against  the  use  of  opium.  Undoubtedly  it  must  be 
given  with  caution,  but,  judging  from  its  effects  in  cholera  nostras,  I  should 
say  that  collapse  per  se  was  not  a  contra-indication.  The  patient  may  be 
allowed  to  drink  freely.  For  the  vomiting,  which  is  very  difficult  to  check, 
cocaine  may  be  tried,  and  lavage  with  hot  water.  Creasote,  hydrocyanic  acid, 
and  creolin  have  been  found  useless.  Eumpf  advises  calomel  (gr.  i)  every 
two  hours. 

External  applications  of  heat  should  be  made  and  a  hot  bath  may  be 
tried.  Warm  applications  to  the  abdomen  are  very  grateful.  Hypodermic 
injections  of  ether  will  be  found  serviceable.- 

Irrigation  of  the  bowel — enteroclysis — with  warm  water  and  soap,  or  tan- 
nic acid  (2  per  cent),  should  be  used.  With  a  long,  soft-rubber  tube,  as  much 
as  3  or  4  litres  may  be  slowly  injected.  Not  only  is  the  colon  cleansed,  but 
the  small  bowel  may  also  be  reached,  as  sho-wm  by  the  fact  that  the  tannic-acid 
solutions  have  been  vomited. 

Owing  to  the  profuse  serous  discharges  the  blood  becomes  concentrated, 
and  absorption  takes  place  rapidly  from  the  lymph-spaces.  To  meet  this, 
intravenous  injections  were  introduced  by  Latta,  of  Leith,  in  the  epidemic 
of  1832.  My  preceptor,  Bovell,  first  practised  the  intravenous  injections  of 
milk  in  Toronto,  in  the  epidemic  of  1854.  A  litre  of  salt  solution  at  107°  may 
be  injected,  and  repeated  in  a  few  hours  if  no  reaction  follows.  Less  risky 
and  equally  efficacious  is  the  subcutaneous  injection  of  a  saline  solution.  For 
this,  common  salt  should  be  used  in  the  proportion  of  about  four  grammes  to 
the  litre.  With  rubber  tubing,  a  cannula  from  an  aspirator,  or  even  with  a 
hypodermic  needle,  the  warm  solution  may  be  allowed  to  run  by  pressure 
beneath  the  skin.  It  is  rapidly  absorbed,  and  the  process  may  be  continued 
until  the  pulse  shows  some  sign  of  improvement.  This  is  really  a  valuable 
method,  thoroughly  physiological,  and  should  be  tried  in  all  severe  cases. 

In  the  stage  of  reaction  special  pains  should  be  taken  to  regulate  the  diet 
and  to  guard  against  recurrences  of  the  severe  diarrhoea. 

XXI.     YELLOW    FEVER. 

Definition. — ^A  fever  of  tropical  and  subtropical  countries,  characterized  by 
a  toxaemia  of  varying  intensity,  with  jaundice,  albuminuria,  and  a  marked  ten- 
dency to  haemorrhage,  especially  from  the  stomach,  causing  the  "  black  vomit." 
The  specific  organism  has  not  yet  been  found,  but  the  disease  is  capable  of 
being  transmitted  through  the  bite  of  a  mosquito,  the  Stegomyia  fasciata. 

Etiolog-y. — The  disease  prevails  endemically  in  certain  sections  of  the 
Spanish  Main.  Until  recently  it  has  existed  in  Cuba,  From  these  regions 
it  occasionally  extends  and,  under  suitable  conditions,  prevails  epidemically 
in  the  Southern  States.  Now  and  then  it  is  brought  to  the  large  seaports  of 
the  Atlantic  coast.  Formerly  it  occurred  extensively  in  the  United  States. 
In  the  latter  part  of  the  eighteenth  century  and  the  beginning  of  the  nine- 
teenth, frightful  epidemics  prevailed  in  Philadelphia  and  other  jSTorthern 
cities.  The  epidemic  of  1793,  in  Philadelphia,  so  graphically  described  by  Mat- 
17 


234  SPECIFIC  INFECTIOUS  DISEASES. 

thew  Carey,  was  the  most  serious  that  has  ever  visited  any  city  of  the  Middle 
States.  The  mortality,  as  given  by  Carey,  during  the  months  of  August,  Sep- 
tember, Octol)er.  and  November,  was  4,o4l,  of  whom  3,435  died  in  the  months 
of  -September  and  October.  The  population  of  the  city  at  the  time  was  only 
40,000.  Epidemics  occurred  in  the  United  States  in  1797,  1798,  1799,  and 
in  1803,  when  the  disease  prevailed  slightly  in  Boston  and  extensively  in  Balti- 
more. In  1803  and  1805  it  again  appeared;  then  for  many  years  the  out- 
breaks were  slight  and  localized.  In  1853  the  disease  raged  throughout  the 
Southern  States.  There  were  moderately  severe  epidemics  in  1867,  1873,  and 
1878;  and  still  milder  ones  in  1897,  18*98,  and  1899.  In  July,  1899,  a  local 
outbreak  occurred  in  the  Soldiers'  Home,  at  Hampton,  Ya.  There  were  45 
cases,  with  13  deaths.  In  September.  1903,  yellow  fever  became  epidemic 
along  the  Mexican  side  of  the  Eio  Grande.  It  crossed  into  Texas  and  pre- 
vailed in  several  of  the  border  towns.  In  Laredo  there  were  1,014  cases,  with 
107  deaths.  The  efficient  work  of  the  public  health  service  is  shown  by  the 
differences  between  'Kew  Laredo  on  the  Mexican  border,  just  across  the  river, 
where  50  per  cent  of  the  population  contracted  the  disease,  and  Laredo,  Texas, 
in  which  only  10  per  cent  out  of  a  population  of  10,000  were  attacked.  In 
Europe  it  has  occasionally  gained  a  foothold,  but  there  have  been  no  wide- 
spread epidemics  except  in  the  Spanish  ports.  The  disease  has  existed  on  the 
west  coast  of  Africa.  It  is  sometimes  carried  to  ports  in  Great  Britain  and 
France,  but  it  has  never  extended  into  those  countries.  The  history  of  the  dis- 
ease and  its  general  SAinptomatolog}'  are  exhaustively  treated  of  in  the  classical 
works  of  Eene  La  Eoche  and  Berenger-Feraud. 

Guiteras  recognizes  three  areas  of  infection:  (1)  The  focal  zone  in  which 
the  disease  is  never  absent,  including  Vera  Cruz,  Eio,  and  other  Spanish- Amer- 
ican ports.  (2)  The  perifocal  zone  or  regions  of  periodic  epidemics,  includ- 
ing the  ports  of  the  tropical  Atlantic  in  America  and  Africa.  (3)  The  zone 
of  accidental  epidemics,  lying  between  the  35th  and  45th  parallels  of  north 
latitude. 

COXDITIOXS   FAVORIXG  THE    DEVELOPMENT    OF   EPIDEMICS. Yellow    fever 

is  a  disease  of  the  sea-coast,  and  rarely  prevails  in  regions  with  an  elevation 
above  1,000  feet.  Its  ravages  are  most  serious  in  cities,  particularly  when  the 
sanitary  conditions  are  unfavorable.  It  is  always  most  severe  in  the  badly 
drained,  unhealthy  portions  of  a  city,  where  the  population  is  crowded  together 
in  ill-ventilated,  dark  houses.  The  disease  prevails  during  the  hot  season. 
Humidity  and  heat  seem  to  be  the  proper  coefficients  for  the  preservation  of 
the  poison. 

The  epidemics  in  the  United  States  have  always  been  in  the  summer  and 
autumn  montlis,  disappearing  rapidly  with  the  onset  of  cold  weather. 

Mode  of  Transmission. — Xo  belief  has  been  more  strong  among  the  laity 
than  tbat  the  disease  is  transmitted  by  infected  clothing,  and  quarantine  efforts 
are  chiefly  directed  to  the  disinfection  of  fomites  of  all  sorts  shipped  from 
infected  ports.  The  remarkable  series  of  experiments  carried  out  by  the  Yel- 
low Fever  Commission  of  the  United  States  Army,  consisting  of  Drs.  Walter 
Eeed,  Carroll,  Lazear,  and  Agramonte,  have  demonstrated  conclusively  that 
the  disease  can  not  be  conveyed  in  this  way.  At  Camp  Lazear,  Cuba,  a  frame 
house  was  so  constructed  as  to  shut  out  the  sunlight  and  fresh  air,  and  the 
vestibule  was  thoroughly  screened.     The  average  temperature  for  sixty-three 


YELLOW  FEVER.  235 

days  was  kept  about  76°  F.  Boxes  filled  with  sheets,  pillow-slips,  blankets, 
etc.,  contaminated  by  contact  with  cases  of  yellow  fever  and  the  discharges, 
were  placed  in  the  house.  Dr.  K.  P.  Cooke  and  two  privates  of  the  hospital 
corps,  all  non-immunes,  entered  this  building  and  unpacked  the  boxes,  and 
for  a  period  of  twenty  days  occupied  the  room,  each  morning  packing  the 
infected  articles  in  the  boxes,  and  at  night  unpacking  them.  In  their  experi- 
ments with  the  fomites,  seven,  in  all,  non-immune  subjects  during  the  period 
of  sixty-three  days  lived  in  contact  with  the  fomites  and  remained  perfectly 
well.  These  experiments,  conducted  in  the  most  rigid  and  scientific  man- 
ner, completely  discredit  the  belief  in  the  transmission  of  the  disease  by 
fomites. 

Carlos  Finlay,  of  Havana,  in  1881  suggested  that  the  disease  was  trans- 
mitted by  mosquitoes.  Stimulated  by  the  work  of  Eoss  on  malaria,  the  Amer- 
ican Commission  above-named  has  demonstrated  conclusively  that  yellow  fever 
is  transferred  by  a  mosquito,  Stegomyia  fasciata,  previously  fed  on  the  blood  of 
infected  persons.  The  Commission  showed  also  that  in  non-immunes  the 
disease  could  be  produced  by  either  the  subcutaneous  or  the  intravenous  injec- 
tion of  blood  taken  from  patients  suffering  with  the  disease. 

An  interval  of  about  twelve  days  or  more  after  contamination  appears 
to  be  necessary  before  the  mosquito  is  capable  of  introducing  the  infection. 
The  bite  at  an  early  period  after  contamination  does  not  confer  immunity 
against  a  subsequent  attack.  The  period  of  incubation  in  13  cases  of  experi- 
mental yellow  fever  varied  from  forty-one  hours  to  five  days  and  seventeen 
hours. 

We  must  bear  testimony  to  the  heroism  of  the  young  soldiers  who  vol- 
untarily, without  compensation  and  purely  in  the  interests  of  humanity,  sub- 
mitted to  the  experiments,  and  also  to  the  zeal  with  which  members  of  our 
profession  have,  at  great  personal  risk,  attempted  to  solve  the  riddle  of  this 
most  serious  disease.  The  death  of  Dr.  Lazear,  of  the  American  Commission, 
and  of  Dr.  Myers,  of  the  Liverpool  Commission,  adds  two  more  names  to  the 
already  long  roll  of  the  martyrs  of  science.  Major  Gorgas  carried  out  in 
Havana  sanitary  measures  based  upon  their  reports,  and  stamped  out  the  dis- 
ease. No  cases  occurred  from  1901  to  1904.  Under  Cuban  control  there  was 
a  slight  recrudescence  in  the  island,  but  it  has  again  been  stamped  out. 

As  Eeed  points  out,  the  mosquito  theory  fits  in  with  well-recognized  facts 
in  connection  with  the  epidemics.  After  the  importation  of  a  case  into  an 
uninfected  region,  a  definite  period  elapses,  rarely  less  than  two  weeks,  before 
a  second  case  occurs.  Like  malaria,  the  disease  prevails  most  during  the  mos- 
quito season,  and  disappears  with  the  appearance  of  frost.  Probably,  too,  as 
in  very  malarious  districts,  the  disease  is  kept  up  by  its  prevalence  in  a  very 
mild  form  among  children.  As  Guiteras  remarks,  "  the  foci  of  endemicity 
are  essentially  maintained  by  the  Creole  infant  population,  which  is  subject 
to  the  disease  in  a  very  mild  form."  In  all  probability  the  immunity  which 
is  acquired  by  prolonged  residence  in  a  locality  in  which  the  disease  is  endemic 
is  due  to  the  occurrence  of  very  slight  attacks. 

One  attack  does  not  always  confer  immunity.  Eosenau  reports  two  attacks 
within  a  period  of  eight  years,  and  Libby  two  attacks  within  a  period  of  two 
years. 

The  specific  germ  has  not  yet  been  discovered. 


236  SPECIFIC  INFECTIOUS  DISEASES. 

Morbid  Anatomy. —The  skin  is  more  or  less  jaundiced,  even  thougli  the 
patient  did  not  appear  yellow  before  death.  Cutaneous  hemorrhages  may  be 
present.  Xo  specific  or  distinctive  internal  lesions  have  been  found.  The 
blood-serum  may  contain  haemoglobin,  owing  to  destruction  of  the  red  cells, 
just  as  in  pernicious  malaria.  The  heart  sometimes,  not  invariably,  shows 
fatty  change;  the  stomach  presents  more  or  less  hj-persemia  of  the  mucosa 
with  catarrhal  swelling.  It  contains  the  material  which,  ejected  during  life, 
is  known  as  the  hlacTc  vomit.  The  essential  ingredient  in  tliis  is  transformed 
blood-pigment.  There  is  often  general  glandular  enlargement;  the  cervical 
axillary  and  mesenteric  groups  are  most  involved.  The  liver  is  usually  of  a 
pale  yellow  or  brownish-yellow  color,  and  the  cells  are  in  various  stages  of 
fatty  degeneration.  From  the  date  of  Louis'  observations  at  Gibraltar  in  1828, 
the  appearances  of  this  organ  have  been  very  carefully  studied,  and  some  have 
thought  the  changes  in  it  to  be  characteristic.  Fatty  degeneration  and  regions 
of  necrosis  are  present  in  all  cases.  The  kidneys  alwa3^s  show  traces  of  dif- 
fuse nephritis.  The  epithelium  of  the  convoluted  tubules  is  swollen  and  very 
granular;  there  may  also  be  necrotic  changes. 

Symptoms. — The  incubation  is  usually  three  or  four  daj'S;  in  13  experi- 
mental cases  it  ranged  from  forty-one  hours  to  five  days  seventeen  hours.  The 
onset  is  sudden,  as  a  rule,  without  premonitory  symptoms,  and  in  the  early 
hours  of  the  morning.  Chilly  feelings  are  common,  and  are  usually  associated 
with  headache  and  very  severe  pains  in  the  back  and  limbs.  The  fever  rises 
rapidly  and  the  skin  feels  very  hot  and  dry.  The  tongue  is  furred,  but  moist ; 
the  throat  sore.  Nausea  and  vomiting  are  not  constant,  and  become  more 
intense  on  the  second  or  third  day.  The  bowels  are  usually  constipated.  The 
following,  in  detail,-  are  the  more  important  characteristics : 

Facies. — Even  as  early  as  the  first  morning  the  patient  may  present  a 
characteristic  facies,  one  of  the  three  distinguishing  features  of  the  disease, 
which  Guiteras  describes  as  follows :  The  face  is  flushed,  more  so  than  in  any 
other  acute  infectious  disease  at  such  an  early  period.  The  eyes  are  injected, 
the  color  is  a  bright  red,  and  there  may  be  a  slight  tumefaction  of  the  e3'elids 
and  of  the  lips.  Even  at  this  early  date  there  is  to  be  noticed  in  connection 
with  the  injection  of  the  superficial  capillaries  of  the  face  and  conjunctivae  a 
slight  icteroid  tint,  and  "  the  early  manifestation  of  jaundice  is  undoubtedly 
the  most  characteristic  feature  of  the  facies  of  yellow  fever." 

The  Fever. — On  the  morning  of  the  first  day  the  temperature  may  range 
from  100°  to  106°,  usually  it  is  between  102°  and  103°.  During  the  evening 
of  the  first  day  and  the  morning  of  the  second  day  the  temperature  keeps  about 
the  same.  There  is  a  slight  diurnal  variation  on  the  second  and  third  day.  In 
very  mild  cases  the  fever  may  fall  on  the  evening  of  the  second  or  on  the  morn- 
ing of  the  third  day,  or  in  abortive  cases  even  at  the  end  of  twenty-four  hours. 
In  cases  that  are  to  terminate  favorably  the  defervescence  takes  place  by  lysis 
during  a  period  of  two  or  three  days.  The  remission  or  stage  of  calm,  as  it 
has  been  called,  is  succeeded  by  a  febrile  reaction  or  secondary  fever,  which 
lasts  one,  two,  or  three  days,  and  in  favorable  cases  falls  by  a  short  lysis.  On 
the  other  hand,  in  fatal  cases  the  temperature  is  continuous,  becomes  higher 
than  in  the  initial  fever,  and  death  follows  shortly. 

The  Pulse. — On  the  first  day  the  pulse  is  rarely  more  than  100  or  110. 
On  the  second  or  third  day,  whHe  the  fever  still  keeps  up,  the  pulse  begins 


YELLOW  FEVER.  237 

to  fall,  as  mTieh  perhaps  as  20  beats  while  the  temperature  has  risen  1.5°  or  2°. 
On  the  evening  of  the  third  day  there  may  be  a  temperature  range  of  103°  and 
a  pulse  of  only  75,  or  "  a  temperature  between  103°  and  104°  with  a  pulse 
running  from  70  to  80."  This  important  diagnostic  feature  was  first  de- 
scribed by  Faget,  of  New  Orleans.  During  defervescence  the  pulse  may  be- 
come still  lower,  down  to  50,  48,  or  45,  or  even  as  low  as  30 ;  a  slow  pulse  at 
this  period  is  not  the  special  circulatory  feature  of  the  disease,  but  the  slowing 
of  the  pulse  ivith  a  steady  or  even  rising  tem,perature. 

Albuminuria. — This,  the  third  characteristic  symptom  of  the  disease, 
occurs  as  early  as  the  evening  of  the  third  day.  Guiteras  says  very  truly  that 
it  is  very  rare  so  early  in  other  fevers  except  those  of  an  unusually  severe  type. 
"'  Even  in  the  mild  cases  that  do  not  go  to  bed — cases  of  '  walking  yellow  fever ' 
— on  the  second,  third,  or  fourth  day  of  the  disease  albuminuria  will  show 
itself."  It  may  be  quite  transient.  In  the  severer  cases  the  amount  of  albu- 
min is  very  large,  and  there  may  be  numerous  tube-casts  and  all  the  signs  of 
an  acute  nephritis;  or  complete  suppression  of  the  urine  may  supervene,  and 
death  may  occur  in  uremic  convulsions  or  coma  within  twenty-four  or  thirty- 
six  hours. 

GrASTRio  Features. — "  BlacJc  Vomit." — Irritability  of  the  stomach  is  pres- 
ent from  the  very  outset,  and  the  vomited  matter  consists  of  the  contents  of 
the  stomach,  and  subsequently  of  mucus  and  a  grayish  fluid.  In  the  third 
stage  of  the  disease  the  vomiting  becomes  more  pronounced  and  in  the  severe 
cases  is  characterized  by  the  presence  of  blood.  It  may  be  copious  and  forci- 
ble, producing  much  pain  in  the  abdomen  and  along  the  gullet.  There  is 
nothing  specific  in  this  "  black  vomit,"  which  consists  of  altered  blood,  and 
it  is  not  necessarily  a  fatal  symptom,  though  occurring  only  in  the  severer 
forms  of  the  disease.  Other  hgemorrhagic  features  may  be  present — petechias 
on  the  skin  and  bleeding  from  the  gums  or  from  other  mucous  membranes. 
The  bowels  are  usually  constipated,  the  stools  not  clay-colored,  except  late 
in  the  disease.    They  are  sometimes  tarry  from  the  presence  of  altered  blood. 

Mental  Features. — In  very  severe  cases  the  onset  may  be  with  active 
delirium.  "  As  a  rule,  in  a  majority  of  cases,  even  when  there  is  black  vomit, 
there  is  a  peculiar  alertness;  the  patient  watches  ever3^thing  going  on  about 
him  with  a  peculiar  intensity  and  liveliness.  This  may  be  due  in  part  to  the 
terror  the  disease  inspires"   (Guiteras). 

Eelapses  occasionally  occur.  Among  the  varieties  of  the  disease  it  is  impor- 
tant to  recognize  the  mild  cases,  characterized  by  slight  fever,  continuing  for 
one  or  two  days,  anc^  succeeded  by  a  rapid  convalescence.  In  the  absence  of  a 
prevailing  epidemic,  they  would  scarcely  be  recognized  as  yellow  fever.  Cases 
of  greater  severity  have  high  fever  and  the  features  of  the  disease  are  well 
marked — ^vomiting,  extreme  prostration,  and  haemorrhages.  And  lastly,  in  the 
malignant  form  the  patient  is  overwhelmed  by  the  intensity  of  the  fever,  and 
death  takes  place  in  two  or  three  days. 

In  severe  cases  convalescence  may  be  complicated  by  parotitis,  abscesses 
in  various  parts  of  the  body,  and  diarrhoea. 

Diagnosis. —  (a)  From  Dengue. — -The  difficulty  in  the  differential  diag- 
nosis of  these  two  diseases  lies  in  their  frequent  coexistence,  as  during  the  epi- 
demic of  1897  in  parts  of  the  Southern  States.  During  the  autumn  of  1897 
the  profession  of  Texas  was  divided  on  the  question  of  Ihe  existence  of  yellow 


238  SPECIFIC  INFECTIOUS  DISEASES. 

fever  in  the  State,  some  claiming  that  the  disease  was  dengue,  others,  includ- 
ing Guiteras  and  West,  that  yellow  fever  also  existed.  In  a  majority  of  the 
eases  the  three  diagnostic  points  upon  which  Guiteras  lays  stress — the  f acies, 
the  alhumiiniria,  and  the  slowing  of  the  pulse  with  maintenance  or  elevation 
of  the  fever — are  sufficient  for  the  diagnosis.  He  states,  too,  that  jaundice, 
which  does  sometimes  occur  in  dengue,  rarely  appears  as  early  as  the  second 
or  third  day  of  the  disease,  and  on  this  much  stress  should  be  laid.  Hem- 
orrhages are  much  less  common  in  dengue,  but  that  they  do  occur  has  been 
recognized  by  authorities  even  since  the  time  of  Eush. 

(6)  From  Malarial  Fever. — In  the  early  stages  of  an  epidemic  cases 
are  very  apt  to  be  mistaken  for  malarial  fever.  In  the  Southern  States  the 
outbreaks  have  usually  been  in  the  late  summer  months,  the  very  season  in 
which  the  jestivo-autumnal  fever  prevails.  Among  the  points  to  be  specially 
noted  are  the  absence  of  early  jaundice.  Even  in  the  most  intense  types  of 
malarial  infection  the  color  of  the  skin  is  rarely  changed  within  four  or  five 
days.  To  the  experienced  eye  the  facies  would  be  of  considerable  help  if  the 
case  was  seen  from  the  outset.  Albumin  is  rarely  present  in  the  urine  so 
early  as  the  second  day  in  a  malarial  infection.  Other  important  points  are 
the  marked  swelling  of  the  spleen  in  malaria,  while  in  yellow  fever  it  is  not 
much  enlarged.  Haemorrhages,  and  particularly  the  black  vomit,  epistaxis, 
and  bleeding  gums  are  very  rare  in  malarial  infection.  In  the  so-called  h^em- 
orrhagic  malarial  fever  the  jDatient  has  usually  had  previous  attacks  of  malaria. 
Hematuria  is  a  prominent  feature,  while  in  yellow  fever  it  is  by  no  means 
frequent.  A  special  point  of  greater  importance,  perhaps,  than  any  of  these 
general  symptomatic  features  is  the  examination  of  the  blood  for  the  small, 
ring-shaped  organisms  of  the  gestivo-autumnal  infection.  As  a  rule,  their 
presence  is  readily  determined  by  any  one  familiar  with  their  general  charac- 
ters. They  are,  however,  of  all  forms  the  most  difficult  to  recognize,  and, 
while  very  abundant  in  many  cases,  there  are  others  in  which  they  are  ex- 
tremely scanty  in  the  peripheral  circulation.  The  work  of  the  army  surgeons 
in  Cuba  shows  that  in  a  large  proportion  of  cases  there  is  not  much  difficulty 
in  recognizing  the  gestivo-autumnal  fever  from  yellow  fever. 

Prog'nosis. — In  its  graver  forms,  yellow  fever  is  one  of  the  most  fatal  of 
epidemic  diseases.  The  mortality  has  ranged,  in  various  epidemics,  from  15 
to  85  per  cent.  In  heavy  drinkers  and  those  who  have  been  exposed  to  hard- 
ships the  death-rate  is  much  higher  than  among  the  better  classes.  In  the 
epidemic  of  1878,  in  Xew  Orleans,  while  the  mortality  in  hospitals  was  over 
50  per  cent  of  the  white  and  21  per  cent  of  the  colored  patients,  in  private 
practice  it  was  not  more  than  10  per  cent  among  the  white  patients.  The 
death-rate  was  very  low  in  the  epidemic  of  1897. 

Prophylaxis. — The  measures  carried  out  at  Havana,  already  referred  to, 
and  in  the  Canal  Zone,  Panama,  by  Major  Gorgas  illustrate  the  practical  value 
of  scientific  medicine.  During  1905,  the  year  after  the  American  Commission 
began  work,  yellow  fever  prevailed  to  the  great  demoralization  of  the  em- 
ployees, but  it  was  gradually  stamped  out,  and  there  have  been  no  epidemics 
for  the  past  two  years.  The  important  measures  are:  (1)  the  protection  of 
the  sick  from  the  bites  of  mosquitoes;  (2)  the  screening  of  houses,  the  use 
of  mosquito  nets,  and  the  destruction  of  the  insects  in  the  house;  (3)  meas- 
ures such  as  already  referred  to  under  malaria,  which  diminish  the  possibility 


THE  PLAGUE.  239 

of  the  mosquito  breeding  in  the  neighborhood  of  dwellings.  New-comers 
should  be  particularly  careful  in  infected  regions,  and  medical  officers  in 
charge  of  camps  should  exercise  the  most  scrupulous  care  to  prevent  the  spread 
of  infection  through  mosquitoes. 

Treatment. — Careful  nursing  and  a  symptomatic  plan  of  treatment  prob- 
ably give  the  best  results.  The  patient  should  be  removed  at  once  from  the 
infected  house.  Care  should  be  taken  to  prevent  chilling  of  the  skin,  and 
sweating  should  be  promoted.  Bleeding  has  long  since  been  abandoned.  An 
early  purge,  followed  by  phenacetin  to  relieve  the  backache,  is  recommended 
by  Geddings.  Of  special  remedies  quinine  is  warmly  recommended,  and, 
when  hsemorrhage  sets  in,  the  perchloride  of  iron.  Digitalis,  aconite,  and 
jaborandi  have  been  employed.  The  fever  is  best  treated  by  hydrotherapy. 
There  are  several  reports  of  the  good  effects  of  cold  baths,  sponging,  and  the 
application  of  ice-cold  water  to  the  head  and  the  extremities  in  this  disease. 
Vomiting  is  a  very  difficult  symptom  to  control.  Ice  in  small  quantities  is 
probably  the  best  remedy.  Cocaine  may  be  tried  in  doses  of  |-|  gr.  every 
hour  or  two  (Geddings). 

We  have  no  drug  which  can  be  depended  upon  to  check  the  haemorrhages. 
Ergot  and  acetate  of  lead  and  opium  are  recommended.  The  urgemic  symp- 
toms are  best  treated  by  the  hot  bath.  Stimulants  should  be  given  freely  dur- 
ing the  second  stage,  when  the  heart's  action  becomes  feeble  and  there  is  a 
tendency  to  collapse.  The  patient  should  be  carefully  fed;  but  when  the 
vomiting  is  incessant  it  is  best  not  to  irritate  the  stomach,  but  to  give  nutri- 
tive enemata  until  the  gastric  irritation  is  allayed.  Washing  out  the  lower 
bowel  is  very  advantageous,  and  in  the  cases  with  extreme  toxaemia  the  sub- 
cutaneous or  intravenous  injection  of  saline  solution  may  be  tried. 

XXII.     THE   PLAGUE. 

Definition. — A  specific,  infectious  disease,  caused  by  Bacillus  pestis,  char- 
acterized by  inflammation  of  the  lymphatic  glands  (buboes),  carbuncles,  pneu- 
monia, and  often  haemorrhages. 

History  and  Geographical  Distribution. — The  disease  was  probably  not 
known  to  the  classical  Greek  writers.  The  earliest  positive  account  dates 
from  the  second  century  of  our  era.  The  plague  of  Athens  and  the  pestilence 
of  the  reign  of  Marcus  Aurelius  were  apparently  not  thia  disease  (Payne). 
From  the  great  plague  in  the  days  of  Justinian  (sixth  century)  to  the  middle 
of  the  seventeenth  century  epidemics  of  varying  severity  occurred  in  Europe. 
Among  the  most  disastrous  was  the  famous  "  black  death  "  of  the  fourteenth 
century,  which  overran  Europe  and  destroyed  a  fourth  of  the  population.  In 
the  seventeenth  century  it  raged  virulently,  and  during  the  great  plague  of 
London,  in  1665,  about  70,000  people  died.  During  the  eighteenth  and  nine- 
teenth centuries  the  ravages  of  the  disease  lessened. 

The  revival  of  plague  is  the  most  important  single  fact  in  epidemiology 
of  the  past  decade.  Throughout  the  nineteenth  century  it  waned  progress- 
ively, outbreaks  of  some  extent  occurring  in  Turkey  and  Asia  Minor  and 
Astrakan,  but  we  had  begun  to  place  it  with  sweating  siclcness  and  typhus 
among  the  diseases  of  the  past.  We  knew  that  it  slumbered  in  parts  of 
China,  and  in  northwest  India,  but  the  epidemic  of  1894  at  Hong-Kong 


240  SPECIFIC  INFECTIOUS  DISEASES. 

showed  that  the  "  hlaek  death  "  was  still  virulent.  Since  then  it  has  spread 
in  an  ominous  manner,  reaching  India,  China,  French  Indo-China,  Japan, 
Formosa,  Australia,  the  Philippine  Islands,  South  America,  the  West  Indies, 
the  United  States,  Cape  Colony,  Madagascar,  Egypt,  Asia  Minor,  and  Eussia 
in  Asia.  In  Europe,  cases  have  heen  carried  to  Marseilles  and  other  Medi- 
teri'ancan  ports  and  to  Hamburg  and  Glasgow.  In  the  latter  city  there  was 
a  small  outbreak  in  1900,  36  cases.  In  the  next  year  there  were  two  cases 
and  in  1907  two  cases — this  without  fresh  importation.  In  San  Francisco 
there  has  been,  1907-1908,  a  recrudescence  of  the  disease,  and  to  March  15, 
190S,  tliere  were  121  cases  with  77  deaths.  In  India  the  ravages  continue 
unabated — more  than  a  million  deaths  were  caused  by  it  in  1907,  chiefly  in 
the  Punjab,  and  the  plague  problem  of  that  country  is  one  of  extraordinary 
complexity.  To  Simpson's  Croonian  lectures,  1907,  the  student  is  referred 
for  full  information.  He  thus  emphasizes  the  danger  of  the  situation:  The 
feature  of  the  present  pandemic  that  presages  danger  in  the  future  is  the 
marvellous  powers  of  recrudescence  and  resistance  to  all  known  measures  of 
prevention,  even  when  the  cases  are  few,  as  in  Glasgow  and  San  Francisco. 
The  slight  mortality  and  the  small  number  of  cases  lull  the  authorities  into  a 
dangerous  frame  of  mind,  as  at  any  time  the  conditions — ^unknown  at  present 
— may  arise  which  enable  it  to  develop  into  a  wide-spread  epidemic.  The  dis- 
ease may  be  kept  in  check,  but  the  danger  remains  while  the  rats  are  infected. 

Etiology. — The  specific  organism  of  the  disease  is  a  bacillus  discovered 
by  Kitasato.  It  resembles  somewhat  the  bacillus  of  chicken  cholera,  and  grows 
in  a  perfectly  characteristic  manner.  Bacillus  pestis  occurs  in  the  blood  and 
in  the  organs  of  the  body,  and  has  also  been  found  in  the  dust  and  in  the  soil 
of  houses  in  which  the  patients  have  lived. 

The  disease  prevails  most  frequently  in  hot  seasons,  though  an  outbreak 
may  occur  during  the  coldest  weather.  Persons  of  all  ages  are  attacked.  It 
spreads  chiefly  among  the  poor,  in  the  slums  of  the  great  cities. 

The  following  are  the  conclusions  of  the  Plague  Commission  (1908)  :  1. 
Contagion  occurs  in  less  than  3  per  cent  of  the  cases,  playing  a  very  small  part 
in  the  general  spread  of  the  disease.  2.  Bubonic  plague  in  man  is  entirely 
dependent  on  the  disease  in  the  rat.  3.  The  infection  is  conveyed  from  rat 
to  rat  and  from  rat  to  man  solely  by  means  of  the  rat-flea.  4.  A  case  in  man 
is  not  in  itself  infectious.  5.  A  large  majority  of  cases  occur  singly  in  houses. 
AVhen  more  than  one  case  occurs  in  a  house,  the  attacks  are  generally  nearly 
simultaneous.  6.  Plague  is  usually  conveyed  from  place  to  place  by  imported 
rat-fleas,  which  are  carried  by  people  on  their  persons  or  in  their  baggage. 
The  human  agent  may  himself  escape  infection.  7.  Insanitary  conditions 
have  no  relation  to  the  occurrence  of  plague,  except  in  so  far  as  they  favor 
infestation  by  rats.  8.  The  non-epidemic  season  is  bridged  over  by  acute 
plague  m  the  rat,  accompanied  by  a  few  cases  among  human  beings. 

Clinical  Forms.— Pestis  Mixoe.— In  this  variety,  also  known  as  the  am- 
bulant, tlie  patient  has  a  few  days  of  fever,  with  swelling  of  the  glands  of  the 
grom,  and  possibly  suppuration.  He  may  not  be  ill  enough  to  seek  medical 
relief.  These  cases,  often  found  at  the  beginning  and  end  of  an  epidemic, 
are  a  very  serious  danger,  as  the  urine  and  faeces  contain  bacilli. 

Bubonic  Plague.— This  constitutes  the  common  variety,  77  65  per  cent 
of  11,600  cases  of  plague  treated  in  the  Arthur  Road  Hospital,  Bombay 


THE  PLAGUE.  241 

(N.  H.  Choksy).  The  stage  of  invasion  is  characterized  by  headache,  hack- 
ache,  stiffness  of  the  limbs,  a  feeling  of  anxiety  and  restlessness,  and  great 
depression  of  spirits.  There  is  a  steady  rise  in  the  fever  until  the  evening  of 
the  third  or  fourth  day,  when  there  is  a  drop  of  two  or  three  degrees.  There 
is  then  a  secondary  fever,  as  some  writers  describe  it,  in  which  the  tempera- 
ture reaches  a  still  higher  point.  The  tongue  becomes  brown,  collapse  symp- 
toms are  apt  to  supervene,  and  in  very  severe  infections  the  patient  may  die 
at  this  stage.  In  at  least  two-thirds  of  all  cases  there  are  glandular  swellings 
or  buboes.  An  analysis  of  9,500  cases  of  buboes  gave  more  than  54  per  cent 
with  the  glands  of  the  groin  affected.  The  swelling  appears  usually  from  the 
third  to  the  fifth  day.  Eesolution  may  occur,  or  suppuration,  or  in  rare  cases 
gangrene.  Suppuration  is  a  favorable  feature,  as  noted  by  De  Foe  in  his 
graphic  account  of  the  London  plague. 

Petechige  very  commonly  show  themselves,  and  may  be  very  extensive. 
These  have  been  called  the  "  plague  spots,'^  or  the  "  tokens  of  the  disease,"  and 
gave  to  it  in  the  middle  ages  the  name  of  the  Black  Death.  Haemorrhages 
from  the  mucous  membranes  may  also  occur;  in  some  epidemics  haemoptysis 
has  been  especially  frequent. 

Septicemic  Plague. — In  this,  the  most  rapid  form,  the  patient  succumbs 
in  three  or  four  days  with  a  virulent  infection  before  the  buboes  appear.  'This 
form  constituted  14.25  per  cent  of  the  11,600  cases.  Hsemorrhages  are  com- 
mon.    The  bacilli  can  be  obtained  from  the  blood. 

Pneumonic  Plague. — This  remarkable  variety  presents  the  features  of 
a  pneumonia,  and  the  sputum  contains  the  bacilli  in  enormous  numbers.  It 
is  even  more  fatal  than  the  septicgemic  type.  The  mortality  in  514  cases  was 
96.69  per  cent.  It  is  of  short  duration.  The  fever  is  high,  the  respirations 
rapid,  the  pneumonia  is  chiefly  lobular,  the  sputa  hgemorrhagic,  and  contain 
the  bacilli  in  almost  pure  culture. 

In  other  varieties  the  chief  manifestations  may  be  in  the  skin  and  subcu- 
taneous tissues,  or  in  the  intestines,  causing  diarrhoea  and  sometimes  the 
features  of  typhoid  fever. 

Diagnosis. — At  the  early  stage  of  an  outbreak  plague  cases  are  easily  over- 
looked, but  if  the  suspicious  cases  are  carefully  studied  by  a  competent  bac- 
teriologist, there  is  no  disease  which  can  be  more  positively  identified.  The 
San  Francisco  epidemic  illustrates  this.  The  nature  of  the  cases  was  recog- 
nized by  Kellog  and  by  Kinyoun,  but  with  an  amazing  stupidity  (which  was 
shared  by  not  a  few  physicians,  who  should  have  known  better)  the  Governor 
of  the  State  refused  to  recognize  the  presence  of  plague,  and  the  United  States 
Government  had  to  intervene  and  send  a  board  of  experts  to  settle  the  ques- 
tion. In  the  early  Glasgow  cases  Colvin,  while  suspecting  typhoid  fever,  saw 
that  there  was  something  unusual,  and  at  once  took  precautionary  measures. 
Probably,  too,  the  association  of  four  cases  in  one  family  made  him  suspicious. 
The  limitation  of  the  outbreak  was  due  to  the  prompt  and  effective  measures 
taken  by  A.  K.  Chalmers  and  his  associates.  The  widespread  prevalence  of 
the  disease  makes  it  the  imperative  duty  of  the  health  authorities  to  have  on 
hand,  in  connection  with  large  ports,  skilled  men  who  can  promptly  make  the 
bacteriological  diagnosis.  There  are  dangers  from  the  cultures  in  laboratories, 
as  shown  by  the  experiences  of  Vienna  and  Ann  Arbor,  but  with  proper  precau- 
tions they  may  be  reduced  to  a  minimum. 


242  SPECIFIC  INFECTIOUS  DISEASES. 

Prophylaxis. — Wherever  plague  exists  an  organized  staff,  an  intelligent 
policy,  and  a  long  purse  are  needed.  In  India,  where  fifteenth-century  con- 
ditions prevail,  and  where  the  scale  of  the  epidemic  is  so  enormous,  the  prob- 
lem of  prophylaxis  looks  hopeless.  Simpson's  recommendation  of  a  specially 
trained  plague  service,  organized  on  proper  lines  and  on  a  liberal  basis,  should 
be  carried  out.  Quarantine,  to  be  of  any  value,  must  be  most  vigorous.  A 
most  important  prophylactic  measure  relates  to  the  destruction  of  rats,  which 
are  the  chief  agents  in  the  distribution  of  the  disease.  As  Ashburton  Thomp- 
son remarks  (Eeport  on  Plague  at  Sydney),  "during  an  epidemic  the  only 
proceeding  of  much  value  is  destruction  of  rats  and  of  their  nests,  burrows, 
and  liabitual  liaunts,  and  those  others  which  are  calculated  to  prevent  access 
of  surviving  rats  to  proximity  with  human  beings — in  other  words,  to  expel 
them  from  occupied  premises,  and  to  keep  them  outside.  .  .  .  On  premises 
where  indigenous  cases  had  occurred,  moreover,  the  presence  of  freshly  deceased 
rats  was  discovered  quite  often  enough  to  support  the  general  proposition  that 
the  danger  of  contracting  plague  stood  in  relation  to  the  presence  of  rats  in 
dwellings  or  inclosed  premises.  A  general  slaughter  of  rats  would  answer  the 
purpose,  if  it  could  be  carried  out  quickly  and  with  tolerable  completeness." 
Koch  recommends  the  breeding  of  improved  strains  of  cats  as  fitted  most 
naturally  for  the  task. 

Treatment. — In  a  disease  the  mortality  of  which  may  reach  as  high  as  80 
or  90  per  cent  the  question  of  treatment  resolves  itself  into  making  the  patient 
as  comfortable  as  possible,  and  following  out  certain  general  principles  such 
as  guide  us  in  the  care  of  fever  patients.  Cantlie  recommends  purgation  and 
stimulation  from  the  outset,  and  the  use  of  morphia  for  the  pain.  The  local 
treatment  of  the  buboes  is  important.  Ice  may  be  applied  to  them,  and  good 
results  apparently  follow  the  injection  of  the  bichloride  of  mercury.  The 
pyrexia  of  the  disease  is  best  treated  by  systematic  hydrotherapy. 

A  plague  serum,  chiefly  the  Lustig  and  the  Yersin-Eouse,  has  been  used. 
Choksy  has  collected  the  statistics  to  date  (1907),  1,408  cases,  with  a  mortal- 
ity of  53.3  per  cent.  Of  those  treated  on  the  first  day  the  death-rate  was  only 
28.9.  Choksy  concludes  that  a  reduction  of  20-25  per  cent  in  the  mortality 
may  be  obtained  by  its  use. 

Preventive  Inoculation.— With  Haffkine's  serum  in  12  districts,  of 
224,228  persons  inoculated,  3,399  took  the  disease;  of  639,600  uninoeulated, 
49,430  were  attacked.  C.  J.  Martin  concludes  that  the  chances  of  subsequent 
infection  are  reduced  four-fifths,  and  the  chances  of  recovery  are  two  and  a 
half  times  as  great  as  in  the  case  of  the  uninoeulated. 

XXIII.    BACILLARY   DYSENTERY. 

Definition.— A  form  of  intestinal  flux,  usually  of  an  acute  type,  occurring 
sporadically  and  in  severe  epidemics,  attacking  children  as  well  as  adults 
characterized  by  pain,  frequent  passages  of  blood  and  mucus,  and  due  to  the 
action^  of  a  specific  bacillus,  of  which  there  are  various  strains. 

Etiology.— Owing  to  improved  sanitation,  dysentery  has  become  less  fre- 
quent. In  temperate  climates  sporadic  cases  occur  from  time  to  time,  and  at 
intervals  epidemics  prevail,  particularly  in  overcrowded  institutions.  The  sta- 
tistics of  general  hospitals  for  the  past  twenty  years  show  a  decided  decrease 


BACILLARY  DYSENTERY.  243 

in  the  number  of  cases  admitted.  Eecords  of  widespread  epidemics  have  been 
collected  by  Woodward.  The  most  serious  was  that  which  prevailed  from  1847 
to  1856.  In  Great  Britain  and  Ireland  epidemics  of  the  disease  have  become 
less  frequent.  In  institutions,  particularly  in  overcrowded  asylums,  dysen- 
tery is  very  common,  and  this  form  has  been  made  the  subject  of  a  valuable 
report  by  Mott  and  Durham.  In  the  tropics  "  dysentery  is  a  destructive 
giant  compared  to  which  strong  drink  is  a  mere  phantom"  (Macgregor). 
Dysentery  is  one  of  the  great  camp  diseases,  and  it  has  been  more  destructive 
to  armies  than  powder  and  shot.  In  the  Federal  service  during  the  civil  war, 
according  to  Woodward,*  there  were  259,071  cases  of  acute  and  28,451  cases 
of  chronic  dysentery.  The  disease  prevails  in  Porto  Eico,  the  Philippines, 
and  to  a  less  extent  in  Cuba.  In  the  South  African  campaign  dysentery  pre- 
vailed widely.  For  many  years  a  very  fatal  form  of  dysentery  has  prevailed 
in  Japan,  particularly  in  the  summer  and  autumn  months,  having  a  mortality 
of  from  26  to  27  per  cent;  in  1899  there  were  125,989  cases,  with  26,709 
deaths  (Eldridge).  It  is  now  generally  conceded  that  the  severe  epidemics 
of  acute  dysentery  occurring  in  the  tropics  are  of  the  bacillary  type,  and  the 
same  form  prevails  in  temperate  climates. 

Bacillus  Dysenteric. — In  1898,  Shiga,  a  Japanese  observer,  found  in 
the  dysentery  prevailing  in  his  country  a  bacillus  with  special  characters,  which 
he  considered  to  be  the  specific  cause  of  the  disease. 

Flexner  and  Barker,  of  the  Johns  Hopkins  Commission  for  the  Study  of 
Tropical  Diseases,  found  in  the  dysentery  in  the  Philippine  Islands  an  iden- 
tical organism,  and  it  has  been  made  the  subject  of  very  careful  study  by  Flex- 
ner, and  also  by  K.  P.  Strong,  Musgrave,  and  Craig,  of  the  United  States 
army.  It  has  also  been  found  in  cases  of  dysentery  from  Porto  Rico.  The 
organism  appears  to  be  constantly  present  in  the  acute  dysentery  of  the  tropics. 
In  Manila,  according  to  Strong  and  Musgrave,  of  1,328  cases,  712  were  of  the 
acute  specific  variety,  55  suspected  specific  cases,  and  561  of  amoebic  dysentery. 
Kruse,  in  an  outbreak  at  Laar,  in  Germany,  in  which  300  persons  were  at- 
tacked, has  isolated  an  identical  bacillus.  Vedder  and  Duval  demonstrated 
that  sporadic  cases  in  adults  in  Philadelphia,  as  well  as  epidemics  of  dysen- 
tery in  the  Lancaster  County  Asylum,  Pennsylvania,  and  in  the  almshouse  at 
New  Haven,  were  due  to  this  organism.  During  the  summer  of  1902  Duval 
and  Bassett,  working  at  the  Mount  Wilson  Sanitarium,  first  demonstrated  that 
certain  forms  of  summer  diarrhoeas  of  infants  were  due  to  infection  with 
B.  dysenterige.  The  Rockefeller  Institute,  during  the  following  summer,  con- 
ducted a  collective  investigation  into  the  cause  of  infantile  diarrhoeas  in  Bos- 
ton, New  York,  Philadelphia,  and  Baltimore.  Several  observers,  under  Flex- 
ner's  direction,  studied  412  cases  and  found  the  dysentery  bacillus  present  in 
279  or  63.2  per  cent.  Spronck,  working  in  Holland,  also  confirmed  these 
observations. 

The  strain  of  the  bacillus  most  frequently  found  in  the  United  States  is 
the  "  Flexner-Harris  "  type. 

It  is  now  conceded  that  a  number  of  strains  of  the  bacillus  occur.  This 
fact  has  been  determined  by  the  relative  agglutinative  power  of  immune  serum 

*  Medical  and  Surgical  History  of  the  War  of  the  Rebellion,  Medical,  vol.  ii.  The  most 
exhaustive  treatise  extant  on  intestinal  fluxes — an  enduring  monument  to  the  industry  and 
ability  of  the  author. 


244  SPECIFIC  INFECTIOUS  DISEASES. 

upon  the  bacilli  isolated,  as  well  as  by  the  action  of  the  latter  upon  various 
sugars.  Flexner  recognizes  three  types:  (1)  "Shiga"  tj^e:  attacks  glucose, 
without  action  on  other  sugars,  including  mannite  and  lactose.  (2)  "  Flex- 
ner-Harris"  type:  attacks  glucose,  mannite,  and  dextrine;  does  not  attack 
lactose.  (3)  Bacillus  "  Y "  (Hiss  and  Eussell)  :  attacks  glucose  and  mannite; 
no  action  on  dextrine  and  lactose.  The  lesions  produced  by  the  different 
strains  are  identical.  The  organism  agglutinates  ^^•ith  the  blood  serum  of 
cases  with  acute  dysentery  as  well  as  with  the  serum  of  immunized  animals. 

As  yet  nothing  is  Icnown  as  to  how  infection  of  human  beings  occurs.  Its 
habitat  is  unknown,  and  the  organism  has  never  been  isolated  from  sources 
outside  the  human  body.  In  two  instances  the  dysentery  bacillus  has  been 
isolated  by  Duval  from  the  stools  of  healthy  children.  In  dysenteric  stools  the 
organism  is  most  readily  isolated  from  the  particles  of  mucus. 

Morbid  Anatomy. — In  the  acute  cases,  when  death  has  occurred  on  the 
fourth  to  the  seventh  day,  the  mucous  membrane  of  the  large  intestine  is 
swollen,  of  a  deep-red  color,  and  presents  elevated,  coarse  corrugations  and 
folds.  In  addition  to  the  intense  h}^er£emia  there  are  spots  of  hsemorrhages 
scattered  through  the  swollen  mucosa.  Over  the  surface  there  is  usually  a 
superficial  necrotic  layer,  which  can  be  brushed  off  lightly  with  the  finger. 
This  may  be  in  patches,  or  uniform  over  large  areas.  There  is  no  ulceration, 
only  the  superficial,  general  necrosis  of  the  mucosa.  The  solitary  follicles  are 
swollen  and  red,  but  the  prominence  is  obscured  in  the  involvement  of  the 
entire  mucosa.  In  cases  of  great  intensity  the  entire  coats  of  the  colon  may 
be  stiff  and  thick,  and  the  mucous  membrane  enormously  increased  in  thick- 
ness, grayish-black  in  color,  extensivel}^  necrotic,  and,  in  places,  gangrenous. 
The  serous  surface  is  often  deeply  injected.  The  ileum  is,  in  many  cases, 
involved,  having  a  deeply  hgemorrhagic  mucosa,  with  a  superficial  necrosis. 
In  the  subacute  cases  there  is  not  the  same  great  thickening  of  the  intestinal 
wall,  the  solitar}'  follicles  are  more  swollen,  there  is  less  necrosis,  and,  while 
there  are  no  ulcers,  there  are  superficial  erosions. 

Symptoms. — According  to  Strong  and  Musgrave,  the  period  of  incubation 
is  not  more  than  forty-eight  hours.  The  onset,  which  is  usually  sudden,  is 
characterized  by  slight  fever,  pain  in  the  abdomen,  and  frequent  stools.  At  first 
mucus  is  passed,  but  within  twenty-four  hours  blood  appears  with  it,  or  there  is 
pure  blood.  There  is  a  constant  desire  to  go  to  stool,  T\dth  great  straining  and 
tenesmus ;  every  hour  or  half  hour  there  may  be  a  small  amount  of  blood  and 
mucus  passed.  The  temperature  rises  and  may  reach  103°  or  10J:°.  The  pulse 
increases  in  frequency,  and  in  the  severer  cases  becomes  very  small.  The 
tongue  is  coated  with  a  white  fur,  and  there  is  excessive  thirst.  In  the  very 
acute  cases  the  patient  becomes,  seriously  ill  within  fort3^-eight  hours,  the  move- 
ments increase  in  frequency,  the  pain  is  of  great  intensity,  the  patient  becomes 
delirious,  and  death  may  occur  on  the  third  or  fourth  day.  In  cases  of  moder- 
ate severity  the  urgency  of  the  s}Tnptoms  abates,  the  stools  lessen,  the  tem^ 
perature  falls,  and  within  two  or  three  weeks  the  patient  is  convalescent.  The 
mortality  in  the  severe  forms  is  very  high.  There  is  a  subacute  form  which 
lasts  for  many  weeks  or  months.  The  patients  become  greatly  emaciated, 
having  from  three  to  five  stools  in  the  twenty-four  hours.  The  bacillus 
dysenterige  is  found  in  the  stools,  and  it  agglutinates  readily  with  the  blood 
serum. 


BACILLARY  DYSENTERY.  245 

Other  Clinical  Types. — The  foregoing  account  describes  the  essential  fea- 
tures of  bacillary  dysentery  as  seen  in  Japan,  the  Philippines,  and  the  tropics. 
The  clinical  features  of  bacillary  dysentery  in  adults  in  temperate  climates 
differ  in  no  essential  manner  from  those  already  described.  Although  the 
evidence  hardly  warrants  us  at  present  in  making  the  sweeping  statement  that 
all  non-amoebic  cases  of  dysentery  in  this  country  are  bacillary  in  origin,  yet 
experience  will  probably  demonstrate  eventually  that  this  is  the  case.  What 
is  known  as  the  acute  catarrhal  dysentery  is  probably  a  sporadic  form  due  to 
the  Bacillus  dysenteries.  What  is  known  as  diphtheritic  dysentery  is  a  type 
of  the  bacillary  form  with  great  necrosis  and  infiltration  of  the  mucosa.  The 
secondary  diphtheritic  dysentery  is  a  common  terminal  event  in  many  acute 
and  chronic  diseases.  Vedder  and  Duval  have  demonstrated  that  the  bacillus 
is  present  in  these  cases. 

Complications  and  Sequelae.— Penfoni^is  is  rare,  due  either  to  extension 
through  the  wall  of  the  bowel  or  to  perforation.  When  this  occurs  about  the 
csecal  region,  perityphlitis  results ;  when  low  down  in  the  rectum,  periproctitis. 
In  108  autopsies  collected  by  Woodward  perforation  occurred  in  11.  Abscess 
of  the  liver,  so  common  iq  the  amoebic  form,  is  very  rare.  It  is  interesting  to 
note,  as  illustrating  the  probable  type  of  the  disease,  how  comparatively  rare 
abscess  of  the  liver  was  during  the  civil  war.  Very  few  cases  occurred  in  the 
South- African  War  (Eolleston). 

In  the  tropics  malaria  and  acute  dysentery  very  often  coexist.  With  refer- 
ence to  typhoid  fever,  as  a  complication.  Woodward  mentions  that  the  com- 
bination was  exceedingly  frequent  during  the  civil  war,  and  characteristic 
lesions  of  both  diseases  coexisted.    In  civil  practice  it  is  extremely  rare. 

Sydenham  noted  that  dysentery  was  sometimes  associated  with  rheumatic 
pains,  and  in  certain  epidemics  joint  swellings  have  been  especially  prevalent. 
They  are  probably  not  of  the  nature  of  true  rheumatism,  but  rather  analogous 
to  those  of  gonorrhceal  arthritis.  In  severe  cases  there  may  be  pleurisy,  throm- 
bosis, pericarditis,  endocarditis,  and  occasionally  pysemic  manifestations, 
among  which  may  be  mentioned  pylephlebitis.  Chronic  Bright's  disease  is 
also  an  occasional  sequel.  In  protracted  cases  there  may  be  an  ansmic  oedema. 
An  interesting  sequel  of  dysentery  is  paralysis.  Woodward  reports  8  eases. 
Weir  Mitchell  mentions  it  as  not  uncommon,  occcurring  chiefly  in  the  form 
of  paraplegia.  As  in  other  acute  fevers,  this  is  due  probably  to  a  neuritis. 
Kemlinger,  in  two  cases  of  non-amoebic  dysentery  in  Tunis,  observed  an  epi- 
didymitis during  convalescence.  Gonorrhoea  was  excluded.  In  a  third  case 
the  dysentery  was  complicated  by  an  abscess  of  the  spleen,  which  ruptured, 
causing  death.  Intestinal  stricture  is  a  rare  sequence — so  rare  that  no  case 
was  reported  at  the  Surgeon- General's  office  during  the  civil  war.  Among  the 
sequelae  of  chronic  dysentery,  in  persons  who  have  recovered  a  certain  measure 
of  health,  may  be  mentioned  persistent  dyspepsia  and  irritability  of  the  bowels. 

Diagnosis. — In  the  acute  specific  form  the  blood-serum  agglutinates  the 
dysentery  bacillus.  The  "  Flexner-Harris  "  type  of  the  organism  agglutinates 
in  dilutions  of  from  1  to,  1,000  up  to  1  to  "l,500.  This  is  the  form  of  the 
organism  that  prevails  in  the  United  States.  The  "  Shiga  "  type  agglutinates 
less  readily.  The  blood-serum  of  a  dysenteric  patient  will  agglutinate  both 
types,  but  the  former  more  readily  than  the  latter.  In  all  non-amoebic  dys- 
enteries efforts  should  be  made  to 'isolate  the  dysentery  bacillus  from  the  stools. 


246  SPECIFIC  INFECTIOUS  DISEASES. 

Treatment.— Flint  has  showa.  that  sporadic  dysentery  is,  in  its  slighter 
grades  at  least,  a  self-limited  disease,  which  runs  its  course  in  eight  or  nine 
days.  Heading  the  report  of  his  cases,  one  is  struck,  however,  with  their  com- 
parative mildness. 

Prophylactic. — We  are  as  yet  ignorant  of  the  sources  of  infection.  The 
dysentery  bacillus  has  not  been  found  outside  the  human  body.  It  seems  quite 
possible  that  it  is  a  water-borne  organism,  and  the  same  proph3'lactic  pre- 
cautions should  be  followed  as  are  adopted  in  t}^hoid  fever.  Flexner  and 
Gay  have  shown  that  animals  can  be  protected  from  infection  by  a  previous 
treatment  with  immune  horse  serum.  Immunization  of  human  individuals 
has  not  been  so  far  demonstrated. 

Medicinal. — The  enormous  surface  involved,  amounting  to  many  square 
feet,  the  constant  presence  of  irritating  particles  of  food,  and  the  impossibility 
of  getting  absolute  rest,  are  conditions  which  render  the  treatment  of  dysen- 
tery peculiarly  difficult.  Moreover,  in  the  severer  cases,  when  necrosis  of  the 
mucosa  has  occurred,  ulceration  necessarily  follows,  and  .can  not  in  any  way 
be  obviated.  When  a  case  is  seen  early,  particularly  if  there  has  been  consti- 
pation, a  saline  purge  should  be  gi^en.  The  free  watery  evacuations  produced 
by  a  dose  of  salts  cleanse  the  large  bowel  with  the  least  possible  irritation,  and 
if  necessary,  in  the  course  of  the  disease,  particularly  if  scybala  are  present, 
the  dose  may  be  repeated.  The  saline  treatment  is  much  commended.  W.  J. 
Buchanan  has  treated  855  cases  with  only  9  deaths.  He  gives  a  drachm  of 
sodium  sulphate,  four,  six,  or  eight  times  a  day,  and  continues  until  all  blood 
and  mucus  have  disappeared,  usually  for  two  or  three  days.  Of  medicines 
which  are  supposed  to  have  a  direct  effect  upon  the  disease,  ipecacuanha  still 
maintains  its  reputation  in  the  tropics.  Xo  food  is  taken  for  three  hours, 
then  twenty  drops  of  laudanum,  and  half  an  hour  after  from  20  to  60  grains 
of  ipecacuanha.  If  rejected  by  vomiting,  the  dose  is  repeated  in  a  few  hours. 
Washbourne  and  Eichards,  in  the  South  African  campaign,  speak  of  the  good 
results  of  ipecacuanha  combined  with  the  saline  treatment. 

Minute  doses  of  corrosive  sublimate,  one  hundredth  of  a  grain  ever}^  two 
hours,  are  warmly  recommended  by  Einger.  Large  doses  of  bismuth,  half  a 
drachm  to  a  drachm  every  two  hours,  so  that  the  patient  may  take  from  12  to 
15  drachms  in  a  day,  have  in  many  cases  had  a  beneficial  effect.  To  do  good 
it  must  be  given  in  large  doses,  as  recommended  by  Monneret,  who  gave  as 
high  as  70  grammes  a  day.  It  certainly  is  more  useful  in  the  chronic  than 
the  acute  cases.  It  is  best  given  alone.  Opium  is  an  invaluable  remedy  for 
the  relief  of  the  pain  and  to  quiet  the  peristalsis.  It  should  be  given  as  mor- 
phia, hypodermically,  acccording  to  the  needs  of  the  patient. 

The  treatment  of  dysentery  by  topical  applications  is  by  far  the  most 
rational  plan.  A  serious  obstacle,  however,  in  the  acute  cases,  is  the  extreme 
irritability  of  the  rectum  and  the  tenesmus  which  follows  any  attempt  to  irri- 
gate the  colon.  A  preliminary  cocaine  suppository  or  the  injection  of  a  small 
quantity  of  the  4-per-cent  solution  will  sometimes  relieve  this,  and  then  with 
a  long  tube  the  solution  can  be  allowed  to  flow  in  slowly.  The  patient  should 
be  in  the  dorsal  position  with  a  pillow  under  the  hips,  so  as  to  get  the  effect 
of  gravitation.  Water  at  the  temperature  of  100°  is  very  soothing,  but  the 
irritability  of  the  bowel  is  such  that  large  quantities  can  rarely  be  retained  for 
any  time.    When  the  acute  symptoms  subside,  the  injections  are  better  borne. 


MALTA  FEVER.  247 

Various  astringents  may  be  used — alum,  acetate  of  lead,  sulphate  of  zinc  and 
copper,  and  nitrate  of  silver.  Of  these  remedies  the  nitrate  of  silver  is  the 
best,  though,  I  think,  not  in  very  acute  cases.  In  the  chronic  form  it  is  per- 
haps the  most  satisfactory  method  of  treatment  which  we  have.  It  is  useless 
to  give  it  in  the  small  injections  of  two  or  three  ounces  with  1  to  2  grains  of 
the  salt  to  the  ounce.  It  must  be  a  large  irrigating  injection,  which  will  reach 
all  parts  of  the  colon.  This  plan  was  introduced  by  Hare,  of  Edinburgh,  and 
is  highly  recommended  by  Stephen  Mackenzie  and  H.  C.  Wood.  The  solu- 
tion must  be  fairly  strong,  20  to  30  grains  to  the  pint,  and  if  possible  from 
3  to  6  pints  of  fluid  must  be  injected.  To  begin  with  it  is  well  to  use  not 
more  than  a  drachm  to  the  2  pints  or  2^  pints,  and  to  let  the  warm  fluid  run 
in  slowly  through  a  tube  passed  far  into  the  bowel.  It  is  at  times  intensely 
painful  and  is  rejected  at  once.  Argyrm,  so  far  as  I  know,  has  never  followed 
the  prolonged  use  of  nitrate-of-silver  injections  in  chronic  dysentery.  When 
there  is  not  much  tenesmus,  a  small  injection  of  thin  starch  with  half  a  drachm 
to  a  drachm  of  laudanum  gives  great  relief,  but  for  the  tormina  and  tenesmus, 
the  two  most  distressing  symptoms,  a  hypodermic  of  morphia  is  the  only  satis- 
factory remedy.  Local  applications  to  the  abdomen,  in  the  form  of  light 
poultices  or  turpentine  stupes,  are  very  grateful. 

The  diet  in  acute  cases  must  be  restricted  to  milk,  whey,  and  broths,  and 
during  convalescence  the  greatest  care  must  be  taken  to  provide  only  the  most 
digestible  articles  of  food.  In  chronic  dysentery,  diet  is  perhaps  the  most 
important  element  in  the  treatment.  The  number  of  stools  can  frequently 
be  reduced  from  ten  to  twelve  in  the  day  to  two  or  three,  by  placing  the  patient 
in  bed  and  restricting  the  diet.  Many  cases  do  well  on  milk  alone,  but  the 
stools  should  be  carefully  watched  and  the  amount  limited  to  that  which  can 
be  digested.  If  curds  appear,  or  if  much  oily  matter  is  seen  on  microscopical 
examination,  it  is  best  to  reduce  the  amount  of  milk  and  to  supplement  it  with 
beef-Juice  or,  better  still,  egg-albumen.  The  large  doses  of  bismuth  seem 
specially  suitable  in  the  chronic  cases,  and  the  injections  of  nitrate  of  silver, 
in  the  way  already  mentioned,  should  always  be  given  a  trial. 

Serum  Therapy. — Shiga  produced  a  polyvalent  serum  by  immunizing 
horses,  by  which  he  claims  to  have  reduced  the  mortality  in  "  endemic  "  dysen- 
tery in  Japan  from  about  35  per  cent  to  9  per  cent.  The  encouraging  early 
results  of  this  form  of  treatment  have  not  apparently  been  borne  out  by  subse- 
quent experience.  Flexner  has  immunized  horses,  and  this  immune-serum  has 
been  given  a  fair  trial  in  the  treatment  of  infantile  diarrhoeas  of  bacillary  ori- 
gin. The  investigation  was  carried  on  under  the  direction  of  the  Eockefeller 
Institute.  Holt  reports  that  the  anti-dysenteric  serum  was  employed  in  83 
cases,  38  of  which  proved  fatal.  He  states  that  on  the  whole  the  results  were 
disappointing.  In  only  12  cases  did  a  noteworthy  improvement  appear  to 
follow  its  administration. 

XXIV.    MALTA   FEVER. 

(TTndulant  Fever,  Mediterranean  Fever.) 

Definition. — An  endemic  fever,  characterized  by  an  irregular  course,  undu- 
latory  pyrexial  relapses,  profuse  sweats,  rheumatic  pains,  arthritis,  and  an 
enlarged  spleen.    An  organism.  Micrococcus  melitensis,  is  present  in  all  cases. 


248  SPECIFIC  INFECTIOUS  DISEASES. 

Distribution.— Tlie  disease  prevails  in  the  Mediterranean  littoral,  and  en- 
demic foci  exist  in  India,  Africa,  China,  and  Manila.  In  the  Malta  garrison 
in  the  seven  years  1898-1904,  there  were  2,229  cases,  with  an  average  case 
duration  of  one  hundred  and  twenty  days  and  with  77  deaths.  About  the  same 
number  of  cases  occurred  in  the  fleet. 

Etiology. — Tlie  greater  part  of  our  knowledge  of  this  remarkable  disease 
we  owe  to  tlie  work  of  British  army  surgeons  stationed  at  Gibraltar  and  Malta, 
particularly  to  Marston,  Bruce,  and  Hughes.  In  1886  iBruce  isolated  an  or- 
ganism which  he  called  Micrococcus  meUtensis  from  the  spleen  and  blood. 
Hughes,  Wright,  and  others  confirmed  this.  Much  work  was  done  to  establish 
tlie  specificity  of  the  organism.  In  1904-1905  a  Government  Commission  be- 
gan a  study  on  the  island  of  the  problems  of  the  disease  in  all  its  aspects.  It 
was  shown  to  be  a  septicemia,  due  to  the  above-named  organism,  which  had 
an  unusually  prolonged  saprophytic  existence.  Zamit  showed  that  the  goats, 
the  most  important  animals  in  the  domestic  life' of  Malta,  were  largely  infected, 
from  10  to  15  per  cent  having  the  micrococcus  in  their  milk.  Monkeys  were 
successfully  infected  with  milk  which  contained  the  organisms.  Steps  were  at 
once  taken  to  stop  the  use  as  far  as  possible  of  goat's  milk  for  the  troops,  with 
the  result  that  the  number  of  cases  fell  from  750  in  1905  to  145  in  1906,  and 
to  7  for  nine  months  of  1907.  There  were  no  cases  in  1907  in  the  Mediter- 
ranean fleet.  Eyre  has  brought  forward  evidence  to  show  that  the  disease  may 
be  transmitted  by  mosquito  bites. 

Symptoms, — There  is  no  specific  fever  which  presents  the  same  remark- 
able group  of  phenomena.  The  period  of  incubation  is  from  six  to  ten  days. 
"  Clinically  the  fever  has  a  peculiarly  irregular  temperature  curve,  consisting 
of  intermittent  waves  or  undulations  of  pyrexia,  of  a  distinctly  remittent  char- 
acter. These  pyrexial  waves  or  undulations  last,  as  a  rule,  from  one  to  three 
weeks,  with  an  apyrexial  interval  lasting  for  two  or  more  days.  In  rare 
cases  the  remissions  may  become  so  marked  as  to  give  an  almost  intermittent 
character  to  the  febrile  curve,  clearly  distinguishable,  however,  from  the  par- 
oxysms of  p'aludic  infection.  This  pyrexial  condition  is  usually  much  pro- 
longed, having  an  uncertain  duration,  lasting  for  even  six  months  or  more. 
ITnlike  paludism,  its  course  is  not  markedly  affected  by  the  administration  of 
quinine.  Its  course  is  often  irregular  and  even  erratic  in  nature.  This  pyrexia 
is  usually  accompanied  by  obstinate  constipation,  progressive  anaemia,  and 
debility.  It  is  often  complicated  with  and  folloAved  by  neuralgic  symptoms 
referred  to  the  peripheral  or  central  nervous  system,  arthritic  effusions,  painful 
inflammatory  conditions  of  certain  fibrous  structures,  of  a  localized  nature,  or 
swelling  of  the  testicles  "  (Hughes) .  This  author  recognizes  a  malignant  type, 
in  which  the  disease  may  prove  fatal  within  a  week  or  ten  days;  an  undula- 
tory  type — the  common  variety — in  which  the  fever  is  marked  by  intermittent 
waves  or  undulations  of  variable  length,  separated  l)y  periods  of  apyrexia  and 
freedom  from  symptoms.  In  this  really  lie  the  peculiar  features  of  the  disease, 
and  the  unfortunate  victim  may  suffer  a  series  of  relapses  which  may  extend 
from  three  months,  the  average  time,  to  two  years.  Lastly,  there  is  an  inter- 
mittent type,  in  which  the  patient  may  simply  have  daily  pyrexia  toward  even- 
ing, without  any  special  complications,  and  may  do  well  and  be  able  to  go 
about  his  work,  and  yet  at  any  time  the  other  serious  features  of  the  disease 
may  develop. 


BERI-BERL  249 

The  mortality  is  slight,  only  ahout  2  per  cent.  There  are  no  characteristic 
morbid  lesions.  Malta  fever  can  now  be  readily  differentiated  from  enteric 
fever  and  malaria.  The  prophylaxis  is  self-evident,  and  the  brilliant  work 
of  the  commission  has  already  reduced  the  incidence  of  the  disease  to  a 
minimum. 

Treatment. — General  measures  suitable  to  typhoid  fever  are  indicated. 
Fluid  food  should  be  given  during  the  febrile  period.  Hydrotherapy,  either 
the  bath  or  the  cold  pack,  should  be  used  every  third  hour  when  the  tempera- 
ture is  above  103°  F.  Otherwise  the  treatment  is  symptomatic.  No  drugs 
appear  to  have  any  special  influence  on  the  fever.  A  change  of  climate  seems 
to  promote  convalescence. 

XXV.     BERI-BERI. 

Definition. — An  endemic  and  epidemic  multiple  neuritis  of  unknown  etiol- 
ogy, occurring  in  tropical  and  subtropical  countries,  characterized  by  motor 
and  sensory  paralysis  and  anasarca. 

History. — The  disease  is  believed  to  be  of  great  antiquity  in  China,  and 
is  possibly  mentioned  -in  the  oldest  known  medical  treatise.  In  the  early  years 
of  the  nineteenth  century  it  attracted  much  attention  among  the  Anglo-Indian 
surgeons,  and  we  may  date  the  modern  scientific  study  of  the  disease  from 
Malcolmson's  monograph,  published  in  Madras  in  1835.  The  opening  of 
Japan  gave  an  opportunity  to  the  European  physicians  holding  university  posi- 
tions, particularly  Anderson,  Baelz,  Scheube,  and  more  recently  Grimm,  to 
investigate  the  disease.  The  studies  of  the  native  Japanese  physicians,  particu- 
larly Miura  and  Takagi,  and  of  the  Dutch  physicians  in  the  East,  have  con- 
tributed much  to  our  knowledge.  An  added  interest  has  been  given  to  the 
subject  by  the  discovery  of  the  disease  among  the  Cape  Cod  fishermen,  and  by 
the  recurring  outbreaks  of  endemic  neuritis  at  the  Richmond  Asylum  in  Dub- 
lin and  at  the  State  Insane  Hospital  at  Tuscaloosa,  Ala. 

Distribution. — Beri-beri,  Kakke,  or  endemic  neuritis  prevails  most  exten- 
sively in  the  Malay  Archipelago ;  in  certain  of  the  Dutch  colonies  the  mortality 
among  the  coolies  is  simply  frightful.  It  is  widely  distributed  in  China, 
Japan,  and  the  Philippine  Islands.  In  the  Philippines  the  admissions  to  the 
Government  hospitals  for  the  year  ending  June  30,  1903,  were  Q>2:&,  nearly 
all  among  the  Philippine  scouts.  In  India  it  has  become  less  common,  but 
is  still  prevalent  in  parts  of  Burma.  Localized  outbreaks  have  occurred  in 
Australia.  It  prevails  extensively  in  parts  of  South  America  and  in  the  West 
Indies,  and  from  the  ports  of  these  countries  cases  occasionally  reach  the 
United  States,  and  it  occurs  also  among  the  Chinese  and  Japanese  in  Califor- 
nia. Birge,  of  Provincetown,  and  J.  J.  Putnam  encountered  beri-beri  among 
the  fishermen  on  the  Newfoundland  Banks.  Birge  writes  (March  10,  1898) 
that  he  has  seen  47  cases  of  both  the  wet  and  the  dry  form.  The  disease  is  not 
entirely  confined  to  the  fishermen  on  the  Grand  Banks,  but  occurs  occasionally 
among  those  living  on  shore  or  making  "  shore  trips."  In  1895-'96  a  remark- 
able outbreak  of  epidemic  neuritis  occurred  at  the  State  Insane  Hospital  at 
Tuscaloosa,  Ala.,  which  has  been  described  fully  by  E.  D.  Bondurant.  Be- 
tween February,  1895,  and  October,  1896,  in  a  population  of  1,200  there  were 
71  cases  with  21  deaths.    None  occurred  among  the  200  employees  of  the  hos- 


250  SPECIFIC  INFECTIOUS  DISEASES. 

pital.  The  negroes  were  relatively  less  affected  than  the  whites.  The  chief 
symptoms  were  "  muscular  weakness,  tenderness,  pain,  pargesthesis,  loss  of 
deep  reflexes,  followed  by  atrophy  of  muscles  and  the  electrical  reaction  of 
degeneration,  accompanied  by  rise  of  temperature,  gastro-intestinal  disturb- 
ance, general  anasarca,  and  tachycardia."  At  the  Arkansas  State  Insane 
Asylum  at  Little  Eock,  in  1895,  there  was  an  outbreak  of  between  20  and  30 
cases  possibly  of  beri-beri. 

In  Great  Britain  the  disease  is  not  infrequent  at  the  seaports. 

At  the  Eichmond  Asylum,  Dublin,  there  have  been  extensive  outbreaks 
in  the  years  1894,  1896,  1897,  under  conditions  of  overcrowding. 

Etiology. — Two  main  views  prevail  as  to  the  nature  of  the  disease — that 
it  is  an  infection,  and  that  it  is  a  toxaemia  caused  by  food. 

1.  Beri-beri  as  an  Acute  Inpection. — Baelz  and  Scheube,  with  many  of 
the  Dutch  physicians,  hold  that  the  disease  is  due  to  a  germ.  In  favor  of  this 
view,  Scheube  refers  to  the  fact  that  strong,  well-nourished  young  people  are 
attacked,  that  the  disease  has  definite  foci  in  which  it  prevails,  definite  seasonal 
relations,  and  has  of  late  j^ears  spread  in  some  countries  as  an  epidemic  with- 
out any  special  change  in  the  diet  of  the  inhabitants.  So  far  as  seasonal  and 
telluric  influences  are  concerned,  it  is  a  disease  which  resembles  malaria,  with 
which,  in  fact,  some  authors  have  confounded  it.  It  is  probably  not  directly 
contagious.  On  the  other  hand,  Scheube,  Manson  and  others  bring  forward 
evidence  to  show  that  beri-beri  may  probably  be  conveyed  from  one  district  to 
another.  Many  bacteriological  studies  have  been  made  in  the  disease,  par- 
ticularly by  Dutch  physicians,  but  there  is  no  unanimity  as  to  the  results,  and 
we  may  say  that  no  specific  organism  has  as  yet  been  determined  upon. 

Hamilton  Wright,  who  has  made  a  prolonged  study  of  the  disease  in  the 
Malay  States,  describes  a  specific  duodenitis,  a  primary  bacterial  lesion,  from 
which  the  poison  is  evolved.  Just  as  it  is  from  the  throat  in  diphtheria. 

2.  Food  Theory. — This  theory  is  widely  held  in  Japan,  some  believing 
that  it  is  due  to  the  eating  of  bad  rice,  and  others  that  it  is  associated  with  the 
use  of  certain  fish.  In  favor  of  the  dietetic  View  of  its  origin  is  adduced  the 
extraordinary  change  which  has  taken  place  in  the  Japanese  navy  since  the 
introduction  by  Takagi  of  an  improved  diet,  allowing  a  larger  portion  of 
nitrogenous  food,  and  forbidding  the  use  of  fresh  fish  altogether.  Subsequent 
to  this  there  has  certainly  been  the  most  remarkable  diminution  in  the  num- 
ber of  cases — a  reduction  from  about  a  fourth  of  the  entire  strength  attacked 
annually  to  a  practical  abolition  of  the  disease. 

Many  of  the  Dutch  physicians  in  Java  regard  rice  as  the  important  cause 
of  the  disease.  It  is  stated  that  in  the  prisons  of  Java  the  proportion  of  cases 
is  1  to  39  when  the  rice  is  eaten  completely  shelled,  1  to  10,000  when  the  grain 
is  eaten  with  its  pericarp;  in  some  places  the  disease  has  disappeared  when 
the  unshelled  rice  has  been  substituted  for  the  shelled.  Miura,  with  whose 
studies  of  the  disease  all  readers  of  Yirchow's  Archiv  are  familiar,  regards 
ben-beri  as  a  form  of  chronic  poisoning  due  to  the  use  of  the  flesh  of  certain 
fish  eaten  raw  or  improperly  prepared.  Grimm,  in  his  monograph,  regards 
the  immunity  of  Europeans  as  in  great  part  owing  to  the  fact  that  they  do 
not  follow  the  Japanese  custom  of  eating  various  kinds  of  raw  fish. 

_  Among  the  most  important  factors  are  the  following :  Overcrowding,  as  in 
ships,  jails,  and  asylums,  hot  and  moist  seasons,  and  exposure  to  wet.    Euro- 


BERI-BERI.  251 

peans  under  good  hygienic  conditions  rarely  contract  the  disease  in  beri-beri 
regions.  The  natives  and  the  imported  coolies  are  most  often  attacked.  Males 
are  more  subject  to  the  disease  than  females.  Young  men  from  sixteen  to 
twenty-five  are  chiefly  affected. 

Symptoms. — The  incubation  period  is  unknown,  but  it  probably  extends 
over  several  months.  The  following  forms  of  the  disease  are  recognized  by 
Scheube : 

1.  The  incomplete  or  rudimentary  form  which  often  sets  in  with  ca- 
tarrhal symptoms,  followed  by  pains  and  weakness  in  the  limbs  and  a  lower- 
ing of  the  sensibility  in  the  legs,  with  the  occurrence  of  parsesthesiae.  Slight 
oedema  sometimes  appears.  After  a  time  parjEsthesige  are  felt  in  other  parts 
of  the  body,  and  the  patient  may  complain  of  palpitation  of  the  heart,  uneasy 
sensations  in  the  abdomen,  and  sometimes  shortness  of  breath.  There  may  be 
weakness  and  tenderness  of  the  muscles.  After  lasting  from  a  few  days  to 
many  months,  these  sjonptoms  all  disappear,  but  with  the  return  of  the  warm 
weather  there  may  be  a  recurrence.  One  of  Scheube's  patients  suffered  in  this 
way  for  twenty  years. 

3.  The  atrophic  form  sets  in  with  much  the  same  symptoms,  but  the 
loss  of  power  in  the  limbs  progresses  more  rapidly,  and  very  soon  the  patient 
is  no  longer  able  to  walk  or  to  move  the  arms.  The  atrophy,  which  is  associ- 
ated with  a  good  deal  of  pain,  may  extend  to  the  muscles  of  the  face.  T^he 
cedematous  symptoms  and  heart  troubles  play  a  minor  role  in  this  form,  which 
is  known  as  the  dry  or  paralytic  variety. 

3.  The  Wet  or  Dropsical  Form. — Setting  in  as  in  the  rudimentary  vari- 
ety, the  oedema  soon  becomes  the  most  marked  feature,  extending  over  the 
whole  subcutaneous  tissue,  and  associated  with  effusions  into  the  serous  sacs. 
The  atrophy  of  the  muscles  and  disturbance  of  sensation  are  not  such  promi- 
nent symptoms.  On  the  other  hand,  palpitation  and  rapid  action  of  the  heart 
and  dyspnoea  are  common.  The  wasting  may  not  be  apparent  until  the  dropsy 
disappears. 

4.  The  acute,  pernicious,  or  cardiac  form  is  characterized  by  threat- 
enings  of  an  acute  cardiac  failure,  coming  on  rapidly  after  the  existence  of 
slight  symptoms,  such  as  occur  in  the  rudimentary  form.  In  the  most  acute 
type  death  may  follow  within  twenty-four  hours;  more  commonly  the  symp- 
toms extend  over  several  weeks. 

The  mortality  of  the  disease  varies  greatly,  from  2  or  3  per  cent  to  40 
or  50  per  cent  among  the  coolies  in  certain  of  the  settlements  of  the  Malay 
Archipelago. 

Morbid  Anatomy. — The  most  constant  and  striking  features  are  changes 
in  the  peripheral  nerves  and  degenerative  inflammation  involving  the  axis 
cylinder  and  medullary  sheaths.  In  the  acute  cases  this  is  found  not  only  in 
the  peripheral  nerves,  but  also  in  the  pneumogastric  and  in  the  phrenic.  The 
fibres  of  the  voluntary  muscles,  as  well  as  of  the  myocardium,  are  also  much 
degenerated.     Hamilton  Wright  has  described  an  acute  duodenitis. 

Diagnosis. — In  tropical  countries  there  is  rarely  any  difficulty  in  the 
diagnosis.  In  cases  of  peripheral  neuritis,  associated  with  oedema,  coming 
from  tropical  ports,  the  possibility  of  this  disease  should  be  remembered. 
Scheube  states  that  rarely  any  difficulty  offers  in  the  diagnosis  of  the  differ- 
ent forms. 


252  SPECIFIC  INFECTIOUS  DISEASES. 

Treatment.— Much  has  been  done  to  prevent  the  disease,  particularly  in 
Japan  There  is  no  more  remarkable  triumph  of  modern  hygiene  than  that 
which  followed  Takagi's  dietetic  reforms  in  the  Japanese  navy.  In  beri-beri 
districts  Europeans  should  use  a  diet  rich  in  nitrogenous  ingredients.  In  the 
dietary  of  prisons  and  asylums  the  experience  of  the  Javanese  physicians  with 
reference  to  the  remarkable  diminution  of  the  disease  with  the  use  of  unshelled 
rice  should  be  borne  in  mind.  In  ships,  prisons,  and  asylums  the  disease  has 
rarely  occurred  except  in  connection  with  overcrowding,  an  element  which  pre- 
vailed both  at  the  Eichmond  Asylum  and  at  the  State  Hospital  for  the  Insane 
at  Tuscaloosa. 

Baelz  recommends  in  early  cases  a  free  use  of  the  salicylates,  15  or  20 
grains  four  or  five  times  a  day.  Others  favor  early  free  purgation.  In  very 
severe  acute  cases,  both  Anderson  and  Baelz  advise  blood-letting.  The  more 
chronic  cases  demand,  in  addition  to  dietetic  measures,  drugs  to  support  the 
heart  and  treatment  of  the  atrophied  muscles  with  electricity  and  massage. 


XXVI.    ANTHRAX. 

(Splenic  Fever;  Charbon;  Wool-sorter's  Disease.) 

Definition. — An  acute  infectious  disease  caused  by  Bacillus  anthracis.  It 
is  a  wide-spread  affection  in  animals,  particularly  in  sheep  and  cattle.  In 
man  it  occurs  sporadically  or  as  a  result  of  accidental  inoculations  with  the 
virus. 

Etiology. — The  infectious  agent  is  a  non-motile,  rod-shaped  organism.  Ba- 
cillus anthracis,  which  has,  by  the  researches  of  Pollender,  Davaine,  Koch, 
and  Pasteur,  become  the  best  known  perhaps  of  all  pathogenic  microbes.  The 
bacillus  has  a  length  of  from  2  to  25  /a;  the  rods  are  often  united.  The  bacilli 
themselves  are  readily  destroyed,  but  the  spores  are  very  resistant,  and  sur- 
vive after  prolonged  immersion  in  a  5-per-cent  solution  of  carbolic  acid,  or 
withstand  for  some  minutes  a  temperature  of  212°  Fahr.  They  are  capable 
also  of  resisting  gastric  digestion.  Outside  the  body  the  spores  are  in  all  prob- 
ability very  durable. 

In  Animals. — Geographically  and  zoologically  the  disease  is  the  most 
widespread  of  all  infectious  disorders.  It  is  much  more  prevalent  in  Europe 
and  in  Asia  than  in  America.  Its  ravages  among  the  herds  of  cattle  in  Russia 
and  Siberia,  and  among  sheep  in  certain  parts  of  Europe,  are  not  equalled 
by  any  other  animal  plague.  In  the  United  States  anthrax  is  not  very  wide- 
spread. Mohler,  of  the  Bureau  of  Animal  Industry,  informs  me  that  since 
1900  it  has  been  reported  in  cattle  from  sixteen  States.  It  is  not  very  uncom- 
mon in  Delaware,  New  Jersey,  and  Penns5dvania. 

A  protective  inoculation-  with  a  mitigated  virus  was  introduced  by  Pasteur, 
and  has  been  adopted  in  certain  anthrax  regions.  Mendez  describes  excellent 
results  from  his  antitoxin  (1904). 

The  disease  is  conveyed  sometimes  by  direct  inoculation,  as  by  the  bites 
and  stings  of  insects,  by  feeding  on  carcasses  of  animals  which  have  died  of 
the  disease,  but  more  commonly  by  grazing  in  pastures  in  which  the  germs 
have  been  preserved.  Pasteur  believes  that  the  earthworm  plays  an  impor- 
tant part  in  bringing  to  the  surface  and  distributing  the  bacilli  which  have 


ANTHRAX.  253 

been  propagated  in  the  buried  carcass  of  an  infected  animal.  Certain  jfields, 
or  even  farms,  may  thus  be  infected  for  an  indefinite  period  of  time.  It  seems 
probable,  however,  that  if  the  carcass  is  not  opened  or  the  blood  spilt,  spores 
are  not  formed  in  the  buried  animal  and  the  bacilli  quickly  die. 

In  man  the  disease  does  not  occur  spontaneously.  It  results  always  from 
infection,  either  through  the  skin  or  intestines,  or  in  rare  instances  through 
the  lungs.  Workers  in  wool  and  hair,  and  persons  whose  occupations  bring 
them  into  contact  with  animals  or  animal  products,  as  stablemen,  shepherds, 
tanners,  and  butchers,  are  specially  liable  to  the  disease.  In  Pennsylvania  in 
1897  twelve  tanners  died  of  anthrax.  It  is  rare  in  general  hospital  work. 
There  has  been  only  one  case  in  sixteen  years  at  the  Johns  Hopkins  Hospital. 
In  England  and  Wales  in  1903  there  Avere  17  deaths  from  this  cause  in  man 
(Tatham).  For  the  six  years  1899-1904  there  were  261  cases  of  industrial 
anthrax  reported  to  the  Home  Office;  25.6  per  cent  proved  fatal  (Legge). 

Various  forms  of  the  disease  have  been  described,  and  two  chief  groups 
may  be  recognized:  the  external  anthrax  and  the  internal  anthrax,  of  which 
there  are  pulmonary  and  intestinal  forms. 

Symptoms. — (1)   External  Anthrax. 

(a)  Malignant  Pustule. — The  inoculation  is  usually  on  an  exposed  surface 
— the  hands,  arms,  or  face.  At  the  site  of  inoculation  there  are,  within  a  few 
hours,  itching  and  uneasiness,  and  the  gradual  formation  of  a  small  papule, 
which  soon  becomes  vesicular.  Inflammatory  induration  extends  around  this, 
and  within  thirty-six  hours,  at  the  site  of  inoculation  there  is  a  dark  brownish 
eschar,  at  a  little  distance  from  which  there  may  be  a  series  of  small  vesicles. 
The  brawny  induration  may  be  extreme.  The  oedema  produces  very  great 
swelling  of  the  parts.  The  inflammation  extends  along  the  lymphatics,  and 
the  neighboring  lymph-glands  are  swollen  and  sore.  The  fever  at  first  rises 
rapidly,  and  the  concomitant  phenomena  are  marked.  Subsequently  the  tem- 
perature falls,  and  in  many  cases  becomes  subnormal.  Death  may  take  place 
in  from  three  to  five  days.  In  cases  which  recover  the  constitutional  symptoms 
are  slighter,  the  eschar  gradually  sloughs  out,  and  the  wound  heals.  The  cases 
vary  much  in  severity.  In  the  mildest  form  there  may  be  only  slight  swelling. 
At  the  site  of  inoculation  a  papule  is  formed,  which  rapidly  becomes  vesicular 
and  dries  into  a  scab,  which  separates  in  the  course  of  a  few  days. 

(&)  Malignant  Anthrax  CEdema. — This  form  occurs  in  the  eyelid,  and 
also  in  the  head,  hand,  and  arm,  and  is  characterized  by  the  absence  of  the 
papule  and  vesicle  forms,  and  by  the  most  extensive  oedema,  which  may  follow 
rather  than  precede  the  constitutional  symptoms.  The  oedema  reaches  such  a 
grade  of  intensity  that  gangrene  results,  and  may  involve  a  considerable  sur- 
face. The  constitutional  sym_ptoms  then  become  extremely  grave,  and  the 
cases  invariably  prove  fatal. 

The  greatest  fatality  is  seen  in  cases  of  inoculation  about  the  head  and 
face,  where  the  mortality,  according  to  Nasarow,  is  26  per  cent;  the  least  in 
infection  of  the  lower  extremities,  where  it  is  5  per  cent. 

In  a  case  at  the  Johns  Hopkins  Hospital  in  1895,  in  a  hair-picker,  there 
was  most  extensive  enteritis,  peritonitis,  and  endocarditis,  which  last  lesion 
has  been  described  by  Eppinger. 

A  feature  in  both  these  forms  of  malignant  pustule,  to  which  many  writers 
refer,  is  the  absence  of  feeling  of  distress  or  anxiety  on  the  part  of  the  patient. 


254  SPECIFIC  INFECTIOUS  DISEASES. 

whose  mental  condition  may  be  perfectly  clear.  He  may  be  without  any  appre- 
hension, even  though  the  condition  be  most  critical. 

The  diagnosis  in  most  instances  is  readily  made  from  the  character  of  the 
lesion  and  the  occupation  of  the  patient.  When  in  doubt,  the  examination 
of  the  fluid  from  the  pustule  may  show  the  presence  of  the  anthrax  bacilli. 
Cultures  should  be  made,  or  a  mouse  or  guinea-pig  inoculated  from  the  local 
lesion.  It  is  to  be  remembered  that  the  blood  may  not  show  the  bacilli  in 
numbers  until  shortly  before  death. 

(3)  Internal  Anthrax. 

(a)  Intestinal  Form,  Mycosis  intestinalis. — In  these  cases  the  infection 
usually  is  through  the  stomach  and  intestines,  and  results  from  eating  the 
flesh  or  drinking  the  milk  of  diseased  animals;  it  may,  however,  follow  an 
external  infection  if  the  germs  are  carried  to  the  mouth.  The  symptoms  are 
those  of  intense  poisoning.  The  disease  may  set  in  with  a  chill,  followed  by 
vomiting,  diarrhoea,  moderate  fever,  and  pains  in  the  legs  and  back.  In  acute 
cases  there  are  dyspnoea,  cyanosis,  great  anxiety  and  restlessness,  and  toward 
the  end  convulsions  or  spasms  of  the  muscles.  Haemorrhage  may  occur  from 
the  mucous  membranes.  Occasionally  there  are  on  the  skin  small  phlegmonous 
areas  or  petechiae.  The  spleen  is  enlarged.  The  blood  is  dark  and  remains 
fluid  for  a  long  time  after  death.  Late  in  the  disease  the  bacilli  may  be  found 
in  the  blood. 

This  is  one  of  the  forms  of  acute  poisoning  which  may  affect  many  indi- 
viduals together.  Thus  Butler  and  Karl  Huber  describe  an  epidemic  in  which 
twenty-five  persons  were  attacked  after  eating  the  flesh  of  an  animal  which 
had  had  anthrax.    Six  died  in  from  forty-eight  hours  to  seven  days. 

(h)  Wool-soi-ters  Disease. — This  important  form  of  anthrax  is  found  in 
the  large  establishments  in  which  wool  or  hair  is  sorted  and  cleansed.  The 
hair  and  wool  imported  into  Europe  from  Eussia  and  South  America  appear 
to  have  induced  the  largest  number  of  cases.  Many  of  these  show  no  external 
lesion.  The  infective  material  has  been  swallowed  or  inhaled  with  the 
dust.  There  are  rarely  premonitory  symptoms.  The  patient  is  seized  with 
a  chill,  becomes  faint  and  prostrated,  has  pains  in  the  back  and  legs,  and  the 
temperature  rises  to  102°  or  103°.  The  breathing  is  rapid,  and  he  complains 
of  much  pain  in  the  chest.  There  may  be  a  cough  and  signs  of  bronchitis. 
So  prominent  in  some  instances  are  these  bronchial  s3rmptoms  that  a  pulmo- 
nary form  of  the  disease  has  been  described.  The  pulse  is  feeble  and  very 
rapid.  There  may  be  vomiting,  and  death  may  occur  within  twenty-four  hours 
with  symptoms  of  profound  collapse  and  prostration.  Other  cases  are  more 
protracted,  and  there  may  be  diarrhoea,  delirium,  and  unconsciousness.  The 
cerebral  s}Tnptoms  may  be  most  intense ;  in  at  least  four  cases  the  brain  seems 
to  have  been  chiefly  affected,  and  its  capillaries  stuffed  with  bacilli  (Merkel). 
The  recognition  of  wool-sorter's  disease  as  a  form  of  anthrax  is  due  to  J.  H. 
Bell,  of  Bradford,  England. 

In  certain  instances  these  profound  constitutional  symptoms  of  internal 
anthrax  are  associated  with  the  external  lesions  of  malignant  pustule. 

The  rag-picker's  disease  has  been  made  the  subject  of  an  exhaustive  study 
by  Eppinger  (Die  Hadernkrankheit,  Jena,  1894),  who  has  shown  that  it  is 
a  local  anthrax  of  the  lungs  and  pleura,  with  general  infection. 

The  prophylaxis  is  important,  and  should  be  carried  out  by  a  most  rigid 


HYDROPHOBIA.  255 

disinfection  of  the  hides,  hair,  and  rags  before  they  are  placed  in  the  hands 
of  the  workmen. 

Treatment. — In  malignant  pustule  the  site  of  inoculation  should  be  de- 
stroyed by  the  caustic  or  hot  iron,  and  powdered  bichloride  of  mercury  may 
be  sprinkled  over  the  exposed  surface.  The  local  development  of  the  bacilli 
about  the  site  of  inoculation  may  be  prevented  by  the  subcutaneous  injections 
of  solutions  of  carbolic  acid  or  bichloride  of  mercury.  The  injections  should 
be  made  at  various  points  around  the  pustule,  and  may  be  repeated  two  or 
three  times  a  day.  The  internal  treatment  should  be  confined  to  the  admin- 
istration of  stimulants  and  plenty  of  nutritious  food. 

In  malignant  forms,  particularly  the  intestinal  cases,  little  can  be  done. 
Active  purgatives  may  be  given  at  the  outset,  so  as  to  remove  the  infecting 
material.     Quinine  in  large  doses  has  been  recommended. 

An  antianthrax  serum  has  been  prepared  by  Sclavo,  for  which  good  results 
are  claimed.     (Legge,  Milroy  Lectures,  B.  M.  J.,  March  18,  1905.) 


XXVII.     HYDROPHOBIA. 

(Lyssa;  Kabies.) 

Definition. — An  acute  disease  of  warm-blooded  animals,  dependent  upon 
a  specific  virus,  and  communicated  by  inoculation  to  man. 

Etiology. — Eabies  is  very  variously  distributed.  In  Eussia  it  is  common. 
In  North  Germany  it  is  relatively  rare,  owing  to  the  wise  provision  that  all 
dogs  must  be  muzzled.  In  France  it  is  much  more  common.  In  England  the 
muzzling  order  has  been  followed  by  a  complete  disappearance  of  the  disease. 
There  was  no  death  from  hydrophobia  in  1903.  In  the  decennium  ending 
with  1890  the  deaths  averaged  29  annually  (Tatham).  In  the  United  States 
the  disease  occurs  more  often  than  is  generally  supposed,  as  is  shown  by  the 
number  of  authentic  cases  collected  by  Salmon  [Yearbook  of  the  United  States 
Department  of  Agriculture,  p.  210,  1901]. 

Dogs  are  especially  liable  to  the  disease.  It  also  occurs  in  the  wolf,  the 
cat,  and  the  cow.  Most  animals  are  susceptible;  and  it  is  communicable  by 
inoculation  to  the  rabbit,  horse,  or  pig.  The  disease  is  propagated  chiefly  by 
the  dog,  which  seems  specially  susceptible.  In  the  Western  States  the  skunk 
is  said  to  be  very  liable  to  the  disease.  The  nature  of  the  poison  is  as  yet 
unknown.  It  is  contained  chiefly  in  the  nervous  system  and  is  met  with  in 
some  of  the  secretions,  particularly  in  the  saliva.  Bartarelli  has  shown  that 
the  virus  reaches  the  dog's  salivary  glands  by  way  of  the  nerves  and  not 
through  the  blood-vessels. 

A  variable  time  elapses  between  the  introduction  of  the  virus  and  the 
appearance  of  the  symptoms.  Horsley  states  that  this  depends  upon  the  fol- 
lowing factors:  "  (a)  Age.  The  incubation  is  shorter  in  children  than  in 
adults.  For  obvious  reasons  the  former  are  more  frequently  attacked. 
(&)  Part  infected.  The  rapidity  of  onset  of  the  symptoms  is  greatly  deter- 
mined by  the  part  of  the  body  which  may  happen  to  have  been  bitten.  Wounds 
'about  the  face  and  head  are  especially  dangerous;  next  in  order  in  degrees 
of  mortality  come  bites  on  the  hands,  then  injuries  on  the  other  parts  of  the 
body.    TJiis  relative  order  is,  no  doubt,  greatly  dependent  upon  the  fact  that 


256  SPECIFIC  INFECTIOUS  DISEASES. 

the  face  head  and  hands  are  usually  naked,  while  the  other  parts  are  clothed; 
it  would  also  appear  to  depend  somewhat  upon  the  richness  m  nerves  of  the 
part  (c)  The  extent  and  severity  of  the  wound.  Puncture  wounds  are  the 
most  dangerous;  the  lacerations  "are  fatal  in  proportion  to  the  extent  of 
the.surface  afforded  for  absorption  of  the  virus,  (d)  The  animal  conveymg  the 
infection  In  order  of  decreasing  severity  come :  first,  the  wolf ;  second,  the 
cat ;  third,  the  dog ;  and  fourth,  other  animals."  Ouly  a  limited  number  of 
those  bitten  by  rabid  dogs  become  affected  by  the  disease;  according  to  Hors- 
ley  not  more  than  15  per  cent.  On  the  other  hand,  the  death-rate  of  those 
persons  bitten  by  wolves  is  higher,  not  less  than  40  per  cent.  Babes  gives  the 
mortality  as  from  CO  to  80  per  cent. 

The  incubation  period  in  man  is  extremely  variable.  The  average  is  from 
six  weeks  to  two  months.  In  a  few  cases  it  has  been  under  two  weeks.  It 
may  be  prolonged  to  three  months.  It  is  stated  that  the  incubation  may  be 
prolonged  for  a  year  or  even  two  years,  but  this  has  not  been  definitely  settled. 

Morbid  Anatomy. — The  important  lesions  consist  in  the  accumulation  of 
leucocytes  around  the  blood-vessels  and  the  nerve-cells,  particularly  the  motor 
ganglion  cells,  of  the  central  nervous  system  (rabic  tubercles  of  Babes).  Es- 
pecial importance  in  the  rapid  diagnosis  of  rabies  is  attached  by  van  Gehuch- 
ten  and  jSTelis  to  the  accumulation  of  lymphoid  and  endothelioid  cells  around 
nerve-cells  of  the  sympathetic  and  cerebro-spinal  ganglia.  Negri  has  described 
in  the  central  nervous  system  irregular  bodies  varying  from  4  to  10  microns  in 
size,  widespread,  frequently  in  the  cells  of  the  cerebellum,  cerebral  cortex  and 
pons,  and  in  the  spinal  cord.  They  are  probably  protozoa,  and  it  is  stated  that 
they  furnish  a  rapid  and  trustworthy  means  of  diagnosis.  The  inoculation 
experiments  show  that  the  virus  is  not  present  in  the  liver,  spleen,  or  kidneys, 
but  is  abundant  in  the  spinal  cord,  brain,  and  peripheral  nerves. 

Symptoms. — Three  stages  of  the  disease  are  recognized: 

( 1 )  Premonitoet  stage,  in  which  there  may  be  irritation  about  the  bite, 
pain,  or  numbness.  The  patient  is  depressed  and  melancholy;  and  complains 
of  headache  and  loss  of  appetite.  He  is  very  irritable  and  sleepless,  and  has 
a  constant  sense  of  impending  danger.  There  is  often  greatly  increased  sensi- 
bility. A  bright  light  or  a  loud  voice  is  distressing.  The  larynx  may  be 
injected  and  the  first  symptoms  of  difficulty  in  swallowing  are  experienced. 
The  voice  also  becomes  husky.  There  is  a  slight  rise  in  the  temperature  and 
the  pulse. 

(2)  Stage  of  Excitement. — This  is  characterized  by  great  excitability 
and  restlessness,  and  an  extreme  degree  of  hypersesthesia.  "  Any  afferent 
stimulant — i.  e.,  a  sound  or  a  draught  of  air,  or  the  mere  association  of  a 
verljal  suggestion — will  cause  a  violent  reflex  spasm.  In  man  this  symptom 
constitutes  the  most  distressing  feature  of  the  malady.  The  spasms,  which 
affect  particularly  the  muscles  of  the  larynx  and  mouth,  are  exceedingly  pain- 
ful and  are  accompanied  by  an  intense  sense  of  dyspnoea,  even  when  the  glottis 
is  widely  opened  or  tracheotomy  has  been  performed"  (Horsley).  Any 
attempt  to  take  water  is  followed  by  an  intensely  painful  spasm  of  the  mus- 
cles of  the  larynx  and  of  the  elevators  of  the  hyoid  bone.  It  is  this  which 
makes  the  patient  dread  the  very  sight  of  water  and  gives  the  name  hydro- 
phobia to  the  disease.  These  spasmodic  attacks  may  be  associated  with  mania- 
cal symptoms.     In  the  intervals  between  the  patient  is  quiet  and  the  mind 


HYDROPHOBIA.  257 

unclouded.  The  temperature  in  this  stage  is  usually  elevated  and  may  reach 
from  100°  to  103°.  In  some  instances  the  disease  is  afebrile.  The  patient 
rarely  attempts  to  injure  his  attendants,  and  in  the  intense  spasms  may  be 
particularly  anxious  to  avoid  hurting  any  one.  There  are,  however,  occasional 
fits  of  furious  mania,  and  the  patient  may,  in  the  contractions  of  the  muscles 
of  the  larynx  and  pharynx,  give  utterance  to  odd  sounds.  This  stage  lasts 
from  a  day  and  a  half  to  three  days  and  gradually  passes  into  the — 

(3)  Paralytic  Stage. — In  rodents  the  preliminary  and  furious  stages 
ar«  absent,  as  a  rule,  and  the  paralytic  stage  may  be  marked  from  the  outset 
— the  so-called  dumb  rabies.  This  stage  rarely  lasts  longer  than  from  six  to 
eighteen  hours.  The  patient  then  becomes  quiet ;  the  spasms  no  longer  occur ; 
unconsciousness  gradually  supervenes;  the  heart's  action  becomes  more  and 
more  enfeebled,  and  death  occurs  by  syncope. 

Diagnosis. — In  man  the  diagnosis  offers  no  special  difficulties.  It  is  advis- 
able, in  cases  attended  with  any  doubts,  as  soon  as  possible  after  the  injury 
has  been  inflicted,  to  secure  the  medulla  oblongata  of  the  supposed  rabid  ani- 
mal for  the  purpose  of  inoculating  rabbits.  The  subdural  inoculation  of  rab- 
bits with  a  small  quantity  of  the  central  nervous  system  of  a  rabid  animal 
will  be  followed  by  the  occurrence  of  the  paralytic  form  of  the  disease  in 
from  fifteen  to  twenty  days. 

Treatment. — Prophylaxis  is  of  the  greatest  importance,  and  by  a  system- 
atic muzzling  of  dogs  the  disease  can  be,  as  in  parts  of  Germany,  practically 
eradicated. 

The  bites  should  be  carefully  washed  and  thoroughly  cauterized  with 
caustic  potash  or  concentrated  carbolic  acid.  It  is  best  to  keep  the  wound 
constantly  open  for  at  least  five  or  six  weeks.  When  once-  established  the 
disease  is  hopelessly  incurable.  No  measures  have  been  found  of  the  slightest 
avail,  consequently  the  treatment  must  be  palliative.  The  patient  should  be 
kept  in  a  darkened  room,  in  charge  of  not  more  than  two  attendants.  To 
allay  the  spasm,  chloroform  may  be  administered  and  morphia  given  hypo- 
dermically.  It  is  best  to  use  these  powerful  remedies  from  the  outset,  and 
not  to  temporize  with  chloral,  bromide  of  potassium,  and  other  less  potent 
drugs.  By  the  local  application  of  cocaine,  the  sensitiveness  of  the  throat 
may  be  diminished  sufficiently  to  enable  the  patient  to  take  liquid  nourishment. 
Sometimes  he  can  swallow  readily.    Nutrient  enemata  should  be  administered. 

Peeventive  Inoculation. — Pasteur  has  found  that  the  virus,  when  prop- 
agated through  a  series  of  rabbits,  increases  in  its  virulence;  so  that  whereas 
subdural  inoculation  from  the  brain  of  a  mad  dog  takes  from  fifteen  to  twenty 
days  to  produce  the  disease,  in  successive  inoculation  in  a  series  of  rabbits 
the  incubation  period  is  gradually  reduced  to  seven  days  (virus  fixe).  The 
spinal  cords  of  these  rabbits  contain  the  virus  in  great  intensity,  but  when 
they  are  preserved  in  dry  air  this  gradually  diminishes.  If  now  dogs  are 
inoculated  from  cords  preserved  for  from  twelve  to  fifteen  days,  and  then 
from  cords  preserved  for  a  shorter  period,  i.  e.,  with  a  progressively  stronger 
virus,  they  gradually  acquire  immunity  against  the  disease.  A  dog  treated 
in  this  way  will  resist  inoculation  with  the  virus  fixe,  which  otherwise  would 
inevitably  have  proved  fatal.  Eelying  upon  these  experiments,  Pasteur  began 
inoculations  in  the  human  subject,  using,  on  successive  days,  material  from 
cords  in  which  the  virus  was  of  varying  degrees  of  intensity. 
18 


258  SPECIFIC  INFECTIOUS  DISEASES. 

In  1902  there  were  1,103  persons  treated  at  the  Paris  Pasteur  Institute, 
with  2  deaths;  in  1903  there  were  630  persons  treated,  with  4  deaths,  a 
smaller  number  of  cases  than  ever  before  treated,  among  them  10  foreigners, 
one  from  Great  Britain. 

Pseudo-hydrophobia  (Lyssophobia) . — This  is  a  very  interesting  affection, 
which  may  closely  resemble  hydrophobia,  but  is  really  nothing  more  than  a 
neurotic  or  hysterical  manifestation.  A  nervous  person  bitten  by  a  dog,  either 
rabid  or  supposed  to  be  rabid,  has  within  a  few  months,  or  even  later,  symp- 
toms somewhat  resembling  the  true  disease.  He  is  irritable  and  depressed. 
He  constantly  declares  his  condition  to  be  serious  and  that  he  will  inevitably 
become  mad.  He  may  have  paroxysms  in  which  he  says  he  is  unable  to  drink, 
grasps  at  his  throat,  and  becomes  emotional.  The  temperature  is  not  elevated 
and  the  disease  does  not  progress.  It  lasts  much  longer  than  the  true  rabies, 
and  is  amenable  to  treatment.  It  is  not  improbable  that  a  majority  of  the 
cases  of  alleged  recovery  in  this  disease  have  been  of  this  hysterical  form.  In 
a  ease  which  Burr  reported  from  my  clinic  a  few  5'ears  ago  the  patient  had 
paroxysmal  attacks  in  which  he  could  not  swallow.  He  was  greatly  excited 
and  alarmed  at  the  sight  of  water  and  was  extremely  emotional.  The  symptoms 
lasted  for  a  couple  of  weeks  and  yielded  to  treatment  with  powerful  electrical 
currents. 

XXVIII.     TETANUS. 

(Lockjaw.) 

Definition. — An  infectious  malady  characterized  by  tonic  spasms  of  the 
muscles  with  marked  exacerbations.  The  virus  is  produced  by  a  bacillus  which 
occurs  in  earth,  in  putrefying  fluids,  and  manure,  and  is  a  normal  inhabitant 
of  the  intestines  of  many  ruminants. 

Etiolo^. — It  occurs  as  an  idiopathic  affection  or  follows  trauma.  It  is 
frequent  in  some  localities  and  has  prevailed  extensively  in  epidemic  form 
among  new-born  children,  when  it  is  kno"\va  as  tetanus  or  trismus  neonatorum. 
It  is  more  common  in  hot  than  in  temperate  climates,  and  in  the  colored  than 
in  the  Caucasian  race.  This  is  particularly  the  case  with  tetanus  following 
confinement  and  in  tetanus  neonatorum.  In  certain  of  the  West  Indian 
Islands  more  than  one-half  of  the  mortality  among  the  negro  children  has 
been  due  to  this  cause.  St.  Kilda,  one  of  the  western  Hebrides,  had  been 
scourged  for  years  by  the  "  eight  days'  sickness  "  among  the  new-bom.  Of  125 
children,  84  died  within  fourteen  days  of  birth.  Since  the  discovery  of  the 
bacillus  and  the  introduction  of  proper  methods  of  treating  the  cord  27  chil- 
dren have  been  born,  of  whom  only  one  died  of  the  disease  (G.  IS^.  Turner, 
1908) ,  which  has  now  practically  disappeared.  In  4  majority  of  the  cases  there 
is  an  injury  which  may  be  of  the  most  trifling  character.  It  is  more  common 
after  punctured  and  contused  than  after  incised  wounds,  and  frequently  fol- 
lows those  of  the  hands  and  feet.  The  sjTnptoms  usually  appear  within  two 
weeks  of  the  injury.  In  some  militarj^  campaigns  tetanus  has  prevailed  exten- 
sively, but  in  others,  as  in  the  Civil  War,  the  cases  have  been  comparatively 
few.  ^  The  tetanus  bacillus  has  contaminated  vaccines,  and  its  presence  in  com- 
mercial gelatine  is  a  grave  danger.  Owing  to  the  careless  preparation  of 
the  virus  many  cases  of  tetanus  occurred  in  the  neighborhood  of  Philadelphia 
in  1901  among  vaccinated  children.    In  1902  nineteen  persons  who  had  been 


TETANUS.  259 

inoculated  against  the  plague  in  the  village  of  Mulkowal  died  of  tetanus. 
In  1904  a  remarkable  outbreak  occurred  in  a  general  hospital  in  the  United 
States  in  which  10  cases  died  after  surgical  operation.  In  all  probability  the 
catgut  (which  is  made  from  sheep's  bowels)  was  at  fault.  The  disease  has 
occurred  after  prolonged  use  of  the  hypodermic  needle  to  inject  morphia  or 
quinine;  and  it  has  followed  the  use  of  gelatine  as  a  haemostatic. 

The  infectious  nature  of  tetanus  was  suggested  by  its  endemic  occurrence 
and  from  the  manner  of  its  behavior  in  certain  institutions.  Veterinarians 
have  long  been  of  this  belief,  as  cases  are  apt  to  occur  together  in  horses  in 
one  stable.  On  the  eastern  end  of  Long  Island,  where  formerly  the  disease 
was  very  prevalent,  it  is  now  rarely  seen.  An  extraordinary  number  of  cases 
of  tetanus  have  occurred  in  the  United  States  as  a  result  of  injuries  from  the 
toy  pistols  during  the  4th  of  July  celebration.  The  Journal  of  the  American 
Medical  Association  collected  415  cases  in  1903,  and  began  a  propaganda 
against  the  pistol,  with  the  result  that  the  fatalities  have  been  reduced  to  73 
in  1907  and  76  in  1908 !  There  has  been  a  remarkable  increase  in  the  number 
of  deaths  from  the  disease  in  England  and  Wales  of  late:  348  in  1905,  177  in 
1903,  151  in  1903,  44  in  1901  (Tatham). 

The  Tetanus  Bacillus. — The  observations  of  Eosenbach,  ISTicolaier,  and 
Kitasato  have  demonstrated  that  there  is  in  connection  with  the  disease  a 
specific  organism  which  can  be  isolated  and  cultivated.  Bacillus  tetani  is  a 
slender  rod,  which  may  grow  into  long  threads.  One  end  is  often  swollen  and 
occupied  by  a  spore.  It  is  motile,  grows  at  ordinary  temperatures,  and  is 
anaerobic.  The  bacilli  grow  at  the  site  of  the  wound  (and  do  not  invade  the 
blood  and  organs),  where  alone  the  toxin  is  manufactured,  and  it  travels 
upward  along  the  nerves  (Meyer).  The  antitoxin  passes  along  the  blood 
stream  (Wassermann).  With  small  quantities  of  the  culture  the  disease  may 
be  transmitted  to  animals,  which  die  with  symptoms  of  tetanus.  The  poison 
is  a  tox-albumin  of  extraordinary  potency,  which  has  been  separated  by  Brieger 
and  Cohn  in  a  state  of  tolerable  purity.  It  is  perhaps  the  most  virulent  poison 
known.  Whereas  the  fatal  dose  of  strychnine  for  a  man  weighing  70  kilos  is 
from  30  to  100  milligrammes,  that  of  the  tetanus  toxin  is  estimated  at  0.33 
milligramme.  Every  feature  of  the  disease  can  be  produced  by  it  experimen- 
tally without  the  presence  of  the  bacilli.  The  symptoms  do  not  arise  imme- 
diately, as  in  the  case  of  ordinary  poisons,  but  slowly,  and  it  has  been  suggested 
that  it  acts  only  after  undergoing  some  further  change  in  the  body.  The 
natural  home  of  the  tetanus  bacillus  is  the  soil  and  the  intestinal  canal  of 
herbivorous  animals.  The  disease  can  be  produced  by  inoculating  animals 
with  garden  earth.  A  high  degree  of  antitoxic  immunity  can  be  conferred  on 
animals,  which  then  yield  a  protective  serum.  It  is,  however,  difficult  to  cure 
animals  with  this  serum  on  account  of  the  combination  of  the  toxin  with  nerve- 
cells  by  the  time  symptoms  appear. 

Morbid  Anatomy. — 'Ho  characteristic  lesions  have  been  found  in  the  cord 
or  in  the  brain.  Congestions  occur  in  diiferent  parts,  and  perivascular  exu- 
dations and  granular  changes  in  the  nerve-cells  have  been  found.  The 
condition  of  the  wound  is  variable.  The  nerves  are  often  found  injured,  red- 
dened, and  swollen.  In  the  tetanus  neonatorum  the  umbilicus  may  be  inflamed. 

Symptoms. — After  an  injury  the  disease  sets  in  usually  within  ten  days. 
In  Yandell's  statistics  in  at  least  two-fifths,  and  in  Joseph  Jones's  in  four- 


260  SPECIFIC  INFECTIOUS  DISEASES. 

fifths,  the  symptoms  occurred  before  the  fifteenth  day.  The  patient  complains 
at  first  of  slight  stiffness  in  the  neck,  or  a  feeling  of  tightness  in  the  jaws, 
or  difficulty  in  mastication.  Occasionally  chilly  feelings  or  actual  rigors  may 
precede  these  symptoms.  Gradually  a  tonic  spasm  of  the  muscles  of  these 
parts  produces  the  condition  of  trismus  or  lockjaw.  The  eyebrows  may  be 
raised  and  the  angles  of  the  mouth  drawn  out,  causing  the  so-called  sardonic 
grin — risus  sardonicus.  In  children  the  spasm  may  be  confined  to  these  parts. 
Sometimes  the  attack  is  associated  with  paralysis  of  the  facial  muscles  and 
difficulty  in  swallowing — the  head-tetanus  of  Eose,  which  has  most  commonly 
followed  injuries  in  the  neighborhood  of  the  fifth  nerve.  Gradually  the  pro- 
cess extends  and  involves  the  muscles  of  the  body.  Those  of  the  back  are 
most  affected,  so  that  during  the  spasm  the  unfortunate  victim  may  rest  upon 
the  head  and  heels — a  position  known  as  opisthotonos.  The  rectus  abdom- 
inis muscle  has  been  torn  across  in  the  spasm.  The  entire  trunk  and  limbs 
may  be  perfectly  rigid — orthotonos.  Flexion  to  one  side  is  less  common — 
pleurothotonos ;  while  spasm  of  the  muscles  of  the  abdomen  may  cause  the 
body  to  be  bent  forward — emprosthotonos.  In  very  violent  attacks  the  thorax 
is  compressed,  the  respirations  are  rapid,  and  spasm  of  the  glottis  may  occur, 
causing  asphyxia.  The  paroxysms  last  for  a  variable  period,  but  even  in  the 
intervals  the  relaxation  is  not  complete.  The  slightest  irritation  is  sufficient 
to  cause  a  spasm.  The  paroxysms  are  associated  with  agonizing  pain,  and  the 
patient  may  be  held  as  in  a  vise,  unable  to  utter  a  word.  Usually  he  is  bathed 
in  a  profuse  sweat.  The  temperature  may  remain  normal  throughout,  or  show 
only  a  slight  elevation  toward  the  close.  In  other  cases  the  pyrexia  is  marked 
from  the  outset;  the  temperature  reaches  105°  or  106°,  and  before  death  109° 
or  110°.  In  rare  instances  it  may  go  still  higher.  Death  either  occurs  during 
the  paroxysm  from  heart-failure  or  asphyxia,  or  is  due  to  exhaustion. 

The  cephalic  tetanus  {Kopftetanus  of  Eose)  originates  usually  from  a 
wound  on  one  side  of  the  head,  and  is  characterized  by  stiffness  of  the  muscles 
of  the  jaw  and  paralysis  of  the  facial  muscles  on  the  same  side  as  the  wound, 
with  difficulty  in  swallowing.  The  prognosis  is  good  in  the  chronic  cases; 
of  those  in  Willard's  table  only  8  of  32  died;  but  in  the  acute  form,  of  45 
cases,  only  4  recovered. 

Diagnosis. — Well-marked  cases  following  a  trauma  could  not  be  mis- 
taken for  any  other  disease.  The  spasms  are  not  unlike  those  of  strychnia- 
poisoning,  and  in  the  celebrated  Palmer  murder  trial  this  was  the  plea  for 
the  defence.  The  jaw-muscles,  however,  are  never  involved  early,  if  at  all, 
and  between  the  paroxysms  in  strychnia-poisoning  there  is  no  rigidity.  In 
tetany  the  distribution  of  the  spasm  at  the  extremities,  the  peculiar  position, 
the  greater  involvement  of  the  hands,  and  the  condition  under  which  it  occurs, 
are  sufficient  to  make  the  diagnosis  clear.  In  doubtful  cases  cultures  should 
be  made  from  the  pus  of  the  wound. 

Escherich  has  described  in  children  a  form  of  generalized  tonic  contrac- 
tures of  the  muscles  of  the  jaw,  neck,  back,  and  limbs,  usually  a  sequel  of 
some  acute  infection,  occasionally  occurring  as  an  independent  malady.  The 
contractures  may  be  either  intermittent  or  persistent.  The  condition  may  last 
from  a  week  to  a  couple  of  months.    The  eases  as  a  rule  recover. 

Prognosis. — Two  of  the  Hippocratic  aphorisms  express  tersely  the  general 
prognosis  even  at  the  present  day :  "  The  spasm  supervening  on  a  wound  is 


GLANDERS.  "  261 

fatal,"  and  "such  persons  as  are  seized  with  tetanus  die  within  four  days, 
or  if  they  pass  these  they  recover." 

The  mortality  in  the  traumatic  cases  is  not  less  than  80  per  cent  (Con- 
ner) ;  in  the  idiopathic  cases  it  is  under  50  per  cent.  According  to  Yandell, 
the  mortality  is  greatest  in  children.  Favorable  indications  are:  late  onset 
of  the  attack,  localization  of  the  spasms  to  the  muscles  of  the  neck  and  jaw, 
and  an  absence  of  fever. 

Treatment. — Local  treatment  of  -the  wound  is  essential,  as  the  poison  is 
manufactured  here.  Tizzoni  advises  nitrate  of  silver  as  the  best  germicide 
for  the  tetanus  bacillus.  Thorough  excision  and  antiseptic  treatment  should 
be  carried  out,  and  the  serum  applied  locally.  It  should  also  be  used  as  a 
prophylactic  in  suspicious  wounds  of  gardeners  and  stable  men.  The  patient 
should  be  kept  in  a  darkened  room,  absolutely  quiet,  and  attended  by  only  one 
person.  All  possible  sources  of  irritation  should  be  avoided.  Veterinarians 
appreciate  the  importance  of  this  complete  seclusion  in  treating  horses. 

When  the  lockjaw  is  extreme  the  patient  may  not  be  able  to  take  food  by 
the  mouth,  under  which  circumstances  it  is  best  to  use  rectal  injections,  or 
to  feed  by  a  catheter  passed  through  the  nose.  The  spasm  should  be  controlled 
by  chloroform,  which  may  be  repeatedly  exhibited  at  intervals.  It  is  more 
satisfactory  to  keep  the  patient  thoroughly  under  the  influence  of  morphia 
given  hypodermically.  Chloral  hydrate,  bromide  of  potassium.  Calabar  bean, 
curara,  Indian  hemp,  belladonna,  and  other  drugs  have  been  recommended, 
and  recovery  occasionally  follows  their  use.  Resection  of  the  nerve  and 
amputation  of  the  limb  have  been  advised.  Although  tetanus  antitoxin  of 
great  strength  can  be  obtained,  its  use  in  the  treatment  of  human  tetanus 
has  been  disappointing.  The  best  results  are  obtained  in  the  subacute  cases, 
but  here  the  prognosis  is  relatively  favorable  even  with  other  methods  of 
treatment.  There  may  be  occasion  for  the  prophylactic  use  of  the  antitoxin 
in  man,  as  already  successfully  practised  in  arresting  the  spread  of  the  disease 
in  horses  occupying  infected  stables.  Of  the  antitoxic  serum  20  to  30  cc.  may 
be  used  for  the  first  dose  and  15  to  20  cc.  every  five  or  ten  hours  after.  Tiz- 
zoni advises  2.25  grammes  of  his  antitoxin  for  the  first  dose  and  0.6  grammes 
for  subsequent  doses, 

XXIX.     GLANDERS  (Farcy). 

Definition. — An  infectious  disease  of  the  horse,  caused  by  Bacillus  mal- 
lei, communicated  occasionally  to  man.  In  the  horse  it  is  characterized  by  the 
formation  of  nodules,  chiefly  in  the  nares  (glanders),  and  beneath  the  skin 
(farcy). 

Etiology. — The  disease  belongs  to  the  infective  granulomata.  The  local 
manifestations  in  the  nostrils  and  the  skin  of  the  horse  are  due  to  one  and 
the  same  cause.  The  specific  germ  was  discovered  by  Loeffler  and  Schutz. 
It  is  a  short,  non-motile  bacillus,  not  unlike  that  of  tubercle,  but  exhibits  dif- 
ferent staining  reactions.  It  grows  readily  on  the  ordinary  culture  media. 
For  the  full  recognition  of  glanders  in  man  we  are  indebted  to  the  labors  of 
Eayer,  whose  monograph  remains  one  of  the  best  descriptions  ever  given  of 
the  disease.  Man  becomes  infected  by  contact  with  diseased  animals,  and 
usually  by  inoculation  on  an  abraded  surface  of  the  skin.    The  contagion  may 


262  SPECIFIC  INFECTIOUS  DISEASES. 

also  be  received  on  the  mucous  membrane.  In  a  Montreal  case  a  gentleman 
was  probably  infected  by  the  material  expelled  from  the  nostril  of  his  horse, 
which  was  not  suspected  of  having  the  disease.  It  is  a  rare  disease.  Only  6 
deaths  were  registered  from  this  cause  in  England  and  Wales  in  1903.  Among 
laboratory  workers  the  Bacillus  mallei  has  caused  more  deaths  than  any  other 
germ,  and  in  working  with  it  the  greatest  possible  precautions  should  be  taken. 

Morbid  Anatomy. — As  in  the  horse,  the  disease  may  be  localized  in  the 
nose  (glanders)  or  beneath  the  sldn  (f'arcy).  The  essential  lesion  is  the 
granulomatous  tumor,  characterized  by  the  presence  of  numerous  lymphoid 
and  epithelioid  cells,  among  and  in  which  are  seen  the  glanders  bacilli.  These 
nodular  masses  tend  to  break  do^vn  rapidly,  and  on  the  mucous  membrane 
result  in  ulcers,  while  beneath  the  skin  they  form  abscesses.  The  glanders  nod- 
ules may  also  occur  in  the  internal  organs. 

Symptoms. — An  acute  and  a  chronic  form  of  glanders  may  be  recognized 
in  man,  and  an  acute  and  a  chronic  form  of  ioxcj. 

Acute  Glaxders. — The  period  of  incubation  is  rarely  more  than  three  or 
four  days.  There  are  signs  of  general  febrile  disturbance.  At  the  site  of 
infection  there  are  swelling,  redness,  and  hinphangitis.  Within  two  or  three 
days  there  is  involvement  of  the  mucous  membrane  of  the  nose,  the  nodules 
break  down  rapidly  to  ulcers,  and  there  is  a  muco-purulent  discharge.  An 
eruption  of  papules,  which  rapidly  become  pustules,  breaks  out  over  the  face 
and  about  the  joints.  It  has  been  mistaken  for  variola.  In  a  Montreal  case 
this  copious  eruption  led  the  attending  physician  to  suspect  small-pox,  and 
the  patient  was  isolated.  There  is  great  swelling  of  the  nose.  The  ulceration 
may  go  on  to  necrosis,  in  which  case  the  discharge  is  very  offensive.  The 
hinph-glands  of  the  neck  are  usually  much  enlarged.  Subacute  pneumonia  is 
very  apt  to  occur.  This  form  runs  its  course  in  about  eight  or  ten  da3'S,  and 
is  invariably  fatal.  Glanders  pneumonia  ma}"  appear  after  subcutaneous  infec- 
tion (one  case  from  infection  with  hj-podermic  s3Tinge  stuck  into  thumb). 
Grossly  the  lung  appeared  like  a  caseous  pneumonia. 

Chronic  glaxders  is  rare  and  difficult  to  diagnose,  as  it  is  usually  mis- 
taken for  a  chronic  cor3'za.  There  are  ulcers  in  the  nose,  and  often  laryn- 
geal symptoms.  It  may  last  for  months,  or  even  longer,  and  recovery  some- 
times takes  place.  Tedeschi  has  described  a  case  of  chronic  osteomj^elitis,  due 
to  the  bacillus  mallei,  which  was  followed  by  a  fatal  glanders  meningitis. 
The  diagnosis  may  be  extremely  difficult.  In  such  cases  a  suspension  of  the 
secretion,  or  of  cultures  upon  agar-agar  made  from  the  secretion,  should  be 
injected  into  the  peritoneal  cavity  of  a  male  guinea-pig.  At  the  end  of  two 
days,  in  positive  cases,  the  testicles  are  found  to  be  swollen  and  the  skin  of 
the  scrotum  reddened.  The  testicles  continue  to  increase  in  size,  and  finally 
suppurate.  Death  takes  place  after  the  lapse  of  two  or  three  weeks,  and  gen- 
eralized glanders  nodules  are  found  in  the  viscera.  The  use  of  mallein  for 
diagnostic  purposes  is  highly  recommended.  The  principles  and  methods  of 
application  are  the  same  as  for  tuberculin.  McFadyean  and  others  have  shown 
that  while  the  glanders  bacilli  are  agglutinated  in  a  dilution  of  1  to  200  by 
normal  horse  serum,  that  of  a  glanders  horse  will  agglutinate  at  1  to  1,000. 
The  test  must  be  made  before  maUein  is  given. 

Acute  farcy  in  man  results  usually  from  the  inoculation  of  the  virus  into 
the  skin.     There  is  an  intense  local  reaction  with  a  phlegmonous  inflamma- 


ACTINOMYCOSIS.  263 

tion.  The  lymphatics  are  early  affected,  and  along  their  course  there  are  nod- 
ular subcutaneous  enlargements,  the  so-called  farcy  buds,  which  may  rapidly 
go  on  to  suppuration.  There  are  pains  and  swelling  in  the  joints,  and  abscesses 
may  form  in  the  muscles.  The  symptoms  are  those  of  an  acute  infection, 
almost  like  an  acute  septicaemia.  The  nose  is  not  involved  and  the  superficial 
skin  eruption  is  not  common.  The  bacilli  have  been  found  in  the  urine  in 
acute  cases  in  man  and  animals. 

The  disease  is  fatal  in  a  large  proportion  of  the  cases,  usually  in  from 
twelve  to  fifteen  days. 

Cheonic  farcy  is  characterized  by  the  presence  of  localized  tumors,  usu- 
ally in  the  extremities.  These  tumors  break  down  into  abscesses,  and  some- 
times form  deep  ulcers,  without  much  inflammatory  reaction  and  without 
special  involvement  of  the  lymphatics.  The  disease  may  last  for  months  or 
even  years.  Death  may  result  from  pyaemia,  or  occasionally  acute  glanders 
develops.    The  celebrated  French  veterinarian  Bouley  had  it  and  recovered. 

The  disease  is  transmissible  also  from  man  to  man.  Washerwomen  have 
been  infected  from  the  clothes  of  a  patient.  In  the  diagnosis  of  this  affec- 
tion the  occupation  is  very  important.  ISTowadays,  in  cases  of  doubt  the  inocu- 
lation should  be  made  in  animals,  as  in  this  way  the  disease  can  be  readily 
determined.  Mallein,  a  product  of  the  growth  of  the  bacilli,  is  now  used  for 
the  purpose  of  diagnosing  glanders  in  animals.  Several  instances  of  cured 
glanders  have  been  reported  in  animals  treated  with  small  and  repeated  doses 
of  mallein  (Pilavios,  Babes). 

Treatment. — If  seen  early,  the  wound  should  be  either  cut  out  or  thor- 
oughly destroyed  by  caustics  and  an  antiseptic  dressing  applied.  The  farcy 
buds  should  be  early  opened.  In  the  acute  cases  there  is  very  little  hope.  In 
the  chronic  cases  recovery  is  possible,  though  often  tedious. 


XXX.    ACTINOMYCOSIS. 

Definition. — A  chronic  infective  disorder  produced  by  the  actinomyces  or 
ray-fungus,  Streptothrix  actinomyces. 

Etiology. — The  disease  is  widespread  among  cattle,  and  occurs  also  in  the 
pig.  It  was  first  described  by  Bollinger  in  the  ox,  in  which  it  forms  the  affec- 
tion known  in  this  country  as  "  big-jaw."  The  first  accurate  description 
of  the  disease  in  man  was  given  by  James  Israel,  and  subsequently  Ponfick 
insisted  upon  the  identity  of  the  disease  in  man  and  cattle. 

In  the  United  States  and  England  the  disease  is  less  common  than  in  Ger- 
many. In  1902  Erving  collected  100  cases  in  America.  It  is  nearly  three 
times  as  common  in  men  as  in  women. 

The  parasite  belongs  probably  to  the  StreptotJirix  group  of  bacteria.  In 
both  man  and  cattle  it  can  be  seen  in  the  pus  from  the  affected  region  as  yel- 
lowish or  opaque  granules  from  one-half  to  two  millimetres  in  diameter,  which 
are  made  up  of  cocci  and  radiating  threads,  which  present  bulbous,  club-like 
terminations.  The  youngest  granules  are  gray  in  color  and  semi-translucent; 
in  these  the  bulbous  extremities  are  wanting. 

The  parasite  has  been  successfully  cultivated,  and  the  disease  has  been 
inoculated  both  with  the  natural  and  artificially  grown  organism. 


264  SPECIFIC  INFECTIOUS  DISEASES. 

The  Mode  .of  Infection.— There  is  no  evidence  of  direct  infection  with  the 
flesh  or  milk  of  diseased  animals.  The  streptothrix  has  not  been  detected  out- 
side the  body.  It  seems  highly  probable  that  it  is  taken  in  with  the  food.  The 
site  of  infection  in  a  majority  of  cases  in  man  and  animals  is  in  the  mouth 
or  neighboring  passages.  In  the  cow,  possibly  also  in  man,  barley,  oats,  and 
rye  have  been  carriers  of  the  germ. 

Morbid  Anatomy.— As  in  tubercle,  the  first  effect  is  the  destruction  of 
adjacent  cells  and  the  attraction  of  leucocytes— later  the  surrounding  cells 
begin  to  proliferate.  After  the  tumor  reaches  a  certain  size  there  is  great 
proliferation  of  the  surrounding  connective  tissue,  and  the  growth  may,  par- 
ticularly in  the  jaw,  look  like,  and  was  long  mistaken  for,  osteo-sarcoma. 
Finally  suppuration  occurs,  which  in  man,  according  to  Israel,  may  be  pro- 
duced directly  by  the  streptothrix  itself. 

Clinical  Forms. — (a)  Digestive  Tract. — Israel  is  said  to  have  found 
the  fungus  in  the  cavities  of  carious  teeth.  The  jaw  has  been  affected  in  a 
number  of  cases  in  man.  The  patient  comes  under  observation  with  swelling 
of  one  side  of  the  face,  or  with  a  chronic  enlargement  of  the  jaw  which  may 
simulate  sarcoma. 

The  tongue  has  been  involved  in  several  cases,  showing  small  growths, 
either  primary  or  following  disease  of  the  jaw.  In  the  intestines  the  dis- 
ease may  occur  either  as  a  primary  or  secondary  affection.  Cases  have  been 
reported  of  pericgecal  abscess  due  to  the  germ.  An  actinomycotic  appendi- 
citis has  been  described;  primary  actinomycosis  of  the  large  intestine  with 
metastases  has  also  been  found.  Eansom  has  found  the  actinomyces  in  the 
stools.  Actinomycotic  peritonitis  due  to  infection  through  a  gastrostomy 
wound  has  been  described.  Actinomycosis  of  the  liver  is  rare.  Auvray  in 
1903  could  only  collect  31  cases  (Eolleston).  It  forms  a  most  characteristic 
lesion — an  alveolar  honey-combed  abscess — like  a  sponge  soaked  in  pus.  It 
is  usually  secondary  to  an  intestinal  lesion,  but  in  a  few  cases  no  other  focus 
has  been  found, 

(h)  Pulmonary  Actinomycosis. — In  September,  1878,  James  Israel  de- 
scribed a  remarkable  mycotic  disease  of  the  lungs,  which  subsequent  observa- 
tion showed  to  be  the  affection  described  the  year  before  by  Bollinger  in  cattle. 
Since  that  date  many  instances  have  been  reported  in  which  the  lungs  were 
affected.  It  is  a  chronic  infectious  pulmonary  disorder,  characterized  by 
cough,  fever,  wasting,  and  a  muco-purulent,  sometimes  foetid,  expectoration. 
The  lesions  are  unilateral  in  a  majority  of  the  cases.  Hodenpyl  classifies  them 
in  three  groups:  (1)  Lesions  of  chronic  bronchitis;  the  diagnosis  has  been 
made  by  the  presence  of  the  actinomyces  in  the  sputum.  (2)  Miliary  actino- 
mycosis, closely  resembling  miliary  tubercle,  but  the  nodules  are  seen  to  be 
made  up  of  groups  of  fungi,  surrounded  by  granulation  tissue.  This  form  of 
pulmonary  actinomycosis  is  not  infrequent  in  oxen  with  advanced  disease  of 
the  jaw  or  adjacent  structures.  (3)  The  cases  in  which  there  is  more  exten- 
sive destructive  disease  of  the  lungs,  broncho-pneumonia,  interstitial  changes, 
and  abscesses,  the  latter  forming  cavities  large  enough  to  be  diagnosed  during 
life.  Actinomycotic  lesions  of  other  organs  are  often  present  in  connection 
with  the  pulmonary  disease;  erosion  of  the  vertebrae,  necrosis  of  the  ribs  and 
sternum,  with  node-like  formations,  subcutaneous  abscesses,  and  occasionally 
metastases  in  all  parts  of  the  body. 


SYPHILIS.  265 

(c)  Cutaneous  Actinomycosis. — In  several  instances  in  connection  with 
chronic  ulcerative  diseases  of  the  skin  the  ray-fungus  has  been  found.  It  is 
a  very  chronic  affection  resembling  tuberculosis  of  the  skin,  associated  with 
the  growth  of  tumors  which  suppurate  and  leave  open  sores,  which  may  remain 
for  years. 

(d)  Cerebral  Actinomycosis. — Bollinger  has  reported  an  instance  of 
primary  disease  of  the  brain.  The  symptoms  were  those  of  tumor.  A  second 
remarkable  case  has  been  reported  by  Gamgee  and  Delepine.  The  patient  was 
admitted  to  St.  George's  Hospital  with  left-sided  pleural  effusion.  At  the 
post  mortem  three  pints  of  purulent  fluid  were  found  in  the  left  pleura ;  there 
was  an  actinomycotic  abscess  of  the  liver,  and  in  the  brain  there  were  abscesses 
in  the  frontal,  parietal,  and  temporo-sphenoidal  lobes  which  contained  the 
mycelium,  but  no  clubs.  A  third  case,  reported  by  0.  B.  Keller,  had  empyema 
necessitatis,  which  was  opened  and  actinomycetes  were  found  in  the  pus.  Sub- 
sequently she  had  Jacksonian  epilepsy,  for  which  she  was  trephined  twice  and 
abscesses  opened,  which  contained  actinomyces  grains.  Death  occurred  after 
the  second  operation. 

Symptoms. — The  fever  is  of  an  irregular  type  and  depends  largely  on  the 
existence  of  suppuration.  The  cough  is  an  important  symptom,  and  the  diag- 
nosis in  18  of  the  cases  was  made  during  life  by  the  discovery  of  the  actino- 
myces. Death  results  usually  with  septic  symptoms.  Occasionally  there  is  a 
condition  simulating  typhoid  fever.  The  average  duration  of  the  disease  was 
ten  months.  Eecovery  is  very  rare.  Clinically  the  disease  closely  resembles 
certain  forms  of  pulmonary  tuberculosis  and  of  foetid  bronchitis.  It  is  not 
to  be  forgotten  in  the  examination  of  the  sputum  that,  as  Bizzozero  mentions, 
certain  degenerated  epithelial  cells  may  be  mistaken  for  the  organism.  The 
radiating  leptothrix  threads  about  the  epithelium  of  the  mouth  sometimes 
present  a  striking  resemblance. 

Diagnosis. — The  disease  is  in  reality  a  chronic  pyaemia.  The  only  test  is 
the  presence  of  the  actinomyces  in  the  pus.  Metastases  may  occur  as  in  pyae- 
mia and  in  tumors.  The  tendency,  however,  is  rather  to  the  production  of 
a  local  purulent  affection  which  erodes  the  bones  and  is  very  destructive. 

Treatment. — This  is  largely  surgical  and  is  practically  that  of  pyaemia. 
Incision  of  the  abscess,  removal  of  the  dead  bone,  and  thorough  irrigation 
are  appropriate  measures.  Thomassen  has  recommended  iodide  of  potassium, 
which,  in  doses  of  from  40  to  60  grains  daily,  has  proved  curative  in  a  number 
of  recent  cases. 

XXXI.    SYPHILIS. 

Definition. — A  specific  disease  of  slow  evolution,  caused  by  the  Spirochceta 
pallida,  propagated  by  inoculation  (acquired  syphilis)  or  by  hereditary  trans- 
mission (congenital  syphilis). 

I.  General  Etiology  and  Morbid  Anatomy. 

Since  the  sixth  edition  of  this  work  appeared  there  have  been  three  remark- 
able advances  in  our  knowledge  of  syphilis — the  discovery  of  the  germ,  the 
transmission  of  the  disease  to  apes,  and  the  serum  diagnosis  of  the  disease. 
19 


266  SPECIFIC  INFECTIOUS  DISEASES. 

The  Spirochceta  pallida,  discovered  by  Schaudinn,  a  spirally  curved  organ- 
ism from  10  to  15  /A  in  length,  is  found  in  primary,  secondary  and  tertiary 
lesions,  and  may  be  inoculated  successfully  into  apes,  monkeys,  and  rabbits.  It 
is  believed  to  be  a  protozoan,  but  it  has  not  yet  been  cultivated.  In  the  con- 
genital lesions  it  is  present  in  extraordinary  numbers. 

Modes  of  Infection. —  (1)  In  a  large  majority  of  all  cases  the  disease  is 
transmitted  by  sexual  congress,  but  the  designation  venereal  disease  {lues 
venerea)  is  not  always  correct,  as  there  are  many  other  modes  of  inoculation. 
In  the  St.  Louis  collection  there  are  illustrations  of  26  varieties  of  extra- 
genital chancres. 

(2)  Accidental  Infection. — In  surgical  and  in  midwifery  practice  physi- 
cians are  not  infrequently  inoculated.  General  infection  may  occur  without 
a  characteristic  local  sore.  Midwifery  chancres  are  usually  on  the  fingers, 
but  they  may  be  on  the  back  of  the  hand.  The  lip  chancre  is  the  most  com- 
mon of  these  erratic  or  extra-genital  forms,  and  may  be  acquired  in  many  ways 
apart  from  direct  infection.  Mouth  and  tonsillar  sores  result  as  a  rule  from 
improper  practices.  Wet-nurses  are  sometimes  infected  on  the  nipple,  and  it 
occasionally  happens  that  relatives  of  a  syphilitic  child  are  accidentally  con- 
taminated. 

(3)  Hereditary  Transmission. — This  is  most  common  from  (a)  the  father, 
the  mother  being  healthy  (sperm  inheritance).  S.  pallida  has  not  yet  been 
found  in  the  sperm  cell,  but  we  do  not  know  its  life  phases,  and  from  what  we  do 
know  of  the  history  of  syphilis,  it  seems  probable  that  all  the  sperms  cells  are  in- 
fective. A  syphilitic  father  may  beget  an  apparently  healthy  child,  even  when 
the  disease  is  fresh  and  full-blown.  On  the  other  hand,  in  very  rare  instances,  a 
man  may  have  had  syphilis  when  young,  undergo  treatment,  and  for  years 
present  no  signs  of  disease,  and  yet  his  first-born  may  show  very  characteristic 
lesions.  The  closer  the  begetting  to  the  primary  sore,  the  greater  the  chance 
of  infection.  A  man  with  tertiary  lesions  may  beget  healthy  children.  As  a 
general  rule  it  may  be  said  that  with  judicious  treatment  the  transmissive 
power  rarely  exceeds  three  or  four  years. 

(&)  Maternal  transmission  (germ  inheritance).  While  the  father  may 
not  be  affected,  in  a  large  number  of  instances  both  parents  are  diseased,  the 
one  having  infected  the  other,  in  which  case  the  chances  of  foetal  infection  are 
greatly  increased.  Heredity  through  the  mother  alone  is  much  more  fatal  to 
the  offspring  than  paternal  heredity.  It  is  a  remarkable  and  interesting  fact 
that  a  woman  who  has  borne  a  syphilitic  child  is  herself  immune,  and  can  not 
be  infected,  though  she  may  present  no  signs  of  the  disease.  This  is  known 
as  Beaumes'  or  Colles'  law,  and  was  thus  stated  by  the  distinguished  Dublin 
surgeon :  "  That  a  child  born  of  a  mother  who  is  without  obvious  venereal 
symptoms,  and  which,  without  being  exposed  to  any  infection  subsequent 
to  its  birth,  shows  this  disease  when  a  few  weeks  old,  this  child  will  infect  the 
most  healthy  nurse,  whether  she  suckle  it,  or  merely  handle  and  dress  it ;  and 
yet  this  child  is  never  Imown  to  infect  its  own  mother,  even  though  she  suckle 
it  while  it  has  venereal  ulcers  of  the  lips  and  tongue."  In  a  majority  of  these 
cases  the  mother  has  received  a  sort  of  protective  inoculation,  without  having 
had  actual  manifestations  of  the  disease.  A  child  showing  no  taint,  but  born 
of  a  woman  suffering  with  syphilis  may  with  impunity  be  suckled  by  its  mother 
(Prof eta's  law). 


SYPHILIS.  267 

(:c)  Placental  transmission.  The  mother  may  be  infected  after  concep- 
tion, in  which  case  the  child  may  be,  but  is  not  necessarily,  born  syphilitic. 
If  the  infection  is  late  in  pregnancy,  after  the  seventh  month,  the  child  usually 
escapes. 

Morbid  Anatomy.— The  primary  lesion,  or  chancre,  shows:  (a)  A  diffuse 
infiltration  of  the  connective  tissue  with  small,  round  cells.  (&)  Larger  epi- 
thelioid cells,  (c)  Giant  cells,  (d)  Changes  in  the  small  arteries  and  veins, 
chiefly  thickening  of.  the  intima,  and  alterations  in  the  nerve-fibres  going  to  the 
part.  The  sclerosis  is  due  in  part  to  this  acute  obliterative  endarteritis.  Asso- 
ciated with  the  initial  lesions  are  changes  in  the  adjacent  lymph-glands,  which 
undergo  hyperplasia,  and  finally  become  indurated. 

The  secondary  lesions  of  syphilis  are  too  varied  for  description  here.  They 
consist  of  condylomata,  skin  Eruptions,  affections  of  the  eye,  etc. 

The  tertiary  lesions  consist  of  circumscribed  tumors  known  as  gummata, 
various  skin  lesions,  and  a  special  type  of  arteritis. 

Gummata. — Syphilomata  occur  in  the  bones  or  periosteum—here  they  are 
called  nodes — in  the  muscles,  skin,  brain,  lung,  liver,  kidneys,  heart,  testes, 
and  adrenals.  They  vary  in  size  from  small,  almost  microscopic  bodies  to 
large  solid  tumors  from  3  to  5  cm.  in  diameter.  They  are  usually  firm  and 
hard,  but  in  the  skin  and  on  the  mucous  membranes  they  tend  to  break  down 
rapidly  and  ulcerate.  On  cross-section  a  medium-sized  gumma  has  a  grayish- 
white,  homogeneous- appearance,  presenting  in  the  centre  a  firm,  caseous  sub- 
stance, and  at  the  periphery  a  translucent,  fibrous  tissue.  Often  there;  are 
groups  of  three  or  more  surrounded  by  dense  sclerotic  tissue. 

The  arteritis  will  be  considered  in  a  separate  section. 

~  II.  Acquired  Syphilis. 

Primary  Stage. — This  extends  from  the  appearance  of  the  initial  sore  until 
the  onset  of  the  constitutional  symptoms,. and  has  a  variable  duration  of  from 
six  to  twelve  weeks!  The  initial  sore  appears  within  a  month  after  inocula- 
tion, and  it  first  shows  itself  as  a  small  red  papule,  which  gradually  enlarges 
and  breaks  in  the  centre,  leaving  a  small  ulcer.  The  tissue  about  this  becomes 
indurated  so  that  it  ultimately'  has  a  gristly,  cartilaginous  consistence — ^hence 
the  name,  hard  or  indurated  chancre.  The  size  attained  is  variable,  and  when 
small  the  sore:  may  be  overlooked,  particularly  if  it  is:  just  within  the  urethra. 
The  glands  in  the  lymph-district  of  the  chancre  enlarge  and  become  hard. 
Suppuration  both  in  the  initiallesion  and  in  the  glands  may  occur  as  a  sec- 
ondary change.  The_  general  condition  of  the  patient  in  this  stage  is  good. 
There  may  be  no  fever  and  no  impairment  of  health.  - 

Secondary  Stage,^ — The  first  constitutional  symptoms. are  usually  mani- 
.fested  within  three  months  of  Ithe  appearance  of  the  primary  sore.  They 
rarely  occur  earlier  than  the  sixth  or  later  than  the  twelfth  week: 

(a)  ^ei;er,  slight  or. inten.se>  and  very  variable  in  character,  may  occur 
early  before  the  skin  rash';  more  frequently  it  is  the  "fever  of  invasion"  with 
the  secondary  symptoms,  or  the  fever  may  occur  at  any  period.  It  may  be  a 
mild  continuous  pyrexia,  in  other  instances,  with  marked  remissions,  but  the 
most  remarkable  form  is  the  intermittent,  often  mistaken  for  malaria.  Such 
cases  have  been  reported  by  Yeo  and  by  Sidney  Phillips:.    .The  fever  may  reach 


268  SPECIFIC  INFECTIOUS  DISEASES. 

105°  and  the  paroxysms  persist  for  months.  We  have  had  several  cases  in 
which  typhoid  fever  was  suspected  (T.  B.  Futcher,  Kew  York  Medical  Jour- 
nal, 1901),  and  in  others  tuberculosis. 

(&)  AncEmia.— In  many  cases  the  syphilitic  poison  causes  a  pronounced 
anjemia  which  gives  to  the  face  a  muddy  pallor,  and  there  may  even  be  a 
light-yellow  tinging  of  the  conjunctivae  or  of  the  skin,  a  hsematogenous 
icterus.  This  syphilitic  cachexia  may  in  some  instances  be  extreme.  The  red 
blood-corpuscles  do  not  show  any  special  alterations.  The  blood-count  may 
fall  to  three  millions  per  cubic  millimetre,  or  even  lower.  The  anaemia  may 
come  on  suddenly.  In  a  case  of  s}T)hilitie  arthritis  in  a  young  girl,  following 
three  or  four  inunctions  of  mercury,  the  blood-count  fell  below  two  millions 
per  cubic  millimetre  in  a  few  days. 

(c)  Cutaneous  Lesions. — The  earliest  and  most  common  is  a  macular 
syphilide  or  syphilitic  roseola,  which  occurs  on  the  trunk,  and  on  the  front  of 
the  arms.  The  face  is  often  exempt.  The  spots,  which  are  reddish-brown 
and  symmetrically  arranged,  persist  for  a  week  or  two.  There  may  be  mul- 
tiple relapses  of  roseola,  sometimes  at  long  intervals,  even  eleven  years  (Four- 
nier).  The  papular  sypliilide,  which  forms  acne-like  indurations  about  the 
face  and  trunk,  is  often  arranged  in  groups.  Other  forms  are  the  pustular 
rash,  which  may  so  closely  simulate  variola  that  the  patient  may  be  sent  to 
a  small-pox  hospital.  A  squamous  syphilide  occurs,  not  unlike  ordinary  psori- 
asis, except  that  the  scales  are  less  abundant.  The  rash  is  more  copper-colored 
and  not  specially  confined  to  the  extensor  surfaces. 

In  the  moist  regions  of  the  skin,  such  as  the  perinaeum  and  groins,  the 
axillae,  between  the  toes,  and  at  the  angles  of  the  mouth,  the  so-called  mucous 
patches  occur,  which  are  flat,  warty  outgrowths,  with  well-defined  margins  and 
surfaces  covered  with  a  grayish  secretion.  They  are  among  the  most  distinc- 
tive lesions  of  sj^hilis. 

Frequently  the  hair  falls  out  (alopecia),  either  in  patches  or  by  a  general 
thinning.    Occasionally  the  nails  become  affected  (syphilitic  onychia). 

(d)  Mucous  Lesions. — "With  the  fever  and  the  roseolous  rash  the  throat 
and  mouth  become  sore.  The  pharjTigeal  mucosa  is  h3^peraemic,  the  tonsils 
are  swollen  and  often  present  small,  kidney-shaped  ulcers  with  grayish-white 
borders.  Mucous  patches  are  seen  on  the  inner  surfaces  of  the  cheeks  and  on 
the  tongue  and  lips.  Hypertrophy  of  the  papillae  in  various  portions  of  the 
mucous  membrane  produces  the  syphilitic  warts  or  condylomata  which  are 
most  frequent  about  the  vulva  and  anus. 

(e)  Arthritis  and  pains  in  the  limbs  are  common  secondary  symptoms. 
Occasionally  the  joint  affection  is  severe  and  rheumatic  fever  is  suspected. 

(/)  Other  Lesions. — Iritis  is  common,  and  usually  affects  one  eye  before 
the  other.  It  comes  on  from  three  to  six  months  after  the  chancre.  There 
may  be  only  slight  ciliary  congestion  in  mild  cases,  but  in  severer  forms  there 
is  great  pain,  and  the  condition  is  serious  and  demands  careful  management. 
Choroiditis  and  retinitis  are  rare  secondary  symptoms.  Ear  affections  are  not 
common  in  the  secondary  stage,  but  instances  are  found  in  which  sudden  deaf- 
ness occurs,  which  may  be  due  to  labyrinthine  disease;  more  commonly  the 
impaired  hearing  is  due  to  the  extension  of  inflammation  from  the  throat  to 
the  middle  ear.  EpididjTnitis  and  parotitis  are  rare.  Jaundice  may  occur,  the 
icterus  syphiliticus  precox.     The  acute  nephritis  will  be  referred  to  later. 


SYPHILIS.  269 

Tertiary  Stage. — No  hard  and  fast  line  can  be  drawn  between  the  lesions 
of  the  secondary  and  those  of  the  tertiary  period;  and,  indeed,  in  exceptional 
cases,  manifestations  which  usually  appear  late  may  set  in  even  before  the  pri- 
mary sore  has  properly  healed.  The  special  affections  of  this  stage  are  certain 
skin  eruptions,  gummatous  growths  in  the  viscera,  and  amyloid  degenerations. 

(a)  The  late  syphilides  show  a  greater  tendency  to  ulceration  and  destruc- 
tion of  the  deeper  layers  of  the  skin,  so  that  in  healing  scars  are  left.  They 
are  also  more  scattered  and  seldom  symmetrical.  One  of  the  most  character- 
istic of  the  syphilides  is  rupia,  the  dry  stratified  crusts  of  which  cover  an  ulcer 
which  involves  the  deeper  layers  of  the  skin  and  in  healing  leaves  a  scar. 
It  may  be  a  secondary  lesion. 

(&)  Gummata.— These  may  occur  in  the  skin,  subcutaneous  tissue,  mus- 
cles, or  internal  organs.  The  general  character  has  been  already  described. 
In  the  skin  they  tend  to  break  down  and  ulcerate,  leaving  ugly  sores  which 
heal  with  difficulty.  In  the  solid  organs  they  undergo  fibroid  transformation 
and  produce  puckering  and  deformity.  On  the  mucous  membranes  these  ter- 
tiary lesions  lead  to  ulceration,  in  the  healing  of  which  cicatrices  are  formed; 
thus,  in  the  larynx  great  narrowing  may  result,  and  in  the  rectum  ulceration 
with  fibroid  thickening  and  retraction  may  lead  to  stricture.  Gummatous 
ulcers  may  be  infective. 

(c)  Amyloid  Degeneration. — Syphilis  plays  a  most  important  role  in  the 
production  of  this  affection.  Of  344  instances  analyzed  by  Fagge,  76  had 
syphilis,  and  of  these  42  had  no  bone  lesions.  It  follows  the  acquired  form  and 
is  very  common  in  association  with  rectal  syphilis  in  women.  In  congenital 
lues  amyloid  degeneration  is  rare. 

Quaternary  Stage. — Long  years  it  may  be  from  the  primary  sore  and  from 
any  active  manifestations,  certain  diseases  may  follow,  not  directly  syphilitic, 
but  dependent  in  some  way  upon  its  poison,  and  hence  termed  meta-  or  para- 
syphilitic  affections,  the  chief  of  which  are  locomotor  ataxia  and  dementia 
paralytica  and  aneurism. 

III.  Congenital  Syphilis. 

With  the  exception  of  the  primary  sore,  every  feature  of  the  acquired  dis- 
ease may  be  seen  in  the  congenital  form. 

The  intra-uterine  conditions  leading  to  the  death  of  the  foetus  do  not  here 
concern  us.  The  child  may  be  born  healthy-looking,  or  with  well-marked  evi- 
dences of  the  disease.  In  the  majority  of  instances  the  former  is  the  case, 
and  within  the  first  month  or  two  the  signs  of  the  disease  appear. 

Symptoms. —  (a)  At  Birth. — When  the  disease  exists  at  birth  the  child 
is  feebly  developed  and  wasted,  and  a  skin  eruption  is  usually  present,  com- 
monly in  the  form  of  bullae  about  the  hands  and  feet  (pemphigus  neonatorum 
syphiliticus).  The  child  snuffles,  the  lips  are  ulcerated,  the  angles  of  the 
mouth  fissured,  and  there  is  enlargement  of  the  liver  and  spleen.  The  bone 
symptoms  may  be  marked,  and  the  epiphyses  may  even  be  separated.  In  such 
cases  the  children  rarely  survive  long. 

(&)  Early  Manifestations. — When  born  healthy  the  child  thrives,  is  fat 
and  plump,  and  shows  no  abnormity  whatever;  then  from  the  fourth  to  the 
eighth  week,  rarely  later,  a  nasal  catarrh  occurs,  syphilitic  rhinitis,  which 
impedes  respiration,  and  produces  the  characteristic  symptom  which  has  given 


270  SPECIFIC  INFECTIOUS  DISEASES. 

the  name  snuffles  to  the  disease.  The  discharge  may  be  sero-punilent  or 
bloody.  The  child  nurses  with  great  difficulty.  In  severe  cases  ulceration 
takes  place  with  necrosis  of  the  bone,  leading  to  a  depression  at  the  root  of 
the  nose  and  a  deformity  characteristic  of  congenital  syphilis.  This  coryza 
may  be  mistaken  at  first  for  an  ordinary  catarrh,  but  the  coexistence  of  other 
manifestations  usually  makes  the  diagnosis  clear.  The  disease  may  extend 
into  the  Eustachian  tubes  and  middle  ears  and  lead  to  deafness. 

The  cutaneous  lesions  arise  mth  or  shortly  after  the  onset  of  the  snuf- 
fles. The  skin  often  has  a  sallow,  earthy  hue.  The  eruptions  are  first  noticed 
about  the  nates.  There  may  be  an  erythema  or  an  eczematous  condition,  but 
more  commonly  there  are  irregular  reddish-brown  patches  with  well-defined 
edges.  A  papular  syphilide  in  this  region  is  by  no  means  uncommon.  Fis- 
sures occur  al)out  the  lips,  either  at  the  angles  of  the  mouth  or  in  the  median 
line.  These  rliagades,  as  they  are  called,  are  very  characteristic.  There  may 
be  marked  ulceration  of  the  muco-cutaneous  surfaces.  The  secretions  from 
these  mouth  lesions  are  very  virulent,  and  it  is  from  this  source  that  the  wet- 
nurse  is  usually  infected.  Not  only  the  nurse,  but  members  of  the  family,  may 
be  contaminated.  There  are  instances  in  which  other  children  have  been  acci- 
dentally inoculated  from  a  syphilitic  infant.  The  hair  of  the  head  or  of  the 
eyebrows  may  fall  out.  The  syphilitic  onychia  is  not  uncommon.  Enlarge- 
ment of  the  glands  is  not  so  frequent  in  the  congenital  as  in  the  acquired 
disease.  When  the  cutaneous  lesions  are  marked,  the  contiguous  glands  can 
usually  be  felt.  As  pointed  out  by  Gee,  the  spleen  is  enlarged  in  many  cases. 
The  condition  may  persist  for  a  long  time.  Enlargement  of  the  liver,  though 
often  present,  is  less  significant,  since  in  infants  it  may  be  due  to  various 
causes.  These  are  among  the  most  constant  symptoms  of  congenital  sj^hilis, 
and  usually  arise  between  the  third  and  twelfth  weeks.  Frequently  they  are 
preceded  by  a  period  of  restlessness  and  wakefulness,  particularly  at  night. 
Some  authors  have  described  a  peculiar  syphilitic  cry,  high-pitched  and  harsh. 
Among  rarer  manifestations  are  hsemorrhages — the  syphilis  hcBmorrliagica 
neonatorum.  The  bleeding  may  be  subcutaneous,  from  the  mucous  surfaces, 
or,^  when  early,  from  the  umbilicus.  All  of  such  cases,  however,  are  not  syphi- 
litic, and  the  disease  must  not  be  confounded  with  the  acute  hsemoglobinuria 
of  new-born  infants.  E.  Fournier  has  described  a  remarkable  enlargement 
of  the  subcutaneous  veins. 

(c)  Late  Manifestations. — Children  with  congenital  syphilis  rarely  thrive. 
Usually  they  present  a  wizened,  wasted  appearance,  and  a  prematurely  aged 
face.  In  the  cases  which  recover,  the  general  nutrition  may  remain  good  and 
the  child  may  show  no  further  manifestations  of  the  disease;  commonly,  how- 
ever, at  the  period  of  second  dentition  or  at  puberty  the  disease  reappears. 
Although  the  child  may  have  recovered  from  the  early  lesions,  it  does  not 
develop  like  other  children.  Growth  is  slow,  development  tardy,  and  there  are 
facial  and  cranial  characteristics  which  often  render  the  disease  recognizable 
at  a  glance.  A  young  man  of  nineteen  or  twenty  may  neither  look  older  nor 
be  more  developed  than  a  boy  of  ten  or  twelve.  Fournier  describes  this  condi- 
tion as  infantilism.  The  forehead  is  prominent,  the  frontal  eminences  are 
marked,  and  the  skull  may  be  very  asymmetrical.  The  bridge  of  the  nose  is 
depressed,  the  tip  retrousse.  The  lips  are  often  prominent,  and  there  are 
striated  lines  running  from  the  corners  of  the  mouth.    The  teeth  are  deformed 


SYPHILIS.  271 

and  may  present  appearances  which  Jonathan  Hutchinson  claims  are  specific 
and  peculiar.  The  upper  central  incisors  of  the  permanent  set  are  the  teeth 
which  give  information.  The  specific  alterations  are — the  teeth  are  peg- 
shaped,  stunted  in  length  and  breadth,  and  narrower  at  the  cutting  edge  than 
at  the  root.  On  the  anterior  surface  the  enamel  is  well  formed,  and  not 
eroded  or  honeycombed,  x^t  the  cutting  edge  there  is  a  single  notch,  usually 
shallow,  sometimes  deep,  in  which  the  dentine  is  exposed. 

Among  late  manifestations,  particularly  apt  to  appear  about  puberty,  is 
the  interstitial  Jceratitis,  which  usually  begins  as  a  slight  steaminess  of  the 
corneaB,  which  present  a  ground-glass  appearance.  It  affects  both  eyes,  though 
one  is  attacked  before  the  other.  It  may  persist  for  months,  and  usually  clears 
completely,  though  it  may  leave  opacities,  which  prevent  clear  vision.  Iritis 
may  also  occur.  Of  ear  affections,  apart  from  those  which  follow  the  pharyn- 
geal disease,  a  form  occurs  about  the  time  of  puberty  or  earlier,  in  which  deaf- 
ness comes  on  rapidly  and  persists  in  spite  of  all  treatment.  It  is  unassoci- 
ated  with  obvious  lesions,  and  is  probably  labyrinthine  in  character.  Bone 
lesions,  occurring  oftenest  after  the  sixth  year,  are  not  rare  among  the  late 
manifestations  of  hereditary  syphilis.  The  tibiae  are  most  frequently  attacked. 
It  is  really  a  chronic  gummatous  periostitis,  which  gradually  leads  to  great 
thickening  of  the  bone.  The  nodes  of  congenital  syphilis,  which  are  often 
mistaken  for  rickets,  are  more  commonly  diffuse  and  affect  the  bones  of  the 
upper  and  lower  extremities.  They  are  generally  symmetrical  and  rarely  pain- 
ful.    They  may  occur  late,  even  after  the  twenty-first  year. 

Joint  lesions  are  rare.  Glutton  has  described  a  symmetrical  synovitis  of 
the  knee  in  hereditary  sjrphilis.  Enlargement  of  the  spleen,  sometimes  with 
the  lymph-glands,  may  be  one  of  the  late  manifestations,  and  may  occur  either 
alone  or  in  connection  with  disease  of  the  liver. 

Gummata  of  the  liver,  brain,  and  kidneys  have  been  found  in  late  hered- 
itary syphilis.     General  paresis  may  follow. 

Is  syphilis  transmitted  to  the  third  generation?  Opinion  on  this  subject 
has  been  divided.  Occasionally  cases  of  pronounced  congenital  syphilis  are 
met  with  in  the  children  of  parents  who  are  perfectly  healthy,  and  who  have 
not,  so  far  as  is  known,  had  syphilis;  and  yet,  as  remarked  by  Coutts  in  re- 
porting such  a  group  of  cases,  they  do  not  always  bear  careful  scrutiny.  E. 
Fournier,  in  his  L'Heredo-Syphilis  Tardive  (1907),  cites  interesting  examples 
which  appear  to  prove  the  transmission  to  the  third  generation,  and  this 
appears  to  be  the  view  of  the  French  syphilographers.  Mr.  Hutchinson  is  still 
opposed  to  this  view. 

IV.  Visceral  Syphilis. 

1.  Syphilis  of  the  Brain  and  Cord. 

There  are  three  anatomical  changes  in  the  central  nervous  system — ^new 
growths,  arteritis,  and  chronic  degenerative  (sclerotic)  processes. 

(1)  The  new  formations  or  gummata  form  definite  tumors,  ranging  in 
size  from  a  pea  to  a  walnut,  usually  multiple  and  attached  to  the  pia  mater, 
sometimes  to  the  dura.  Very  rarely  they  are  found  unassociated  with  the 
meninges.  When  small  they  present  a  uniform,  translucent  appearance,  but 
when  large  the  centre  undergoes  a  fibro-caseous  change,  while  at  the  periphery 


272  SPECIFIC  INFECTIOUS  DISEASES. 

there  is  a  firm,  translucent,  grayish  tissue.  They  may  resemble  large  tubercu- 
lous tumors.  The  growths  are  most  common  in  the  cerebrum.  They  may  be 
multiple  and  may  even  attain  a  considerable  size  \rithout  becoming  caseous. 
Occasionally  gummata  undergo  cystic  degeneration.  In  the  cord  large  growths 
are  not  so  common. 

In  the  neighborhood  of  the  growths  gummous  meningitis  occurs,  in  which 
all  the  membranes  are  involved.  This  is  more  common  at  the  base,  about  the 
chiasma  and  the  interpeduncular  space,  and  along  the  Sylvian  fissures. 

(2)  Arteritis,  in  the  form  of  nodular  tumors  on  the  vessels,  which  may 
break  down  or  lead  to  rupture,  or  there  is  a  progressive  obliterative  endarte- 
ritis.   Heubner's  view  of  the  specific  character  of  these  changes  is  disputed. 

(3)  Degenerative  fibroid  changes,  not  distinctive  anatomically,  but  clin- 
ically directly  connected  with  the  disease,  are  known  as  post-  or  meta-syphilitic. 

Secondary  Changes. — In  the  brain  gummatous  arteritis  is  one  of  the  com- 
mon causes  of  softening,  which  may  be  extensive,  as  when  the  middle  cerebral 
artery  is  involved^  or  when  there  is  a  large  patch  of  meningitis.  In  such 
instances  the  process  is  really  a  meningo-encephalitis,  and  the  symptoms  are 
due  to  the  secondary  changes,  not  directly  to  the  gumma.  In  the  neighborhood 
of  a  gumma  intense  encephalitis  or  myelitis  may  occur,  and  within  a  few  days 
change  the  clinical  picture. 

Syphilitic  disease  of  the  nerve-centres  occurs  usually  in  the  acquired  form. 
In  the  congenital  cases  the  tumors  usually  occur  early,  but  may  be  as  late  as 
the  twenty-first  year.  Of  late  years  it  has  been  recognized  that  the  nervous 
lesions  may  occur  very  early  in  the  disease,  even  before  the  induration  of  the 
primary  sore  has  gone.  In  a  majority  of  the  cases  brain  symptoms  come  on 
within  three  or  four  years  after  infection. 

Symptoms. — The  chief  features  of  cerebral  sj^hilis  are  those  of  tumor 
cerebri,  which  will  be  considered  later.    They  may  be  classified  here  as  follows : 

(1)  Psychical  features.  A  sudden  and  violent  onset  of  delirium  may  be 
the  first  symptom.  In  other  instances  prior  to  the  occurrence  of  delirium 
there  have  been  headache,  alteration  of  character,  and  loss  of  memory.  The 
condition  may  be  accompanied  by  convulsions.  There  may  be  no  neuritis,  no 
palsy,  and  no  localizing  symptoms. 

(2)  More  commonly  following  headache,  giddiness,  or  an  excited  state 
which  may  amount  to  delirium,  the  patient  has  an  epileptic  seizure  or  a  hemi- 
plegic  attack,  or  there  is  involvement  of  the  nerves  of  the  base.  Some  of  these 
cases  display  a  prolonged  torpor,  a  special  feature  of  brain  syphilis  to  which 
both  Buzzard  and  Heubner  have  referred,  which  may  persist  for  as  long  as 
a  month. 

(3)  In  some  cases  the  clinical  picture  is  that  of  general  paralysis — demen- 
tia paralytica. 

(4)  Many  cases  of  cerebral  sjrphilis  display  the  symptoms  of  brain  tumor 
— ^headache,  optic  neuritis,  vomiting,  and  convulsions.  Of  these  symptoms 
convulsions  are  the  most  important,  and  both  Fournier  and  Wood  have  laid 
-great  stress  on  the  value  of  this  symptom  in  persons  over  thirty.  The  first 
symptoms  may,  however,  rather  resemble  those  of  embolism  or  thrombosis; 
thus  there  may  be  sudden  hemiplegia,  with  or  without  loss  of  consciousness. 

The  symptoms  of  spinal  syphilis  are  extremely  varied  and  may  be  caused 
by  large  gummatous  growths  attached  to  the  meninges,  in  "which  case  the 


SYPHILIS.  273 

features  are  those  of  tumor,  by  gummatous  arteritis  with  secondary  soften- 
ing, by  meningitis  with  secondary  cord  changes,  or  by  scleroses  occurring  late 
in  the  disease.  Syphilitic  myelitis  will  be  considered  under  affections  of  the 
spinal  cord. 

Diagnosis. — The  history  is  of  the  first  importance,  but  it  may  be  extremely 
difficult  to  get  a  trustworthy  account.  Careful  examination  should  be  made 
for  traces  of  the  primary  sore,  for  the  cicatrices  of  bubo,  for  scars  of  the  skin 
eruption  or  throat  ulcers,  and  for  bone  lesions.  The  character  of  the  symp- 
toms is  often  of  great  assistance.  They  are  multiform,  variable,  and  often 
such  as  could  not  be  explained  by  a  single  lesion;  thus  there  may  be  anoma- 
lous spinal  symptoms  or  involvement  of  the  nerves  of  the  brain  on  both  sides. 
And  lastly  the  result  of  treatment  has  a  definite  bearing  on  the  diagnosis,  as  the 
symptoms  may  clear  up  and  disappear  with  the  use  of  antisyphilitic  remedies. 

2.  Syphilis  of  the  Respiratory  Organs. 

1.  Syphilis  of  the  Trachea  and  Bronchi. — ^L.  A.  Conner  (Am.  Jour,  of 
Med.  Sci.,  July,  1903)  has  analyzed  128  recorded  cases  of  syphilis  of  the 
trachea  and  bronchi.  In  56  per  cent  of  the  cases  the  trachea  was  alone  in- 
volved. In  only  10  per  cent  were  characteristic  lesions  of  syphilis  found  in 
the  lungs.  Bronchial  dilatation  below  the  lesion  was  found  in  15  per  cent  of 
the  cases.     In  ten  of  the  cases  the  lesion  occurred  in  congenital  syphilis. 

2.  Syphilis  of  the  Lung. — This  is  a  very  rare  disease.  In  the  2,800  post 
mortems  at  the  Johns  Hopkins  Hospital  there  were  12  cases  with  syphilitic 
disease  in  the  lungs ;  in  8  of  these  the  lesions  were  in  congenital  syphilis.  In 
11  cases  there  were  definite  gummata.  Clinically  the  presence  of  syphilis 
of  the  lung  was  suspected  in  three  cases.  Some  years  ago  Fowler  visited  the 
museums  of  the  London  hospitals  and  the  Royal  College  of  Surgeons,  and 
could  find  only  twelve  specimens  illustrating  syphilitic  lesions  of  the  lungs, 
two  of  which  are  doubtful.  For  the  most  full  and  satisfactory  consideration 
of  pulmonary  syphilis,  the  reader  is  referred  to  chapter  xxxvii  of  Fowler  and 
Godlee's  work  on  Diseases  of  the  Lungs. 

It  occurs  under  the  following  forms: 

(1)  The  white  pneumonia  of  the  fcetus.  This  may  affect  large  areas  or 
an  entire  lung,  which  then  is  firm,  heavy,  and  airless,  even  though  the  child 
may  have  been  born  alive.  On  section  it  has  a  grayish-white  appearance— 
the  so-called  white  hepatization  of  Virchow.  The  chief  change  is  in  the 
alveolar  walls,  which  are  greatly  thickened  and  infiltrated,  and  the  section  is 
like  one  of  the  pancreas — "  pancreatization  "  of  the  lung.  In  the  early  stages, 
for  example,  in  a  seven  or  eight  months'  fcetus,  there  may  be  scattered  miliary 
foci  of  this  induration  chiefly  about  the  arteries.  The  air-cells  are  filled  with 
desquamated  and  swollen  epithelium. 

(2)  In  the  form  of  definite  gummata,  which  vary  in  size  from  a  pea  to 
a  goose-egg.  They  occur  irregularly  scattered  through  the  lung,  but,  as  a 
rule,  are  more  numerous  toward  the  root.  They  present  a  grayish-yellow 
caseous  appearance,  are  dry  and  usually  imbedded  in  a  translucent,  more  or 
less  firm,  connective  tissue.  In  a  case  from  my  wards  described  by  Council- 
man, there  was  extensive  involvement  of  the  root  of  the  lungs.  Bands  of  con- 
nective tissue  passed  inward  from  the  thickened  pleura,  and  between  these 
strands  and  surrounding  the  gummata  there  was  in  places  a  mottled  red 


274  SPECIFIC  INFECTIOUS  DISEASES. 

pneumonic  consolidation.  In  the  caseous  nodules  there  is  typical  hyaline 
degeneration.  In  a  few  rare  instances  there  are  most  extensive  caseous  gum- 
mata  with  softening  and  formation  of  bronchiectatic  cavities,  and  clinically 
a  picture  of  pulmonary  tuberculosis  without  the  presence  of  tubercle  bacilli. 
In  one  case,  a  man  aged  twenty-seven,  admitted  in  April,  1903,  had  had  for 
a  year  cough  and  bloody  expectoration  and  died  of  severe  haemoptysis.  Bacilli 
were  never  found  in  the  sputum.  There  were  extensive  caseous  gummata 
throughout  both  lungs,  with  much  fibrous  thickening,  and  in  the  lower  lobe 
of  the  right  lung  a  cavity  3X5  cm.  in  diameter,  on  the  wall  of  which  a 
branch  of  the  pulmonary  artery  was  eroded.  This  is  the  only  instance  among 
my  cases  in  which  there  was  an  extensive  destruction  of  the  lung  tissue  with 
the  clinical  picture  simulating  pulmonary  phthisis. 

(3)  A  majority  of  authors  follow  Virchow  in  recognizing  the  fibrous  in- 
terstitial pneumonia  at  the  root  of  the  lung  and  passing  along  the  bronchi  and 
vessels  as  probably  syphilitic.  This  much  may  be  said,  that  in  certain  cases 
gummata  are  associated  with  these  fibroid  changes.  Again,  this  condition 
alone  is  found  in  persons  with  well-marked  syphilitic  history  or  with  other 
visceral  lesions.  It  seems  in  many  instances  to  be  a  purely  sclerotic  process, 
advancing  sometimes  from  the  pleura,  more  commonly  from  the  root  of  the 
lung,  and  invading  the  interlobular  tissue,  gradually  producing  a  more  or  less 
extensive  fibroid  change.  It  rarely  involves  more  than  a  portion  of  a  lobe  or 
portions  of  the  lobes  at  the  root  of  the  lung.     The  bronchi  are  often  dilated. 

Diagnosis. — It  is  to  be  borne  in  mind,  in  the  first  place,  that  hospital  physi- 
cians and  pathologists  the  world  over  bear  witness  to  the  extreme  rarity  of 
lung  syphilis.  In  the  second  place,  the  therapeutic  test  upon  which  so  much 
reliance  is  placed  is  by  no  means  conclusive.  With  pulmonary  tuberculosis 
there  should  now  be  no  confusion,  owing  to  the  readiness  with  which  the  pres- 
ence of  bacilli  is  determined.  Bronchiectasis  in  the  lower  lobe  of  a  lung, 
dependent  upon  an  interstitial  pneumonia  of  syphilitic  origin,  could  not  be 
distinguished  from  any  other  form  of  the  disease.  In  persons  with  well- 
marked  syphilitic  lesions  elsewhere,  when  obscure  pulmonary  symptoms  occur, 
or  if  there  are  signs  of  chronic  interstitial  pneumonia  with  dilated  bronchi, 
and  no  tubercle  bacilli  are  present,  the  condition  may  possibly  be  due  to  syphi- 
lis. So  far  as  my  experience  goes,  tuberculous  phthisis  occurring  in  a  syphi- 
litic subject  has  no  special  peculiarities.  The  lesions  of  syphilis  and  tubercu- 
losis could  of  course  coexist  in  a  lung. 

3.  Syphilis  of  the  Liver. 

1.  Inherited.— (a)  Congenital— Gnhler  in  1853  first  described  the  dif- 
fuse hepatitis,  which  occurs  in  a  large  percentage  of  all  deaths  in  congenital 
lues.  \\Tiile  there  may  be  little  or  no  macroscopical  change,  the  liver  pre- 
serves its  form  and  is  usually  enlarged,  hard  and  resistant,  and  has  a  yellowish 
color,  compared  by  Trousseau  to  sole-leather,  or  by  Gubler  to  that  of  flint. 
Small  grayish  nodules  may  be  seen  on  the  section.  In  other  cases  there  are 
definite  gummata  with  extensive  sclerosis. 

The  child  may  be  still-born  or  die  shortly  after  birth,  or  it  may  be  healthy 
when  born  and  the  liver  enlarges  within  a  few  weeks.  The  organ  is  firm; 
the  edge  may  be  readily  felt,  usually  far  below  the  navel.  The  spleen  is  also 
enlarged.     The  general  features  are  those  of  a  hypertrophic  cirrhosis    but 


SYPHILIS.  275 

jaundice  and  ascites  are  not  common.  Hochsinger  (whose  exhaustive  work 
on  hereditary  syphilis  has  just  been  completed,  1904)  states  that  of  45  cases 
recovery  took  place  in  30. 

(h)  Delayed  Congenital  Syphilis. — The  condition  is  by  no  means  rare. 
Of  132  cases  of  syphilis  hereditaria  tarda  collected  by  Forbes,  in  34  the  liver 
was  involved.  The  children  are  nearly  always  ill-developed,  sometimes  with 
marked  clubbing  of  the  fingers  and  showing  signs  of  infantilism.  Jaundice 
is  rare.     The  liver  is  usually  enlarged,  or  it  may  show  nodular  masses. 

2.  Acquired  Syphilis. —  (a)  In  the  secondary  stages  of  the  disease  the 
liver  is  not  often  involved.  Jaundice  may  occur  coincident  with  the  rash 
and  with  the  enlargement  of  the  superficial  glands.  Rolleston  thinks  it  is 
probably  due  to  a  catarrhal  condition  of  the  smaller  ducts,  part  of  a  general 
syphilitic  hepatitis.  There  are  cases  in  which  it  has  passed  on  to  a  state  of 
acute  yellow  atrophy.  The  liver  is  slightly  enlarged.  The  prognosis  is  gen* 
erally  good.  (&)  Tertiary  lesions.  The  frequency  with  which  the  liver  is  in- 
volved in  syphilis  in  adults  is  very  variously  estimated.  J.  L.  Allen,  quoted 
by  Eolleston,  found  37  cases  of  hepatic  gummata  among  11,629  autopsies  at 
St.  George's  Hospital,  27  cases  in  which  cicatrices  alone  were  present.  Flex- 
ner  at  the  Philadelphia  Hospital  found  88  cases  of  hepatic  syphilis  among 
5,088  autopsies.  Among  2,300  autopsies  at  the  Johns  Hopkins  Hospital  (Pro- 
fessor Welch)  there  have  been  47  cases  of  syphilis  of  the  liver,  gummata  in  19, 
scars  in  16,  cirrhosis  in  21  cases;  6  of  the  cases  were  congenital.  My  experi- 
ence coincides  with  that  of  Einhorn  and  of  Stockton,  who  hold  that  in  the 
United  States  the  disease  is  by  no  means  uncommon.  In  21  cases  the  diagnosis 
of  syphilis  of  the  liver  was  made  clinically. 

Anatomically  the  lesions  may  be  either  gummata  or  scars  or  a  syphilitic 
sclerosis.  The  gummata  range  in  size  from  a  pea  to  an  orange.  When  small 
they  are  pale  and  gray;  the  larger  ones  present  yellowish  centres;  but  later 
there  is  a  "  pale,  yellowish,  cheese-like  nodule  of  irregular  outline,  surrounded 
by  a  fibrous  zone,  the  outer  edge  of  which  loses  itself  in  the  lobular  tissue,  the 
lobules  dwindling  gradually  in  its  grasp.  This  fibrous  zone  is  never  very 
broad;  the  cheesy  centre  varies  in  consistence  from  a  gristle-like  toughness  to 
a  pulpy  softness ;  it  is  sometimes  mortar-like,  from  cretaceous  change " 
(Wilks).  They  may  form  enormous  tumors,  as  in  the  remarkable  one  figured 
on  page  351  in  Eolleston's  work  on  Diseases  of  the  Liver.  They  may  be  felt 
as  large  as  an  orange  beneath  the  skin  in  the  epigastrium  and  they  may  dis- 
appear with  the  same  extraordinary  rapidity  as  the  subcutaneous  or  periosteal 
gumma.  Macroscopically  they  may  indeed  at  first  look  like  massive  cancer. 
Extensive  caseation,  softening  and  calcification  may  occur.  The  syphilitic 
scars  are  usually  linear  or  star-shaped.  They  may  be  very  numerous  and 
divide  the  liver  into  small  sections — the  so-called  botyroid  organ,  of  which  a 
remarkable  example  is  figured  in  my  Lectures  on  Abdominal  Tumors.  The 
syphilitic  cirrhosis  is  usually  combined  with  gummata,  or  with  marked  scar- 
ring in  the  portal  canal,  leading  to  lobulation  of  the  organ,  but  the  ordinary 
multilobular  cirrhosis  is  not  common. 

Symptoms. — In  the  first  place  the  clinical  picture  may  be  that  of  cirrhosis 
— slight  jaundice,  fever,  portal  obstruction,  ascites.  There  may  not  be  the 
slightest  suspicion  of  the  syphilitic  nature  of  the  case.  One  of  my  patients 
had  been  tapped  thirteen  times  before  admission  to  the  hospital.     The  diag- 


276  SPECIFIC  INFECTIOUS  DISEASES. 

nosis  was  made  by  finding  the  gummata  on  the  shins.  She  recovered 
promptly. 

In  a'  second  group  of  cases  the  patient  is  anaemic,  passes  large  quantities 
of  pale  urine  containing  albumin  and  tube-casts;  the  liver  is  enlarged,  per- 
haps irregular,  and  the  spleen  also  is  enlarged.  Dropsical  symptoms  may 
supervene,  or  the  patient  may  be  carried  off  by  some  intercurrent  disease. 
Extensive  amyloid  degeneration  of  the  spleen,  the  intestinal  mucosa,  and  of 
the  liver,  with  gummata,  are  found. 

Thirdly,  in  a  very  important  group  the  symptoms  are  those  of  tumor  of 
the  liver,  causing  pain  and  distress,  and  on  examination  an  irregular  mass 
is  discovered.  The  tumor  may  be  large,  causing  a  prominent  bulging  in  the 
epigastrium.  N"aturally  carcinoma  is  thought  of,  as  there  may  be  nothing  to 
suggest  s}^hilis.  In  other  cases  the  history  or  the  presence  of  gummata  else- 
where should  aid  in  the  diagnosis.  In  other  instances  the  rapid  disappearance 
under  treatment  even  of  a  large  visible  tumor  makes  the  s}^hilitic  nature  quite 
positive.  Lasth%  in  a  few  cases  the  irre.gular  fever  with  enlargement  and  irreg- 
ularity of  the  liver  may  suggest  suppuration,  or  the  uniform  great  enlargement 
of  the  organ  h}^ertrophic  biliary  cirrhosis,  while  there  are  some  cases  in  which 
the  spleen  is  so  greatly  enlarged,  the  anemia  so  pronounced,  and  the  liver  small 
and  contracted  that  the  diagnosis  of  splenic  anaemia  is  made. 

4,  Syphilis  of  the  Digestive  Tract. 

The  oesophagus  is  very  rarely  affected.  Stenosis  is  the  usual  result. 
Syphilis  of  the  stomach  is  excessively  rare.  Flexner  has  reported  a  remark- 
able case  in  association  with  gummata  of  the  liver.  He  has  collected  14  cases 
in  the  literature.  Sj^hilitic  ulceration  has  been  found  in  the  small  intestine 
and  in  the  cscum. 

The  most  common  seat  in  this  tract  is  the  rectum.  The  affection  is  found 
most  commonly  in  women,  and  results  from  the  growth  of  gummata  in  the 
submucosa  above  the  internal  sphincter.  The  process  is  slow  and  tedious, 
and  may  last  for  years  before  it  finally  induces  stricture.  The  symptoms  are 
usually  those  of  narrowing  of  the  lower  bowel.  The  condition  is  readily  rec- 
ognized by  rectal  examination.  The  history  of  gradual  on-coming  stricture, 
the  state  of  the  patient,  and  the  fact  that  there  is  a  hard,  fibrous  narrowing, 
not  an  elevated  crater-like  ulcer,  usually  render  easy  the  diagnosis  from  malig- 
nant disease.  In  medical  practice  these  cases  come  under  observation  for 
other  symptoms,  particularly  amyloid  degeneration;  and  the  rectal  disease 
may  be  entirely  overlooked,  and  only  discovered  post  mortem. 

5.  Circulatory  System. 

Syphilis  of  the  Heart.— K  fresh,  warty  endocarditis  due  to  syphilis  is  not 
recognized,  though  occasionally  in  persons  dead  of  the  disease  this  form  is 
present,  as  is  not  uncommon  in  conditions  of  debility.  Outgrowths  on  the 
valves  m  connection  with  gummata  have  been  reported  by  Janeway  and  others. 
Loomis  groups  the  lesions  into:  (1)  Gummata,  recent  or  old;  (2)  fibroid 
induration,  localized  or  diffuse;  (3)  amvloid  degeneration;  and  (4)  endar- 
teritis obliterans.  I.  Adler  claims  that  changes^in  the  blood-vessels  of  the 
walls  of  the  heart  are  common  both  in  congenital  and  acquired  syphilis,  even 
m  cases  without  clinical  symptoms  or  gross  lesions. 


SYPHILIS.  277 

Rupture  may  take  place,  as  in  the  cases  reported  by  Dandridge  and  Nalty, 
or  sudden  death,  as  in  the  cases  of  Cayley  and  Pearce  Gould;  indeed,  sudden 
death  is  frequent,  occurring  in  21  of  63  cases  (Mracek). 

Syphilis  of  the  Arteries. — Syphilis  plays  an  important  role  in  arterio-scle- 
rosis  and  aneurism.  Its  connection  with  these  processes  will  be  considered 
later;  here  we  shall  refer  only  to  the  syphilitic  affection  of  the  smaller  vessels, 
which  occurs  in  two  forms : 

(a)  An  obliterating  endarteritis,  characterized  by  a  proliferation  of  the 
subendothelial  tissue.  The  new  growth  lies  within  the  elastic  lamina,  and 
may  gradually  fill  the  entire  lumen ;  hence  the  term  obliterating.  The  media 
and  adventitia  are  also  infiltrated  with  small  cells.  This  form  of  endarteritis 
described  by  Heubner  is  not,  however,  characteristic  of  syphilis,  and  its  pres- 
ence alone  in  an  artery  could  not  be  considered  pathognomonic.  If,  however, 
there  are  gummata  in  other  parts,  or  if  the  condition  about  to  be  described 
exists  in  adjacent  arteries,  the  process  may  be  regarded  as  syphilitic. 

(&)  Gummatous  Periarteritis. — With  or  without  involvement  of  the  in- 
tima,  nodular  gummata  may  develop  in  the  adventitia  of  the  artery,  produc- 
ing globular  or  ovoid  swellings,  which  may  attain  considerable  size.  They 
are  not  infrequently  seen  in  the  cerebral  arteries,  which  seem  to  be  specially 
prone  to  this  affection.  This  form  is  specific  and  distinctive  of  syphilis. 
Eeuter  and  Schmorl  have  found  Spirochceta  pallida  in  the  syphilitic  aortitis, 
and  Benda  in  gummatous  arteritis  of  the  cerebral  vessels. 

6.  Renal  Syphilis. 

(a)  Gummata  occasionally  are  found  in  the  kidneys,  particularly  in  cases 
in  which  there  is  extensive  gummatous  hepatitis.  They  are  rarely  numerous, 
and  occasionally  lead  to  scattered  cicatrices.  Clinically  the  affection  is  not 
recognizable. 

(&)  Acute  Syphilitic  Nephritis. — This  condition  has  been  carefully  stud- 
ied by  the  French  writers  and  by  Lafleur,  of  Montreal.  It  is  estimated  to 
occur  in  the  secondary  stage  in  about  3.8  per  cent,  and  may  occur  in  from 
three  to  six  months,  sometimes  later,  from  the  initial  lesion.  The  outlook 
is  good,  though  often  the  albuminuria  may  persist  for  months;  more  rarely 
chronic  Bright's  disease  follows.  In  a  few  instances  syphilitic  nephritis  has 
proved  rapidly  fatal  in  a  fortnight  or  three  weeks.  The  lesions  are  not  spe- 
cific, but  are  similar  to  those  in  other  acute  infections. 

7.  Syphilitic  Orchitis. 

This  affection  is  of  special  significance  to  the  physician,  as  its  detection 
frequently  clinches  the  diagnosis  in  obscure  internal  disorders.  Syphilis  occurs 
in  the  testes  in  two  forms : 

(a)  The  gummatous  growth,  forming  an  indurated  mass  or  group  of 
masses  in  the  substance  of  the  organ,  and  sometimes  difficult  to  distinguish 
from  tuberculous  disease.  The  area  of  induration  is  harder  and  it  affects 
the  body  of  the  testes,  while  tubercle  more  commonly  involves  the  epididymis. 
It  rarely  tends  to  invade  the  skin,  or  to  break  down,  soften,  and  suppurate, 
and  is  usually  painless. 

(&)  There  is  an  interstitial  orchitis  regarded  as  syphilitic,  which  leads 
to  fibroid  induration  of  the  gland  and  gradually  to  atrophy.     It  is  a  slow. 


278  SPECIFIC  INFECTIOUS  DISEASES. 

progressive  change,  coming  on  without  pain,  usually   involving  one  organ 
more  than  another. 

Diagnosis,  Treatment,  etc. 

General  Diagnosis  of  Syphilis, — There  is  seldom  any  doubt  concerning  the 
existence  of  syphilitic  lesions.  Syphilis  is  common  in  the  community,  and  is  no 
respecter  of  age,  sex,  or  station  in  life.  It  is  possible  that  the  primary  sore 
may  have  been  of  trifling  extent,  or  urethral  and  masked  by  a  gonorrhoea,  and 
the  patient  ma}'  not  have  had  severe  secondary  symptoms,  but  such  instances 
are  extremely  rare.  Inquiries  should  be  made  into  the  history  to  ascertain  if 
the  patient  has  had  skin  rashes,  sore  throat,  or  if  the  hair  has  fallen  out.  Care- 
ful inspection  should  be  made  of  the  throat  and  skin  for  signs  of  old  lesions. 
Scars  in  the  groins,  the  result  of  buboes,  are  uncertain  evidences  of  syphilitic 
infection.  The  cicatrices  on  the  legs  are  often  copper-colored,  though  this  can 
not  be  regarded  as  j^eculiar  to  syphilis.  The  bones  should  be  examined  for 
nodes.  In  doubtful  cases  the  scar  of  the  primary  sore  may  be  found,  or  there 
may  be  signs  of  atrophy  or  of  hardening  of  the  testes.  In  women,  special 
stress  has  been  laid  upon  the  occurrence  of  frequent  miscarriages,  which,  in 
connection  with  other  circumstances,  are  always  suggestive. 

In  the  congenital  disease,  the  occurrence  within  the  first  three  months  of 
snuffles  and  skin  rash  is  conclusive.  Later,  the  characters  of  the  syphilitic 
facies,  already  referred  to,  often  give  a  clew  to  the  nature  of  some  obscure 
visceral  lesion.  Other  distinctive  features  are  the  symmetrical  development 
of  nodes  on  the  bones,  and  the  interstitial  keratitis. 

The  Spirockceta  pallida  may  be  studied  from  the  fresh  lesion.  After 
cleaning  carefully,  serum  is  sucked  out  with  a  small  Biers  apparatus,  and  the 
living  spirochetes  may  be  seen  in  the  special  "  dark  field  "  apparatus  used  for 
the  purpose. 

Seram  Diagnosis. — Wassermann's  reaction  has  reached  the  clinical  stage, 
and  in  good  hands  may  be  accepted  as  valuable  aid  in  diagnosis.  It  is  ob- 
tained in  from  80  to  90  per  cent  of  all  cases  of  S3^philis  with  manifestations. 
Observations  are  not  altogether  in  accord,  but  such  syphilographers  as  Neisser 
and  ringer  are  convinced  of  its  practical  value.  The  results  in  tabes  and 
dementia  paralytica  are  very  constant. 

Therapeutic  Test. — In  a  doubtful  case,  as,  for  example,  an  obstinate  skin 
rash,  or  an  obscure  tumor  in  the  abdomen,  antisyphilitic  treatment  may  prove 
successful,  but  this  can  not  always  be  relied  upon. 

Prophylaxis. — Irregular  intercourse  has  existed  from  the  beginning  of 
recorded  history,  and  unless  man's  nature  wholly  changes — and  of  this  we 
can  have  no  hope— will  continue.  Eesisting  all  attempts  at  solution,  the 
social  evil  remains  the  great  blot  upon  our  civilization,  and  inextricably 
blended  with  it  is  the  question  of  the  prevention  of  syphilis.  Two  measures 
are  available — the  one  personal,  the  other  administrative. 

Personal  purity  is  the  prophylaxis  which  we,  as  physicians,  are  especially 
bound  to  advocate.  Continence  may  be  a  hard  condition  (to  some  harder 
than  to  others),  but  it  can  be  borne,  and  it  is  our  duty  to  urge  this  lesson 
upon  young  and  old  who  seek  our  advice  in  matters  sexual.  Certainly  it  is 
better,  as  St.  Paul  says,  to  marry  than  to  burn,  but  if  the  former  is  not  feas- 


SYPHILIS.  279 

ible  there  are  other  altars  than  those  of  Venus  upon  which  a  young  man  may- 
light  fires.  He  may  practise  at  least  two  of  the  five  means  by  which,  as  the 
physician  Eondibilis  counselled  Panurge,  carnal  concupiscence  may  be  cooled 
and  quelled — hard  work  of  body  and  hard  work  of  mind.  Idleness  is  the 
mother  of  lechery ;  and  a  young  man  will  find  that  absorption  in  any  pursuit 
will  do  much  to  cool  passions  which,  though  natural  and  proper,  can  not  in 
the  exigencies  of  our  civilization  always  obtain  natural  and  proper  gratification. 

To  carry  out  successfully  any  administrative  measures  seems  hopeless,  at 
any  rate,  in  our  Anglo-Saxon  civilization.  The  state  accepts  the  responsi- 
bility of  guarding  citizens  against  small-pox  or  cholera,  but  in  dealing  with 
syphilis  the  problem  has  been  too  complex  and  has  hitherto  baffled  solution. 
Inspection,  segregation,  and  regulation  are  difficult,  if  not  impossible,  to  carry 
out,  and  public  sentiment  is  bitterly  opposed  to  this  plan.  The  compulsory 
registration  of  every  case  of  gonorrhoea  and  syphilis,  with  greatly  increased 
facilities  for  thorough  treatment,  offer  a  more  acceptable  alternative. 

Treatment. — That  the  later  stages  which  come  under  the  charge  of  the 
physician  are  so  common,  results,  in  great  part,  from  the  carelessness  of  the 
patient,  who,  wearied  with  treatment,  can  not  understand  why  he  should 
continue  to  take  medicine  after  all  the  symptoms  have  disappeared;  but,  in 
part,  the  profession  also  is  to  blame  for  not  insisting  more  urgently  that 
acquired  syphilis  is  not  cured  in  a  few  months,  but  takes  at  least  three  years, 
during  which  time  the  patient  should  be  under  careful  supervision. 

The  discovery  of  the  spirochete  suggests  prompt  excision  of  the  local 
breeding  spot — the  chancre — and  in  apes  this  may  be  done  successfully  within 
the  first  two  weeks.  Local  treatment  of  the  chancre  with  mercury  will  also 
prevent  the  development  of  the  disease  in  the  ape.  Much  more  important 
is  the  fact  that  the  virus  is  destroyed  in  the  ape  treated  with  atoxyl  in  from 
three  to  ten  days  after  inoculation,  so  that  the  animal  may  be  reinfected. 
These  are  practical  points,  the  value  of  which  in  human  practice  will  have 
to  be.  tested.  The  atoxyl  (metaroenic  acid  anilide)  is  strongly  toxic  to 
protozoan  parasites,  as  its  use  in  sleeping  sickness  has  shown.  It  may  be 
given  intra-muscularly  in  doses  of  three  grains  every  third  day  for  ten  days, 
and  then  resumed.     Good  results  have  been  reported  by  Lambkin  with  it. 

Mercury  may  be  given  by  the  mouth  in  the  form  of  gray  powder,  the 
hydrargyrum  cum  creta,  which  Hutchinson  recommends  to  be  given  in  pills, 
one-grain  doses  with  a  grain  of  Dover's  powder.  One  pill  from  four  to  six 
times  a  day  will  usually  suffice.  I  warmly  endorse  the  excellent  results  which 
are  obtained  by  this  method,  under  which  the  patient  often  gains  rapidly  in 
weight,  and  the  general  health  improves  remarkably.  It  may  be  continued 
for  months  without  any  ill  effects.  Other  forms  given  by  the  mouth  are  the 
pilules  of  the  biniodide  (gr.  ■^),  or  of  the  protiodide  (gr.  ^) ,  three  times  a 
day.  "  If  mercury  be  begun  as  soon  as  the  state  of  the  sore  permits  of  diagno- 
sis, and  continued  in  small  but  adequate  doses,  the  patient  will  usually  escape 
both  sore  throat  and  eruption"   (Jonathan  Hutchinson). 

Inunction  is  a  still  more  effective  means.  A  drachm  of  the  ordinary  mer- 
curial ointment  is  thoroughly  rubbed  into  the  skin  every  evening  for  six  days ; 
on  the  seventh  a  warm  bath  is  taken,  and  on  the  eighth  the  mercurial  course 
is  resumed.  At  least  half  an  hour  should  be  given  to  each  inunction.  It  is 
well  to  apply  it  at  different  places  on  successive  days.    The  sides  of  the  chest 


280  SPECIFIC  INFECTIOUS  DISEASES. 

and  abdomen  and  the  inner  surfaces  of  the  arms  and  thighs  are  the  best 

positions.  . 

The  mercury  may  be  given  by  direct  injection  into  the  muscles,  it  proper 
precautions  are  taken  in  sterilizing  the  syringe,  and  if  the  injections  are  made 
into  the  muscles,  not  into  the  subcutaneous  tissue,  abscesses  rarely  result. 
One-third  of  a  grain  of  the  bichloride  in  twenty  drops  of  water  may  be  injected 
once  a  week,  or  from  one  to  two  grains  of  calomel  in  glycerin  (20  minims). 

Still  another  method,  greatly  in  vogue  in  certain  parts  of  the  Continent 
and  in  institutions,  is  fumigation.  It  may  be  carried  out  effectively  by  means 
of  Lee's  lamp.  The  patient  sits  on  a  chair  -^Tapped  in  blankets,  with  the 
head  exposed.  The  calomel  is  volatilized  and  deposited  with  the  vapor  on  the 
patient's  skin.  The  process  lasts  about  twenty  minutes,  and  the  patient  goes 
to  bed  \\Tapped  in  blankets  without  washing  or  drying  the  skin. 

A  patient  under  mercurial  treatment  should  avoid  stimulants  and  live  a 
regular  life,  not  necessarily  abstaining  from  business.  Green  vegetables  and 
fruit  should  not  be  taken.  Salivation  is  to  be  avoided.  The  teeth  should  be 
cleansed  twice  a  day,  and  if  the  gums  become  tender,  the  breath  fetid,  or  the 
tongue  swollen  and  indented,  the  drug  should  be  suspended  for  a  week  or 
ten  days. 

In  congenital  syphilis  the  treatment  of  cases  born  with  bullge  and  other 
signs  of  the  disease  is  not  satisfactory,  and  the  infants  usually  die  within  a 
few  days  or  weeks.  The  child  should  be  nursed  by  the  mother  alone,  or,  if 
this  is  not  feasible,  should  be  hand-fed,  but  under  no  circumstances  should  a 
wet-nurse  be  employed.  The  child  is  most  rapidly  and  thoroughly  brought 
under  the  influence  of  the  drug  by  inunction.  The  mercurial  ointment  may 
be  smeared  on  the  flannel  roller.  This  is  not  a  very  cleanly  method,  and 
sometimes  rouses  the  suspicion  of  the  mother.  It  is  preferable  to  give  the 
drug  by  the  mouth,  in  the  form  of  gray  powder,  half  a  grain  three  times  a  day. 
In  the  late  manifestations  associated  with  bone  lesions,  the  combination  of 
mercury  and  iodide  of  potassium  is  most  suitable  and  is  well  given  in  the  form 
of  Gilbert's  s}Tup,  which  consists  of  the  biniodide  of  mercury  (gr.  j),  of 
potassium  iodide  (qSs.),  and  water  (oij).  Of  this  a  dose  for  a  child  under 
three  is  from  five  to  ten  drops  three  times  a  day,  gradually  increased.  Under 
these  measures,  the  cases  of  congenital  syphilis  usually  improve  with  great 
rapidity.  The  medication  should  be  continued  at  intervals  for  many  months, 
and  it  is  well  to  watch  these  patients  carefully  during  the  period  of  second 
dentition  and  at  puberty,  and  if  necessary  to  place  them  on  specific  treatment. 

In  the  treatment  of  the  visceral  lesions  of  syphilis,  which  come  more  dis- 
tinctly within  the  province  of  the  physician,  iodide  of  potassium  is  of  equal 
or  even  greater  value  than  mercury.  Under  its  use  ulcers  rapidly  heal,  gum- 
matous tumors  melt  away,  and  we  have  an  illustration  of  a  specific  action  only 
equalled  by  that  of  mercury  in  the  secondary  stages,  by  iron  in  certain  forms 
of  ansemia,  and  by  quinine  in  malaria.  It  is  as  a  rule  well  borne  in  an  initial 
dose  of  10  grains;  given  in  milk  the  patient  does  not  notice  the  taste.  It 
should  be  gradually  increased  to  30  or  more  grains  three  times  a  day.  In 
syphilis  of  the  nervous  system  it  may  be  used  in  still  larger  doses.  Seguin, 
who  specially  insisted  upon  the  advantage  of  this  plan,  urged  that  the  drug 
should  be  pushed,  as  good  effects  were  not  obtained  with  the  moderate  doses. 

When  syphilitic  hepatitis  is  suspected  the  combination  of  mercury  and 


GONORRHCEAL  INFECTION.  281 

iodide  of  potassium  is  most  satisfactory.  If  there  is  ascites,  Addison's  pill 
(as  it  is  often  called)  of  calomel,  digitalis,  and  squills  will  be  found  very 
useful.  A  patient  of  mine  with  recurring  ascites,  on  whom  paracentesis  was 
repeatedly  performed  and  who  had  an  enlarged  and  irregular  liver,  took  this 
pill  for  more  than  a  year  with  occasional  intermissions,  and  ultimately  there 
was  a  complete  disappearance  of  the  dropsy  and  an  extraordinary  reduction 
in  the  volume  of  the  liver.  Occasionally  the  iodide  of  sodium  is  more  satis- 
factory than  the  iodide  of  potassium.  It  is  less  depressing  and  agrees  better 
with  the  stomach. 

Syphilis  and  Marriage. — 'Upon  this  question  the  family  physician  is  often 
called  to  decide.  He  should  insist  upon  the  necessity  of  two  full  years  elaps- 
ing between  the  date  of  infection  and  the  contracting  of  marriage.  This,  it 
should  be  borne  in  mind,  is  the  earliest  possible  limit,  and  marriage  should  be 
allowed  only  if  the  treatment  has  been  thorough  and  if  at  least  a  year  has 
passed  without  any  manifestation  of  the  disease. 

Syphilis  and  Life  Insurance. — An  individual  with  syphilis  can  not  be  re- 
garded as  a  first-class  risk  unless  he  can  furnish  evidence  of  prolonged  and 
thorough  treatment  and  of  immunity  for  two  or  three  years  from  all  mani- 
festations. Even  then,  when  we  consider  the  extraordinary  frequency  of  the 
cerebral  and  other  complications  in  persons  who  have  had  this  disease  and 
who  may  even  have  undergone  thorough  treatment,  the  risk  to  the  company 
is  certainly  increased  (see  Bramwell,  Clinical  Studies,  vol.  i). 

XXXII.   GONORRHCEAL  INFECTION. 

Gonorrhoea,  one  of  the  most  widespread  and  serious  of  infectious  diseases, 
presents  many  features  for  consideration.  As  a  cause  of  ill-health  and  dis- 
ability the  gonococcus  occupies  a  position  of  the  very  first  rank  among  its 
fellows.  While  the  local  lesion  is  too  often  thought  to  be  trifling,  in  its  singu- 
lar obstinacy,  in  the  possibilities  of  permanent  sexual  damage  to  the  individ- 
ual himself  and  still  more  in  the  "  grisly  troop  "  which  may  follow  in  its 
train,  gonorrhceal  infection  does  not  fall  very  far  short  of  syphilis  in  impor- 
tance. 

The  importance  of  the  infection  in  children  has  been  much  dwelt  upon 
of  late,  particularly  as  in  them  the  severer  systemic  lesions  are  liable  to  occur, 
but  more  especially  from  the  wide-spread  and  obstinate  character  of  the  epi- 
demics in  institutions.  The  gonococcus  vaginitis  and  the  ophthalmia  are 
very  serious  diseases  in  children's  hospitals  and  in  infants'  homes.  The  story 
of  the  gonococcus  infection  in  the  Babies'  Hospital,  New  York,  for  the  past 
eleven  years,  as  told  by  Holt  (N.  Y.  Med.  Jour.,  March,  1905),  illustrates  the 
singular  obstinacy  of  the  infection.  In  spite  of  the  greatest  care  and  pre- 
caution, there  were  in  1903  65  cases  of  vaginitis,  with  2  of  ophthalmia  and 
12  of  arthritis.  In  1904  there  were  52  cases  of  vaginitis,  only  16  of  which 
would  have  been  recognized  without  the  bacteriological  examination.  In  all, 
in  the  eleven  years,  there  were  273  cases  of  vaginitis,  only  6  with  ophthalmia 
and  26  with  arthritis.  Holt  urges  isolation  and  prolonged  quarantine  as  the 
only  measures  to  combat  successfully  the  disease. 

The  immediate  and  remote  effects  of  the  gonococcus  may  be  considered 
under — 


282  SPECIFIC  INFECTIOUS  DISEASES. 

I.  The  primary  infection. 

II.  The  spread  in  the  genito-urinary  organs  by  direct  continuity  of  sur- 
face. 

III.  Systemic  gonorrhoea!  infection. 

The  primary  lesion  we  need  not  here  consider,  but  we  may  call  atten- 
tion to  the  frequency  of  the  complications,  such  as  periurethral  abscess,  gon- 
orrhoeal  prostatitis  in  the  male,  and  vaginitis,  endocervicitis,  and  inflammation 
of  the  glands  of  Bartholini  in  the  female. 

Perhaps  the  most  serious  of  all  the  sequels  of  gonorrhoea  are  those 
which  result  from  the  spread  by  direct  continuity  of  tissue.  Gonorrhoeal  sal- 
pingitis has  been  shown  to  be  a  not  infrequent  event.  ]\Ietritis  and  ovaritis 
are  also  occasionally  met  with,  and  peritonitis.  The  gonococcus  has  been 
found  in  pure  culture  in  cases  of  acute  general  peritonitis.  Equally  impor- 
tant is  the  cystitis,  which  is  probably  much  more  frequently  the  result  of  a 
mixed  infection  than  due  to  the  gonococcus  itself.  There  is  some  danger  of 
extension  upward  through  the  ureters  to  the  kidneys.  The  pyelitis,  like  the 
cystitis,  is  usually  a  mixed  infection. 

Systemic  Goxoeehceal  Infection. 

1.  Gonorrhoeal  Septicaemia  and  Pyaemia. — The  fever  associated  with  the 
primary  disease  is  not  an  indication  of  a  general  infection,  but  probably  fol- 
lows the  absorption  of  toxins.  The  presence  of  the  gonococcus  may  be  demon- 
strated in  the  blood,  usually  in  connection  with  some  local  lesion,  in  which 
the  patient  succumbed  to  an  acute  endocarditis.  In  one  remarkable  case  fol- 
lowing the  gonorrhoea  the  patient  had  an  irregular  fever  for  weeks.  The 
gonococci  were  isolated  from  the  blood  in  pure  culture.  There  was  no  endo- 
carditis and  the  patient  recovered.  Instances  of  severe,  rapidly  fatal  general 
infection  in  gonorrhoea  are  probably  always  associated  with  foci  of  suppura- 
tion in  the  urinary  tract.  I  examined  in  Montreal  a  remarkable  case  of  rapid 
gonorrhoeal  sepsis  in  a  young  man,  who  within  ten  days  of  the  primary  lesion 
was  seized  with  severe  chills  and  high  fever.  He  rapidly  became  unconscious, 
the  fever  persisted,  and  he  fell  into  a  condition  of  profound  toxaemia  and  died 
early  on  the  morning  of  the  fourth  day  from  the  chill.  At  the  autopsy,  which 
was  made  about  twelve  hours  after  death,  there  was  an  acute  urethritis  and  a 
small  prostatic  abscess  not  more  than  2  or  3  cm.  in  diameter.  The  blood  was 
fluid,  tarry  black,  and  unlike  anything  I  have  ever  seen  before  or  since. 

Gonorrhoeal  Endocarditis. — This  is  a  frequent  and  serious  complication. 
Thayer  has  analyzed  the  cases  which  have  been  in  my  wards,  11  in  all.  In  6 
the  gonococci  were  demonstrated  morphologically  and  by  blood  culture.  In 
2  cases  they  were  demonstrated  only  by  staining.  In  2  instances  there  were 
mixed  infections.     One  case  was  t}^ical  clinically  and  at  autopsy. 

Of  other  cardiac  lesions,  pericarditis  occurred  in  7  of  the  30  fatal  cases 
collected  by  Thayer  and  Lazear. 

Acute  myocarditis  was  present  in  .Councilman's  case. 

2.  Gonorrhoeal  Arthritis.— In  many  respects  this  is  the  most  damaging, 
disabling,  and  serious  of  all  the  complications  of  gonorrhcea.  Clement  Lucas 
has  collected  23  cases  in  children,  of  which  18  followed  ophthalmia  neona- 
torum. It  occurs  more  frequently  in  males  than  in  females.  In  a  series  of 
252  cases  collected  by  Korthrup,  230  were  in  males;  130  cases  were  between 


GONORRHCEAL  INFECTION.  283 

twenty  and  thirty  years  of  age.  It  occurs,  as  a  rule,  during  an  acute  attack 
of  gonorrhoea.  In  208  of  ISTorthrup's  series  there  was  a  urethral  discharge 
while  in  hospital.  It  may  occur  as  the  attack  subsides,  or  even  when  it  has 
become  chronic.  A  gonorrhoea!  arthritis  of  great  intensity  may  occur  in  a 
newly  married  woman  infected  by  an  old  gleet  in  her  husband.  As  a  rule, 
many  joints  are  affected.  In  Northrup's  series  three  or  more  joints  were 
affected  in  175  cases,  one  joint  in  56  cases.  It  is  peculiar  in  attacking  certain 
joints  which  are  rarely  involved  in  acute  rheumatism,  as  the  sterno-clavicular, 
the  inter- vertebral,  the  temporo-maxillary  and  sacro-iliac. 

The  anatomical  changes  are  variable.  The  inflammation  is  often  peri- 
articular, and  extends  along  the  sheaths  of  the  tendons.  When  effusion  occurs 
in  the  joints  it  rarely  becomes  purulent.  It  has  more  commonly  the  charac- 
ters of  a  synovitis.  About  the  wrist  and  hand  suppuration  sometimes  occurs 
in  the  sheaths.  It  has  been  suggested  that  the  simple  arthritis  or  synovitis 
follows  absorption  of  ptomaines  from  the  urethral  discharge,  while  the  more 
severe  suppurating  forms  are  due  to  infection  with  pus  organisms.  It  has 
now  been  definitely  shown  that  the  gonococcus  itself  may  be  present  in  the 
inflamed  joint  or  in  the  peri-arthritic  exudate.  The  gonococcus  may  often 
be  obtained  in  pure  culture  from  the  joints.  Sometimes  the  cultures  are  nega- 
tive; in  other  instances  there  is  a  mixed  infection  with  staphylococci  or 
streptococci. 

Clinical  Course. — Variability  and  obstinacy  are  the  two  most  distinguish- 
ing features.     The  following  are  the  most  important  clinical  forms : 

(a)  Arthralgic,  in  which  there  are  wandering  pains  about  the  joints, 
without  redness  or  swelling.     These  persist  for  a  long  time. 

(h)  Poly  arthritic,  in  which  several  joints  become  affected,  just  as  in 
subacute  articular  rheumatism.  The  fever  is  slight;  the  local  inflammation 
may  fijc  itself  in  one  joint,  but  more  commonly  several  become  swollen  and 
tender.     In  this  form  cerebral  and  cardiac  complications  may  occur. 

(c)  Acute  gonorrhoeal  arthritis,  in  which  a  single  articulation  becomes 
suddenly  involved.  The  pain  is  severe,  the  swelling  extensive,  and  due  chiefly 
to  peri-articular  oedema.  The  general  fever  is  not  at  all  proportionate  to  the 
intensity  of  the  local  signs.  The  exudate  usually  resolves,  though  suppura- 
tion occasionally  supervenes. 

{d)  Chronic  Hydrarthrosis. — This  is  usually  mono-articular,  and  is  par- 
ticularly apt  to  involve  the  knee.  It  comes  on  often  without  pain,  redness, 
or  swelling.  Formation  of  pus  is  rare.  It  occurred  only  twice  in  96  cases 
tabulated  by  ISTolen. 

(e)  Bursal  and  Synovial  Form. — This  attacks  chiefly  the  tendons  and 
their  sheaths  and  the  bursDe  and  the  periosteum.  The  articulations  may  not 
be  affected.  The  bursse  of  the  patella,  the  olecranon,  and  the  tendo  Achillis 
are  most  apt  to  be  involved. 

(/)  Septiccemic. — In  which  with  an  acute  arthritis  the  gonococci  invade 
the  blood,  and  the  picture  is  that  of  an  intense  septico-pysemia,  usually  with 
endocarditis. 

(g)  The  Painful  Heel  of  Gonorrhcea. — This  is  a  remarkable  form  of  podo- 
dynia  due  to  local  periosteal  thickening  and  exostosis  on  the  os  calcis,  causing 
pain  and  great  disability.  Baer  has  demonstrated  the  gonococcus  in  the 
periosteal  lesion. 


284  SPECIFIC  INFECTIOUS  DISEASES. 

The  disease  is  much  more  intractable  than  ordinary  rheumatism,  and 
relapses  are  extremely  common.     It  may  become  chronic  and  last  for  years. 

Complications. — Iritis  is  not  infrequent  and  may  reciir  with  successive 
attacks.  The  visceral  complications  are  serious.  Endocarditis,  pericarditis, 
and  pleurisy  may  occur. 

Treatment. — The  salicylates  are  of  very  little  service,  nor  do  they  often 
relieve  the  pain  in  this  affection.  Iodide  of  potassium  has  also  proved  useless 
in  my  hands,  even  in  large  doses.  A  general  tonic  treatment  seems  much 
more  suitable — quinine,  iron,  and,  in  the  chronic  cases,  arsenic. 

The  local  treatment  is  very  important.  The  thermo-cautery  may  be  used 
to  allay  the  pain  and  reduce  the  swelling.  In  acute  cases,  fixation  of  the 
joints  is  very  beneficial,  and  in  the  chronic  forms,  massage  and  passive  motion. 
Good  results  follow  in  a  few  cases  the  use  of  the  dry  hot  air.  The  surgical 
treatment  of  this  affection,  as  carried  out  nowadays,  is  more  satisfactory,  and 
I  have  seen  strikingly  good  effects  from  incision  and  irrigation. 

A  vaccine  treatment  has  been  introduced,  and  good  results  are  reported  by 
Cole  and  others. 

XXXIII.     TUBERCULOSIS. 

I.  General  Etiology  and  Morbid  Anatomy, 

Definition. — An  infective  disease,  caused  by  Bacillus  tuberculosis,  the 
lesions  of  which  are  characterized  by  nodular  bodies  called  tubercles  or  diffuse 
infiltrations  of  tuberculous  tissue  which  undergo  caseation  or  sclerosis  and 
may  finally  ulcerate,  or  in  some  situations  calcify. 

Etiology. — 1.  Zoological  Distribution. — Tuberculosis  is  one  of  the  most 
widesjDread  of  maladies. 

In  cold-blooded  animals  it  is  rare,  owing  doubtless  to  temperature  con- 
ditions unfavorable  to  the  development  of  the  bacillus.  Among  reptiles  in 
confinement  it  is,  however,  occasionally  seen  (Sibley).  In  fowls  it  is  an 
extremely  common  disease,  but  there  are  differences  in  avian  tuberculosis  suf- 
ficient to  warrant  its  separation  from  the  ordinary  form. 

Among  domestic  animals  tuberculosis  is  widely  but  unevenly  distributed. 
Among  ruminants,  bovines  are  chiefly  affected.  In  sheep  the  disease  is  very 
rare.  In  pigs  it  is  frequent  in  some  parts  of  Europe.  Horses  are  rarely 
attacked.  Dogs  and  cats  are  not  prone  to  the  disease,  but  cases  are  described 
in  which  infection  of  pet  animals  has  taken  place  from  phthisical  masters. 
Among  the  semi-domestic  animals,  such  as  the  rabbit  and  guinea-pig,  the  dis- 
ease under  natural  conditions  is  rare,  although  these  animals,  particularly  the 
latter,  are  extremely  susceptible  to  it  when  inoculated.  Among  apes  and  mon- 
keys in  the  wild  state,  tuberculosis  is  unknown,  but  in  confinement  it  is  the 
most  formidable  disease  with  which  they  have  to  contend. 

The  important  etiological  fact  in  connection  with  tuberculosis  in  animals 
is  the  widespread  occurrence  of  the  disease  in  bovines,  from  which  class  we 
derive  nearly  all  the  milk  and  a  very  large  proportion  of  the  meat  used  for 
food. 

2.  General  Statistics  of  the  Disease  in  Man. — Tuberculosis  is  the 
most  universal  scourge  of  the  human  race.  It  prevails  more  particularly  in 
the  larger  cities  and  wherever  the  population  is  massed  together.     Irving 


TUBERCULOSIS.  285 

Fisher  estimates  (1908)  that  the  death-rate  at  present  in  the  United  States 
is  164  per  100,000  living,  that  the  deaths  in  1906  were  138,000,  and  that  of 
those  alive  at  present  5,000,000  would  die  of  the  disease.  In  England  and 
Wales  the  deaths  due  to  tuberculous  disease  in  1903  were  58,107,  11.3  per  cent 
of  the  total  mortality. 

Geographical  position  has  very  little  influence.  The  disease  is  perhaps 
more  prevalent  in  the  temperate  regions  than  in  the  tropics,  but  altitude  is  a 
more  potent  factor  than  latitude;  in  the  high  regions  of  the  Alps  and  Andes 
and  in  the  central  plateau  of  Mexico  the  death-rate  from  tuberculosis  is 
very  low. 

Race. — The  American  Indians'  have  a  death-rate  more  than  double  that 
of  the  whites.  The  negroes  in  the  Southern  States  also  have  an  extraordi- 
narily high  death-rate,  particularly  in  the  cities.  The  Irish,  both  at  home 
and  in  the  United  States,  are  more  prone  to  the  disease  than  other  European 
races.  The  rate  in  Ireland  has  increased,  and  in  America  the  mortality  is 
double  that  of  the  next  highest  European  race.  The.  Italians  in  the  large 
American  cities  show  a  very  high  death-rate.  The  Jews  everywhere  have  a 
low  mortality  from  consumption — about  one-half  that  of  Christians — which 
Fishberg  attributes  to  their  adaptation  to  city  life  for  the  past  2,000  years. 

The  Decrease  of  Tuberculosis. — There  has  been  everywhere  a  remarkable 
diminution  in  the  death-rate  from  the  disease.  The  United  States  Census 
Eeport  shows  a  decrease  of  9.4  per  cent  of  the  general  death-rate  in  1900  over 
1890,  and  a  decrease  of  33.4  per  cent  in  the  death-rate  from  consumption. 
The  English  reports  also  show  a  progressive  decrease.  It  is  more  particularly 
in  the  larger  cities  that  there  has  been  the  most  striking  fall  in  the  mortality. 
This  was  well  brought  out  for  London  by  Beevor's  careful  study,  while  in 
New  York  between  1887  and  1903,  a  period  of  sixteen  years,  there  has  been 
a  decrease  in  the  total  tuberculous  death-rate  of  40  per  cent  (Biggs).  In 
Massachusetts  the  rate  has  declined  from  3.901  per  million  inhabitants  in 
1851  to  1.595  in  1903  (S.  W.  Abbott). 

3.  Bacillus  Tuberculosis. — Eegarded  as  contagious  in  olden  time,  and 
always  in  certain  countries,  Villemin  first  placed  the  infective  nature  of  tuber- 
culosis on  a  solid  experimental  basis.  Cohnheim  and  Salomonsen  confirmed 
his  results.  Finally,  after  years  of  work,  came  the  isolation  of  the  tubercle 
bacillus  by  Koch,  who  demonstrated  its  invariable  association  with  the  dis- 
ease. The  investigations  which  he  had  previously  made  upon  anthrax  and 
experimental  traumatic  infections,  by  perfecting  the  methods  of  research, 
paved  the  way  for  this  brilliant  discovery.  His  preliminary  article  *  and  his 
more  elaborate  later  work  f  should  be  carefully  studied  by  any  one  who  wishes 
to  appreciate  the  value  of  scientific  methods.  It  forms  one  of  the  most  mas- 
terly demonstrations  of  modern  medicine.  Its  thoroughness  appears  in  the 
fact  that  in  the  years  which  have  elapsed  since  its  appearance  the  innumerable 
workers  on  the  subject  have  not,  so  far  as  I  know,  added  a  solitary  essential 
fact  to  those  presented  by  Koch. 

Morphological  Characters. — The  tubercle  bacillus  occurs  usually  as  a  short, 
fine  rod,  often  slightly  bent  or  curved,  and  has  an  average  length  of  nearly 
half  the  diameter  of  a  red  blood-corpuscle  (3  to  4  /a)  ;  more  rarely  it  shows 

*  Berliner  klinische  Wochenschrift,  1883. 

f  Mittheilungen  a.  d.  k.  Gesundheitsamte,  Bd.  3. 


286  SPECIFIC  INFECTIOUS  DISEASES. 

lateral  outgrowths  or  simple  branches.  When  stained  it  often  presents  a 
beaded  appearance,  which  some  have  attributed  to  the  presence  of  spores. 

With  the  basic  aniline  dyes  it  stains  slowly,  except  at  the  body  tempera- 
ture, but  retains  the  dye  after  treatment  with  acids — a  characteristic  which 
it  is  now  known  to  share  with  several  other  bacterial  species — the  bacillus 
leprEB,  bacillus  smegmatis,  the  grass  and  dung  bacilli  of  Moeller,  and  the  butter 
bacillus  of  Eabinowitsch. 

Modes  of  Growth. — It  grows  on  blood-serum,  glycerin-agar,  bouillon,  or 
on  potato — most  readily  on  the  first.  The  cultures  must  be  kept  at  blood- 
heat.  They  grow  slowly,  and  do  not  appear  until  about  the  end  of  the  second 
week.  The  colonies  form  thin,  grayish-white,  dry,  scale-like  or  Avrinkled 
masses  on  the  surface  of  the  culture  medium.  Successive  inoculations  may  be 
made  from  the  cultures,  and  at  the  end  of  an  indefinite  series  material  from 
one  of  them  inoculated  into  a  guinea-pig  will  produce  tuberculosis. 

Variations. —  (a)  In  Form. — The  small  branching  forms  are  found  not 
infrequently  in  tuberculous  lesions.  More  complex  structures,  resembling  the 
"  Driisen "  of  the  actinomyces  are  described,  and  involution  forms  are  not 
uncommon,  particularly  the  small,  oval,  or  round  deeply  staining  bodies  known 
as  Schron's  capsules. 

(&)  Specific  Varieties. — In  1901  Koch  startled  the  scientific  world  with 
the  statement  that  the  bacillus  of  bovine  tuberculosis  did  not  cause  human 
tuberculosis,  and  that  the  bacillus  of  human  tuberculosis  did  not  cause  tuber- 
culosis in  cattle.  At  the  Washington  Congi-ess  (1908)  he  admitted  that  they 
were  not  distinct  species,  but  differed  from  each  other  in  certain  characteristics, 
wliich  have  been  pointed  out  by  Theobald  Smith.  The  researches  of  von 
Behring,  Eavenel,  and  the  English  Commission  have  shown  that  it  is  possible 
to  cause  tuberculosis  in  cattle  with  the  bacillus  from  man;  and  there  are  many 
cases  in  man  caused  by  accidental  infection  from  cattle.  Bacillus  tuberculosis 
avium  appears  in  more  irregular  forms  and  produces  only  local  inflammatory 
processes  in  mammals.    Possibly  infection  with  it  may  sometimes  occur  in  man. 

Composition  and  Products. — Tubercle  bacilli  contain  water,  various  pro- 
teids,  fats  (to  which  the  peculiar  staining  reaction  is  due),  a  carbohydrate 
resembling  glycogen,  cellulose,  free  and  combined  nucleic  acid,  and  ash 
(P.  A.  Levene).  Koch's  tuberculin  is  a  proteid  glycerin  extract  from  the 
bacilli. 

Distribution  of  the  Bacilli. — The  bacilli  are  found  in  all  tuberculous 
lesions;  in  some  in  great  abundance,  in  others  sparsely.  They  are  particu- 
larly numerous  in  actively  growing  tubercles,  but  in  the  chronic  processes  of 
lymph-glands  and  of  the  joints  they  are  scanty.  When  a  tuberculous  focus 
communicates  with  a  vein  or  with  lymph-vessels,  the  bacilli  may  be  spread 
widely  throughout  the  body.  In  old  lesions  they  may  not  be  found  in  the  sec- 
tions, and  the  demonstration  of  the  true  nature  may  be  possible  only  by  culture 
or  inoculation.  They  are  present  in  the  blood  in  many  cases.  Large  amounts 
must  be  used  for  the  cultures.  Jousset  has  isolated  them  in  11  of  35  cases  of 
tuberculosis. 

The  Bacilli  outside  the  Body. — Patients  with  advanced  pulmonary  tuber- 
culosis throw  of  in  the  expectoration  countless  millions  of  the  bacilli  daily. 
From  a  patient  with  moderately  advanced  disease,  the  amount  of  whose  expec- 
toration was  from  70  to  130  cc.  daily,  Xuttall  estimated  that  there  were  in 


TUBERCULOSIS.  287 

sixteen  counts,  between  January  lOtli  and  March  1st,  from  one  and  a  half 
to  four  and  a  third  billions  of  bacilli  thrown  off  in  the  twenty-four  hours. 
These  figures  emphasize  the  danger  associated  with  phthisical  sputa  unless 
most  carefully  dealt  with.  When  expectorated  and  allowed  to  dry,  the  sputum 
rapidly  becomes  dust,  and  is  distributed  far  and  wide.  Cornet  collected  the 
dust  from  the  walls  and  bedsteads  of  various  localities,  and  determined  its 
virulence  or  innocuousness  by  inoculation  into  susceptible  animals.  Material 
was  gathered  from  21  wards  of  7  hospitals,  3  asylums,  2  prisons,  from  the  sur- 
roundings of  62  phthisical  patients  in  private  practice,  and  from  29  other 
localities  in  which  tuberculous  patients  were  only  transient  frequenters  (out- 
patient departments,  streets,  etc.).  Of  118  dust  samples  from  hospital  wards 
or  the  rooms  of  phthisical  patients,  40  were  infective  and  produced  tubercu- 
losis. Negative  results  were  obtained  with  the  29  dust  samples  from  the 
localities  occasionally  occupied  by  consumptives.  Virulent  bacilli  were  ob- 
tained from  the  dust  of  the  walls  of  15  out  of  21  medical  wards.  It  is  inter- 
esting to  note  that  in  2  wards  with  many  phthisical  patients  the  results  were 
negative,  indicating  that  the  dust  in  such  regions  is  not  necessarily  infective. 
The  infectiousness  of  the  dust  of  the  medical  and  surgical  divisions  of  a  hos- 
pital is  in  the  proportion  of  76.6  to  12.5.  In  a  room  in  which  a  tuberculous 
woman  had  lived  the  dust  from  the  wall  in  the  neighborhood  of  the  bed  was 
infective  six  weeks  after  her  death.  No  bacilli  were  found  in  the  dust  of  an 
inhalation-chamber  for  consumptives.  The  experiments  of  Straus  at  the 
Charite  •  Hospital,  Paris,  are  important.  In  the  nostrils  of  29  assistants, 
nurses,  and  ward-tenders  he  placed  plugs  of  cotton-wool  to  collect  the  dust 
of  the  wards.  In  9  of  the  29  cases  these  contained  tubercle  bacilli  and  proved 
infective  to  animals.  The  question  of  the  increase  of  tuberculosis  among  the 
permanent  residents  of  health  resorts  frequented  by  consumptives  is  one  of 
great  interest.  Gardiner  has  studied  the  problem  at  Colorado  Springs,  in 
which  for  twenty  years  tuberculous  patients  have  been  living,  and  he  finds 
the  number  of  cases  of  tuberculosis  originating  in  the  city  to  be  very  small. 

Pseudo-tuberculosis. — While  lesions  resembling  the  nodules  of  tuberculosis, 
but  due  to  a  variety  of  bacteria,  protozoa,  and  nematodes,  are  not  uncom- 
mon in  animals,  pseudo-tuberculous  processes  are  very  rare  in  human  beings. 
Flexner  has  described,  under  the  name  pseudo-tub eixulo sis  hominis  strepto- 
thrica,  a  condition  in  human  beings  in  which  the  lungs  presented  the  appear- 
ance of  a  caseous  pneumonia  and  numerous  tubercle-like  nodules  existed  in 
the  peritonaeum.  The  micro-organism  found  in  the  lesions  was  a  strepto- 
thrix,  which  differed  greatly  from  the  known  forms  of  the  bacillus  tuberculosis 
and  streptothrix  aetinomyces. 

4.  Modes  of  Infection. — (a)  Hereditary  Transmission. — The  possible 
methods  of  transmission  of  the  germ  in  direct  inheritance  are  three — trans- 
mission by  the  sperm,  transmission  by  the  ovum,  and  transmission  through 
the  blood  by  means  of  the  placenta. 

There  is  no  clinical  evidence  to  support  the  view  that  direct  transmission 
can  occur  through  the  sperm.  In  order  that  the  disease  could  be  transmitted 
by  the  sperm  it  would  be  necessary  that  the  tubercle  bacilli  should  lodge  in 
the  individual  spermatozoon  which  fecundates  the  ovum.  The  chances  that 
such  a  thing  could  occur  are  extremely  small,  looking  at  the  subject  from 
a  numerical  point  of  view,  although  we  know  that  tubercle  bacilli  do  occa- 


288  SPECIFIC  INFECTIOUS  DISEASES. 

sionally  exist  in  the  semen;  they  become  still  smaller  when  we  consider  that 
the  spermatozoon  is  made  up  of  nuclear  material,  which  the  tubercle  bacillus 
is  never  known  to  attack.  Experimentation  is  all  opposed  to  sperm  transmis- 
sion, the  work  of  Gartner  and  others  showing  that  the  young  of  healthy 
female  rabbits  impregnated  by  tuberculous  males  are  never  tuberculous,  even 
though  the  females  themselves  often  contract  the  disease. 

The  possibility  of  transmission  by  the  ovum  must  be  accepted.  Baum- 
garten  has  in  one  instance  been  able  to  detect  the  tubercle  bacillus  in  the 
ovum  of  a  female  rabbit  which  he  had  artificially  fecundated  with  tubercu- 
lous semen.  The  work  of  Pasteur  on  pehrine  has  shown  the  possibility  of  this 
form  of  transmission  in  the  lower  forms,  though  the  question  as  to  what  effect 
such  inoculation  would  have  upon  the  human  ovum  can  not  of  course  be 
answered. 

Probably  the  almost  constant  method  of  transmission  in  congenital  tuber- 
culosis is  through  the  blood  current,  the  tubercle  bacilli  penetrating  by  way 
of  the  placenta.  Certain  authors  hold  that  in  these  cases  the  placenta  itself 
is  invariably  the  seat  of  tuberculosis,  and  tubercles,  indeed,  have  been  demon- 
strated in  several  cases;  but  there  are  undoubted  instances  in  which,  with  an 
apparently  sound  placenta,  both  the  placental  blood  and  the  foetal  organs 
contained  tubercle  bacilli,  notwithstanding  the  fact  that  the  organs  also 
appeared  normal. 

Possible  Latency  of  the  Tubercle  Oerms. — Baumgarten  and  his  followers 
assume  that  the  tubercle  bacilli  can  lie  latent  in  the  tissues  and  subsequently 
develop  when,  for  some  reason  or  other,  the  individual  resistance  is  lowered. 
He  likens  such  cases  of  latent  tuberculosis  to  the  late  hereditary  forms  of 
s}^hilis,  and  explains  the  lack  of  development  of  the  germs  by  the  greater 
resisting  power  of  the  tissues  of  children.  Baumgarten  bases  his  belief  in 
germ  transmission  upon  two  main  factors — the  great  frequency  of  the  disease 
in  early  life  and  the  localization  of  tuberculous  lesions  in  children. 

The  mortality  from  tuberculosis  in  the  first  years  of  life  is  relatively  high. 
Of  2,576  autopsies  made  on  children,  27.8  per  cent  who  died  in  the  first  year 
were  tuberculous  (Botz).  Of  182  autopsies  on  children  one  year  or  under,  17 
were  tuberculous  (Comby).  The  localization  of  tuberculous  lesions  in  chil- 
dren in  the  bones  or  joints  is  very  common,  Cnopp's  statistics  showing  that 
out  of  298  tuberculous  children  of  from  a  few  days  to  twelve  years  of  age,  147 
had  bone  or  joint  tuberculosis,  and  only  8  of  these  showed  evidence  of  vis- 
ceral disease.  Baumgarten  is  of  the  opinion  that  the  accidental  conveyance 
of  tubercle  bacilli  to  these  points  would  not  account  for  such  a  large  propor- 
tion of  cases,  and  expresses  the  view  that  the  bacilli  have  been  present  since 
birth  and  have  developed  when  favorable  conditions  offered.  The  evidence  in 
favor  of  Baumgarten's  view  is  both  clinical  and  experimental. 

The  clinical  evidence  exists  in  the  form  of  undoubted  cases  of  congenital 
tuberculosis.  Warthin  and  Cowie  in  a  recent  study  conclude  that  there  are 
only  five  undoubted  cases.  A  large  proportion  of  those  reported  are  doubtful, 
as  the  diagnosis  rested  on  anatomical  appearances  without  the  detection  of 
the  bacilli. 

A  number  of  laboratory  workers  have  been  able  to  show  that  congenital 
tuberculosis  can  be  produced  experimentally,  the  most  prominent  of  these 
being  Gartner,  who  was  able  to  cause  tuberculosis  in  young  mice  by  inocu- 


TUBERCULOSIS.  289 

lating  the  mother  with  tuberculosi.?,  into  either  the  peritoneal  cavit}^  or  tlie 
blood  stream.  Maffucci  showed  that  after  injecting  eggs  with  avian  tubercu- 
losis the  disease  may  remain  latent  in  the  chick  for  weeks  or  even  months. 

Against  Baumgarten's  theory  are  the  facts  that  the  percentage  of  cases  of 
congenital  tuberculosis  is  extremely  small,  and  that  in  the  great  majority  of 
instances  the  organs  of  foetuses  born  of  tuberculous  mothers  give  negative 
results  when  inoculated  into  guinea-pigs. 

The  statistics  of  pulmonary  tuberculosis  with  reference  to  hereditary  trans- 
mission have  been  put  on  a  new  basis  by  the  studies  of  Karl  Pearson.  For- 
merly, the  disease  itself  was  believed  to  be  transmitted,  but  we  know  now 
that  this  is  most  exceptional.  It  is  another  matter  with  the  soil — is  there  a 
special  disposition  of  tissue  favorable  to  the  development  of  the  more  or  less 
ubiquitous  germ?  On  this  point  Pearson  concludes  from  his  researches  (Sta- 
tistics of  Pulmonary  Tuberculosis,  Dulan  &  Co.,  London,  1907)  that  "the 
diathesis  of  pulmonary  tuberculosis  is  certainly  inherited,  and  the  intensity 
of  the  inheritance  is  sensibly  the  same  as  that  of  any  normal  physical  char- 
acter yet  investigated  in  man.  Infection  probably  plays  a  necessary  part, 
but  in  the  artisan  classes  of  the  urban  populations  of- this  country  (England) 
it  is  doubtful  if  their  members  can  escape  the  risks  of  infection,  except  by 
the  absence  of  diathesis — i.  e.,  the  inheritance  of  what  amounts  to  a  counter- 
disposition."  Another  point  of  interest  brought  out  by  Pearson  is  that  whether 
we  deal  with  all  tuberculosis  stocks  or  only  with  those  having  no  parental 
history,  the  elder  children,  particularly  the  first  and  second,  are  subject  to 
tuberculosis  at  a  much  higher  rate  than  the  younger  members — "  if  this  special 
incidence  in  the  earlier  born  be  found  to  be  true  of  other  forms  of  patholog- 
ical inheritance,  we  have  a  very  serious  factor  of  national  deterioration  intro- 
duced by  the  growing  limitations  of  the  family." 

While  the  demonstration  of  the  contagiousness  of  tuberculosis  has  in  some 
quarters  intensified  the  dread  with  which  the  disease  is  regarded,  the  terrible 
Ate  of  hereditary  transmission  has  been  in  great  part  abolished,  to  the  great 
gain  of  suffering  humanity. 

(&)  Inoculation. — The  infective  nature  of  tuberculosis  was  first  demon- 
strated by  Villemin,  who  showed  conclusively  in  1865  that  it  could  be  trans- 
mitted to  animals  by  inoculation.  The  beautiful  experiments  of  Cohnheim 
and  Salomonsen,  who  produced  tuberculosis  in  the  eyes  of  guinea-pigs  and 
rabbits  by  inoculating  fresh  tubercle  into  the  anterior  chamber,  confirmed  and 
extended  Villemin's  original  observations  and  paved  the  way  for  the  reception 
of  Koch's  announcement.  It  is  now  universally  conceded  that  only  tubercu- 
lous matter  can  produce,  when  inoculated,  tuberculosis.  In  man  tuberculosis 
is  not  often  transmitted  by  inoculation,  and  when  it  does  occur  the  disease 
usually  remains  local.  This  mode  of  infection  is  seen  in  persons  whose  occu- 
pation brings  them  in  contact  with  dead  bodies  or  animal  products.  Demon- 
strators of  morbid  anatomy,  butchers,  and  handlers  of  hides  are  subject  to  a 
local  tubercle  of  the  skin,  which  forms  a  reddened  mass  of  granulation  tissue, 
usually  capping  the  dorsal  surface  of  the  hand  or  finger.  This  is  the  so-called 
post-mortem  wart,  the  verruca  necrogenica  of  Wilks.  The  demonstration  of 
its  nature  is  shown  by  the  presence  of  tubercle  bacilli,  and  by  inoculation 
experiments  in  animals. 

The  statement  that  Laennec  contracted  phthisis  from  this  source  is  prob- 
20 


290  SPECIFIC  INFECTIOUS  DISEASES. 

ably  false,  since  he  did  not  die  until  twenty  years  after  the  inoculation  and 
in  the  interval  presented  no  manifestations.  The  possibility,  however,  of  gen- 
eral infection  must  be  borne  in  mind.  Gerber  reports  that  after  accidental 
inoculation  in  the  hand  from  a  case  of  phthisis  he  had  for  months  a  "  Leichen- 
tubercle,"  which  was  excised.  Shortly  afterward  the  lymph-glands  of  the 
axilla  became  enlarged  and  painful,  and  when  removed  showed  characteristic 
tuberculous  changes,  with  bacilli. 

In  the  performance  of  the  rite  of  circumcision  children  have  been  acci- 
dentally inoculated.  Infection  in  these  cases  is  probably  always  associated 
with  disease  in  the  operator,  and  occurs  in  connection  with  the  habit  of  cleans- 
ing the  wound  by  suction. 

Other  means  of  inoculation  have  been  described:  as  the  wearing  of  ear- 
rings, washing  the  clothes  of  phthisical  patients,  the  bite  of  a  tuberculous 
subject,  or  inoculation  from  a  cut  by  a  broken  spit-glass  of  a  consumptive ;  and 
Czerny  has  reported  two  cases  of  infection  by  transplantation  of  skin. 

It  has  been  urged  by  the  opponents  of  vaccination  that  tuberculosis,  as 
well  as  syphilis,  may  be  thus  conveyed,  but  of  this  there  is  no  evidence. 
Lymph  of  revaccinated  consumptives  is  non-infective.  Lupus  has  originated 
at  the  site  of  vaccination  in  a  few  cases  (C.  Fox,  Graham  Little).  It  may 
be  said,  on  the  whole,  that  inoculation  in  man  plays  a  trifling  role  in  the 
transmission  of  tuberculosis. 

(c)  Infection  ly  Inhalation. — A  belief  in  the  contagiousness  of  pulmo- 
nary tuberculosis  has  existed  from  the  days  of  the  early  Greek  physicians, 
and  has  persisted  among  the  Latin  races.  The  investigations  of  Cornet  afford 
conclusive  proof  that  the  dust  of  a  room  or  other  locality  frequented  by 
patients  with  pulmonary  tuberculosis  is  infective.  The  bacilli  are  attached 
to  fine  particles  of  dust  and  in  this  way  gain  entrance  to  the  system  through 
the  lungs. 

Fliigge  denies  that  the  bacillus-containing  dust  is  the  dangerous  element 
in  infection.  Experimentally  he  has  only  succeeded  in  producing  the  disease 
when  there  is  some  lesion  in  the  respiratory  tract.  He  thinks  that  the  danger 
of  infection  by  the  dry  sputum  is  very  improbable.  On  the  other  hand,  he 
thinks  that  the  infection  is  chiefly  conveyed  by  the  free,  finely  divided  par- 
ticles of  sputum  produced  in  the  act  of  coughing,  and  that  these  tiny  frag- 
ments are  suspended  in  the  atmosphere.  Those  who  cough  very  much  and 
with  the  mouth  open  are  most  liable  to  infect  the  surrounding  air. 

It  is  well  remarked  by  Cornet,  "The  consumptive  in  himself  is  almost 
harmless,  and  only  becomes  harmful  through  bad  habits."  It  has  been  fully 
shown  that  the  expired  air  of  consumptives  is  not  infective.  The  virus  is 
only  contained  in  the  sputum,  which  when  dry  is  widely  disseminated  in  the 
form  of  dust,  and  constitutes  the  great  medium  for  the  transmission  of  the 
disease. 

Among  the  points  urged  in  favor  of  this  mode  of  infection  are : 

(1)  Primary  tuberculous  lesions  are  in  a  majority  of  all  cases  connected 
with  the  respiratory  system.  The  frequency  with  which  foci  are  met  with 
in  the  lungs  and  in  the  bronchial  glands  is  extraordinary,  and  the  statistics 
of  the  Paris  morgue  show  that  a  considerable  proportion  of  all  persons  dying 
of  accident  or  by  suicide  present  evidences  of  the  disease  in  these  parts.  The 
post-mortem  statistics  of  hospitals  show  the  same  wide-spread  prevalence  of 


TUBERCULOSIS.  291 

infection  through  the  air-passages.  Biggs  reports  that  more  than  60  per  cent 
of  his  post  mortems  showed  lesions  of  pulmonary  tuberculosis.  In  125  autop- 
sies at  the  Foundling  Hospital,  New  York,  the  bronchial  glands  were  tuber- 
culous in  every  case.  In  adults  the  bronchial  glands  may  be  infected  and  the 
individual  remain  in  good  health.  H.  P.  Loomis  found  in  8  of  30  cases  in 
which  there  were  no  signs  of  old  or  recent  tuberculous  lesions  that  the  bron- 
chial glands  were  infective  to  rabbits. 

(2)  The  greater  prevalence  of  tuberculosis  in  institutions  in  which  the 
residents  are  confined  and  restricted  in  the  matter  of  fresh  air  and  a  free 
open  life — conditions  which  would  favor,  on  the  one  hand,  the  presence  of  the 
bacilli  in  the  atmosphere,  and,  on  the  other,  lower  the  vital  resistance  of  the 
individual.  The  investigations  of  Cornet  upon  the  death-rate  from  consump- 
tion among  certain  religious  orders  devoted  to  nursing  give  some  striking 
facts  in  illustration  of  this.  In  a  review  of  38  cloisters,  embracing  the  aver- 
age number  of  4,028  residents,  among  2,099  deaths  in  the  course  of  twenty- 
five  years,  1,320  (62.88  per  cent)  were  from  tuberculosis.  In  some  cloisters 
more  than  three-fourths  of  the  deaths  are  from  this  disease,  and  the  mortal- 
ity in  all  the  residents,  up  to  the  fortieth  year,  is  greatly  above  the  average, 
the  increase  being  due  entirely  to  the  prevalence  of  tuberculosis.  It  has  been 
stated  that  nurses  are  not  more  prone  to  the  disease  than  other  individuals,  but 
Cornet  says  that  of  100  nurses  deceased,  63  died  of  tuberculosis.  The  more 
perfect  the  prophylaxis  and  hygienic  arrangements  of  an  asylum  or  institu- 
tion, the  lower  the  death-rate  froin  tuberculosis.  The  mortality  in  prisons 
has  been  shown  by  Baer  to  be  four  times  as  great  as  outside.  The  death-rate 
from  phthisis  is  estimated  at  15  per  cent  of  the  total  mortality,  while  in 
prisons  it  constitutes  from  40  to  50  per  cent,  and  in  some  countries,  as  Austria, 
over  60  per  cent.  Flick  has  studied  the  distribution  of  the  deaths  from 
tuberculosis  in  a  single  city  ward  in  Philadelphia  for  twenty-five  years.  His 
researches  go  far  to  show  that  it  is  a  house  disease.  About  33  per  cent  of 
infected  houses  have  had  more  than  one  case.  Less  than  one-third  of  the 
houses  of  the  ward  became  infected  with  tuberculosis  during  the  twenty-five 
years  prior  to  1888.  Yet  more  than  one-half  of  the  deaths  from  this  disease 
during  the  year  1888  occurred  in  those  infected  houses.  There  are,  however, 
opposing  facts.  The  statistics  of  the  Brompton  Consumption  Hospital  show 
that  doctors,  nurses,  and  attendants  are  rarely  attacked.  Dettweiler  claims 
that  no  case  of  tuberculosis  has  been  contracted  among  his  nurses  or  attend- 
ants at  Falkenstein.  On  the  other  hand,  in  the  Paris  hospitals  tuberculosis 
decimates  the  attendants. 

(3)  Special  danger  is  believed  to  exist  when  the  contact  is  very  intimate, 
as  between  man  and  wife.  Until  recently  nearly  all  writers  have  held  that 
under  these  circumstances  the  husband  or  wife  is  much  more  likely  subse- 
quently to  die  of  tuberculosis.  Upon  the  figures  of  the  late  Ernest  Pope,  of 
Saranac,  Karl  Pearson  bases  the  following  conclusions:  (a)  There  is  some  sen- 
sible but  slight  infection  between  married  couples ;  ( & )  this  is  largely  obscured 
or  forestalled  by  the  fact  of  infection  from  outside  sources;  (c)  the  liability 
to  the  infection  depends  on  the  presence  of  the  necessary  diathesis;  (d)  assorta- 
tive  mating  probably  accounts  for  at  least  two-thirds,  and  infective  action  not 
more  than  one-third  of  the  whole  correlation  observed  in  these  cases.  There 
are  cases  in  which  this  source  of  infection  seems  to  play  an  important  role. 


292  SPECIFIC  INFECTIOUS  DISEASES. 

(d)  Infection  by  Ingestion. — The  work  of  the  past  few  years  has  shown 
that  we  have  taken  too  restricted  a  view  in  supposing  infection  in  tubercu- 
losis to  be  chiefly  through  the  lungs.  There  are  two  other  channels,  the  ton- 
sils and  the  intestines,  both  of  great  importance. 

Tonsillar  Infection. — The  frequency  of  involvement  of  these  glands  has 
been  shown  by  Schlenker,  Arthur  Latham,  and  Walsham.  The  bacilli  pass 
to  the  glands  of  the  neck  and  of  the  mediastinum,  and  reach  the  circulation 
through  the  lymph-channels.  Or  an  infected  bronchial  gland  becomes  adher- 
ent to  a  branch  of  the  pulmonary  artery;  if  a  large  number  of  bacilli  escape, 
miliary  tuberculosis  follows;  if  only  a  small  number,  they  reach  the  lungs, 
at  the  apices  of  which  they  fmd  conditions  suitable  for  their  growth.  Through 
this  tonsillar-cervical  route  bacilli  may  gain  entrance  without  causing  local 
disease  at  the  portal  of  entry.  It  is  a  common  method  of  infection  in  chil- 
dren, causing  the  "  scrofulous  "  glands  of  the  neck. 

Intestinal  Infection. — Behring  announced  in  1903  that  pulmonary  tuber- 
culosis could  be  induced  through  intestinal  infection,  and  he  further  main- 
tained that  milk  fed  to  infants  was  the  chief  cause  of  consumption  in  adults, 
the  infection  remaining  latent.  Behring's  first  contention  was  supported  by 
Eavenel  and  others,  who  produced  pulmonary  tuberculosis  in  animals  by  feed- 
ing experiments,  and  it  was  demonstrated  that  the  intestinal  surface  itself 
might  remain  intact.  This  does  away  with  the  objection  raised  by  Koch 
that  if  infection  through  the  milk  of  tuberculous  cattle  were  common,  primary 
intestinal  tuberculosis  should  be  more  frec|uent,  whereas  in  ten  years  among 
3,10-1  cases  of  tuberculosis  in  children  there  were  only  16  of  primary  bowel 
infection.  Eecent  experiments  have  shown  in  a  striking  manner  how  the 
lungs  act  as  filters  for  particles  absorbed  from  the  intestines.  Vansteenberghe 
and  Grysez  have  produced  anthracosis  of  the  lungs  by  introducing  china-ink 
emulsion  directly  into  the  stomach  (see  Anthracosis,  p.  631).  They  found 
a  remarkable  difference  in  young  and  adult  guinea-pigs,  in  the  former  the 
carbon  particles  were  filtered  out  by  the  mesenteric  glands,  while  the  lungs 
remained  free;  in  the  latter  the  glands  were  unaffected,  but  the  lungs  were 
carbonized.  Calmette  and  Guerin,  repeating  the  experiments  of  Eavenel  with 
improved  technique,  have  shown  how  easily  the  lungs  may  be  infected  through 
the  intestinal  route  without  leaving  the  slightest  trace  of  disease  of  the  bowel 
itself.  Behring's  view  of  the  importance  of  infection  through  the  intestinal 
route  has  thus  received  the  strongest  support,  and  many  go  so  far  as  to  main- 
tain that  a  majority  of  all  cases  of  phthisis  originate  in  this  manner.  The 
truth  is  that  this  ubiquitous  bacillus  is  not  particular,  and  gains  entrance 
through  many  portals — throat,  lungs,  and  intestines.  The  important  matter 
for  the  individual  is  the  nature  of  the  soil  on  which  it  falls. 

Of  foods,  milk  alone  is  a  common  source  of  infection,  particularly  in  the 
large  cities.  In  Xew  York,  Hess  found  tubercle  bacilli  in  16  per 'cent  of 
107  specimens!     The  ordinary  commercial  pasteurization  does  not  kill  them. 

The  flesh  of  tuberculous  animals  is  rarely  dangerous. 

5.  Conditions  Influencing  Infection. — (a)  General. — Environment  is 
an  all-important  predisposing  factor.  Dwellers  in  cities  are  much  more  prone 
to  the  disease  than  residents  of  the  country.  Not  only  is  the  liability  to  infec- 
tion very  much  greater,  but  the  conditions  of  life  are  such  that  the  powers 
of  resistance  are  apt  to  be  weakened.    As  already  stated,  sunlight  is  one  of 


TUBERCULOSIS.  293 

the  most  powerful  agents  in  destroying  the  tubercle  bacillus,  so  that  in  im- 
perfectly ventilated  dwellings  and  workshops,  and  in  residences  in  close,  dark 
alleys,  and  in  tenement  houses  the  liability  to  infection  is  very  much  increased. 
The  influence  of  environment  was  never  better  demonstrated  than  in  the  now 
well-known  experiment  of  Trudeau,  who  found  that  rabbits  inoculated  with 
tuberculosis  if  confined  in  a  dark,  damp  place  without  sunlight  and  fresh  air 
rapidly  succumbed,  while  others  treated  in  the  same  way,  but  allowed  to  run 
wild,  either  recovered  or  showed  very  slight  lesions.  The  occupants  of 
prisons,  asylums,  and  poorhouses,  too  often,  indeed,  in  barracks  and  large 
workshops,  are  in  the  position  of  Trudean's  rabbits  in  the  cellar,  and  under 
conditions  most  favorable  to  foster  the  development  of  the  bacilli  which  may 
have  lodged  in  their  tissues.  The  frequent  respiration  of  air  already  breathed, 
upon  which  MacCormac  of  Belfast  laid  so  much  stress,  appears  to  render  the 
lungs  less  capable  of  resisting  infection. 

The  observations  of  Henry  I.  Bowditeh  in  this  country  and  of  Buchanan 
in  England  show  that  the  disease  prevails  more  widely  in  the  wet,  ill-drained 
districts — an  increase  which  is  associated  with  heightened  vulnerability  and 
greater  liability  to  catarrhal  affections  of  all  kinds.  Gordon  of  Exeter  has 
shown  that  the  mortality  is  high  in  regions  exposed  to  strong  rainy  winds. 
The  influence  of  the  dwelling  has  been  already  referred  to  in  connection  with 
Flick's  work.  No  single  condition  is  of  greater  importance  than  that  which 
relates  to  the  proper  arrangement  and  ventilation  of  the  dwelling  house. 

(&)  Individual  Predisposition. — The  fathers  of  medicine,  more  particu- 
larly Hippocrates,  Aretseus,  and  Galen,  laid  great  stress  upon  the  bodily  con- 
formation of  those  prone  to  consumption.  A  great  deal  was  written  on  the 
so-called  habitus  phthisicus,  which  Hippocrates  described  in  the  following 
terms :  "  The  form  of  body  peculiar  to  subjects  of  phthisical  complaints  was 
the  smooth,  the  whitish,  that  resembling  the  lentil ;  the  reddish,  the  blue-eyed, 
the  leuco-phlegmatic ;  and  that  with  the  scapulge  having  the  appearance  of 
wings."  Undoubtedly  the  long,  narrow,  flat  chest  with  depressed  sternum  is 
commonly  enough  seen  in  tuberculous  patients,  but  there  are  only  too  many 
individuals  with  perfectly  well-shaped  chests  who  fall  victims  annually  to 
the  disease.  The  tuberculous  or  scrofulous  diathesis,  upon  which  formerly 
so  much  stress  was  laid,  is  now  regarded  simply  as  an  indication  of  a  type 
of  conformation  in  which  the  tissues  are  more  vulnerable  and  less  capable  of 
resisting  infection.  Beneke's  investigations  on  the  viscera  of  phthisical 
patients  indicate  that  the  heart  is  relatively  small,  the  arteries  proportionately 
narrow,  and  the  pulmonary  artery  relatively  wider  than  the  aorta.  He  sug- 
gests that  this  may  lead  to  increase  in  the  intrapulmonary  blood  pressure, 
and  so  favor  catarrhal  processes.  The  lung  volume  he  found  relatively  greater 
in  those  affected  with  tuberculosis.  A  study  of  the  composite  portraiture  of 
pulmonary  tuberculosis  has  been  made  by  Gallon  and  Mahomed.  In  443 
patients  they  separated  two  types  of  face — one  ovoid  and  narrow,  the  other 
broad  and  coarse-featured.  This  corresponds  in  an  interesting  way  to  the 
diathetic  states  formerly  recognized — namely,  the  tuberculous,  with  thin  skin, 
bright  eyes,  oval  face,  and  long,  thin  bones;  and  the  scrofulous,  with  thick 
lips  and  nose,  opaque  skin,  large,  thick  bones,  and  heavy  figure.  These  con- 
ditions, on  which  so  much  stress  was  formerly  laid,  indicate,  as  Fagge  states, 
nothing  more  than  delicacy  of  constitution,  incomplete  growth,  and  imperfect 


294  SPECIFIC  INFECTIOUS  DISEASES. 

dovolopmcnt.  Sir  A.  E.  Wright  lias  shown  that  the  natural  protective  ele- 
ments, the  opsonins,  of  tlie  hlood  are  low  in  tuberculous  patients,  whose  phago- 
cytic index  is  also  very  much  below  the  normal  standard. 

(c)  Influence  of  Age. — Xo  age  is  exempt.  The  disease  is  met  with  in 
the  suckling  and  in  the  octogenarian.  Pulmonary  tuberculosis  occurs  most 
frequently,  as  stated  by  Hippocrates,  from  the  eighteenth  to  the  thirty-fifth 
year.  From  the  fifth  to  the  tenth  year  individuals  are  less  prone  to  the  dis- 
ease. Barbier  and  Bondin  (1908)  have  studied  the  frequency  of  tuberculosis 
in  children  up  to  the  fifteenth  year  in  the  Paris  Hospitals.  Of  1,364,  396 
were  tuberculous,  31  per  cent.  At  different  ages  different  organs  are  more 
prone  to  be  involved.  During  the  first  decade  the  bones,  meninges,  and  IjTuph- 
glands  are  more  frequently  affected  than  at  subsequent  periods. 

(d)  Sex. — The  infiuence  of  sex  is  very  slight.  Women  are  perhaps  some- 
what more  frequently  attacked  than  men,  possibly  from  the  fact  that  in  a 
more  sedentary,  indoor  life  they  are  more  liable  to  infection.  Pregnancy  and 
lactation  also  are  two  conditions  which  are  apt  to  lower,  perhaps,  the  resistance 
of  the  organism. 

(e)  Race. —  (See  page  285.) 

(f)  Influence  of  Occupation. — The  characteristics  of  an  employment 
which  tends  to  make  tuberculosis  unusually  prevalent  may  be  thus  summa- 
rized :  a  low  rate  of  wage,  unsanitary  surroundings,  exposure  to  dust,  excessive 
physical  exertion,  close  confinement  indoors,  exposure  to  excessive  heat,  temp- 
tations to  intemperance,  with  long  and  irregular  hours   (L.  Brandt). 

{g)  Certain  local  conditions  influence  infection,  among  which  the  follow- 
ing are  the  most  important: 

The  influence  of  catarrh  of  the  respiratory  passages  in  pulmonary  tuber- 
culosis is  well  recognized.  How  often  is  a  neglected  cold  blamed  as  the 
starting-point  of  the  disease !  It  seems  to  act  by  lowering  the  resistance  and 
favoring  the  conditions  which  enable  the  bacilli  either  to  enter  the  system  or, 
when  once  in  it,  to  grow.  The  liability  of  children  to  lymphatic  tuberculosis 
is  probably  associated  with  the  common  catarrhal  processes  in  the  tonsils, 
throat,  and  bronchi. 

Certain  of  the  specific  fevers  predispose  to  tuberculosis,  among  which 
measles  and  whooping-cough  stand  pre-eminent.  They  are  often  associated 
with  a  bronchial  catarrh.  In  some  of  the  cases  it  is  probably  not  a  fresh 
infection  which  follows,  but  the  blazuig  of  a  smouldering  fire.  Typhoid  fever, 
influenza,  variola,  and  syphilis  are  all  believed  to  favor  the  occurrence  of  the 
disease.  Diabetes,  as  is  well  known,  very  often  terminates  in  pulmonary 
tuberculosis,  particularly  in  young  persons. 

Chronic  heart-disease,  arterio-sclerosis,  aneurism  of  the  aorta,  forms  of 
chronic  nephritis,  cirrhosis  of  the  liver,  and  the  various  forms  of  cerebro- 
spinal sclerosis,  all  are  conditions  which  favor  infection.  It  is  remarkable 
in  how  many  of  the  subjects  of  these  disorders  in  general  hospital  practice  the 
fatal  event  is  a  terminal  acute  tuberculosis,  most  frequently  of  the  serous 
membranes.  Subjects  of  congenital  or  acquired  contraction  of  the  orifice  of 
the  pulmonary  artery  usually  die  of  tuberculosis.  On  the  other  hand,  mitral 
valve  disease,  particularly  stenosis,  is  stated  to  antagonize  the  disease  (J.  E. 
Graham).  In  children  catarrhal  entero-colitis  probably  favors  the  origin  of 
tabes  mesenterica. 


TUBERCULOSIS.  295 

The  influence  of  haemoptysis  and  pleurisy  will  be  referred  to  later. 

Trauma. — The  relation  of  injury  to  tuberculosis  is  well  known.  A  blow 
upon  the  chest  may  cause  a  pulmonary  or  pleural  tuberculosis;  injury  to 
the  knee,  a  tuberculous  arthritis ;  a  blow  on  the  head,  tuberculous  meningitis. 
Probably  in  these  cases  the  injured  part  is  for  a  time  a  locus  minoris  resisten- 
tice,  and  if  bacilli  are  present  they  may  receive  a  stimulus  to  growth  or  under 
the  altered  conditions  become  capable  of  multiplying.  The  whole  question 
is  very  fully  discussed  by  Stern  in  his  work  on  the  relation  of  internal  disease 
to  injury.  The  relation  of  surgical  intervention  in  local  tuberculosis  to  the 
generalization  of  the  disease  is  important.  An  existing  lesion  may  be  aggra- 
vated, and  fresh  local  lesions  may  appear,  and,  most  serious  of  all,  acute  mil- 
iary tuberculosis  may  follow. 

General  Morbid  Anatomy  and  Histology  of  Tuberculous  Lesions. — (1) 
Distribution  of  the  Tubercles  in  the  Body. — The  organs  of  the  body  are 
variously  affected  by  tuberculosis.  In  adults,  the  lungs  may  be  regarded  as 
the  seat  of  election;  in  children,  the  lymph-glands,  bones,  and  joints.  In 
1,000  autopsies  there  were  275  cases  with  tuberculous  lesions.  With  but  two 
or  three  exceptions  the  lungs  were  aflected.  The  distribution  in  the  other 
organs  was  as  follows :  Pericardium,  7 ;  peritonasum,  36 ;  brain,  31 ;  spleen,  33 ; 
liver,  13 ;  kidneys,  33 ;  intestines,  65 ;  heart,  4 ;  and  generative  organs,  8. 

The  tuberculosis  which  comes  under  the  care  of  the  surgeon  has  a  differ- 
ent distribution,  as  shovni  by  the  following  figures  from  the  Wiirzburg  clinic. 
Among  8,873  patients,  1,287  were  tuberculous,  with  the  following  distribu- 
tion of  lesions:  Bones  and  joints,  1,037;  lymph-glands,  196;  skin  and  con- 
nective tissues,   77;  mucous  membranes,   10;  genito-urinary  organs,  30. 

(2)  The  Changes  produced  by  the  Tubercle  Bacilli. 

{a)  The  Nodular  Tubercle. — The  body  which  we  term  a  "  tubercle  "  pre- 
sents in  its  early  formation  nothing  distinctive  or  peculiar,  either  in  its  com- 
ponents or  in  their  arrangement.  Identical  structures  are  produced  by  other 
parasites,  such  as  the  actinomyces,  and  by  the  strongjdus  in  the  lungs  of  sheep. 

The  researches  of  Baumgarten  have  enabled  us  to  follow  in  detail  the  evo- 
lution of  a  tubercle. 

(a)  The  multiplication  of  the  tubercle  bacilli,  which  is  rapid  and  is  ac- 
companied by  their  dissemination  in  the  surrounding  tissues  partly  by  growth, 
partly  in  the  lymph  currents. 

(^)  The  multiplication  of  the  fixed  cells,  especially  those  of  connective 
tissue  and  the  endothelium  of  the  capillaries,  and  the  gradual  production  from 
them  of  rounded,  cuboidal,  or  polygonal  bodies  with  vesicular  nuclei — the  epi- 
thelioid cells — inside  some  of  which  the  bacilli  are  soon  seen. 

(y)  Prom  the  vessels  of  the  infected  focus,  leucocytes,  chiefly  polynuclear, 
migrate  in  numbers  and  accumulate  about  the  focus  of  infection.  They  do 
not  survive.  Many  undergo  rapid  destruction.  Later,  as  the  little  tuber- 
cle grows,  the  leucocytes  are  chiefly  of  the  mononuclear  variety  (lymphocytes), 
which  do  not  undergo  the  rapid  degeneration  of  the  polynuclear  forms. 

(8)  A  reticulum  of  fibres  is  formed  by  the  fibrillation  and  rarefaction 
of  the  connective-tissue  matrix.  This  is  most  apparent,  as  a  rule,  at  the 
margin  of  the  growth. 

(e)  In  some,  but  not  all,  tubercles  giant  cells  are  formed  by  an  increase 
in  the  protoplasm  and  in  the  nuclei  of  an  individual  cell,  or  possibly  by  the 


296  SPECIFIC  INFECTIOUS  DISEASES. 

fusion  of  several  cells.  The  giant  cells  seem  to  be  in  inverse  ratio  to  the 
number  and  virulence  of  the  bacilli.  In  lupus,  joint  tuberculosis,  and  scrofu- 
lous glands,  in  which  the  bacilli  are  scanty,  the  giant  cells  are  numerous; 
■while  in  miliarv  tubercles  and  all  lesions  in  which  the  bacilli  are  abundant  the 
giant  cells  are  few  in  number. 

The  bacilli  then  cause,  in  the  first  place,  a  proliferation  of  the  fixed  ele- 
ments, with  the  production  of  epithelioid  and  giant  cells;  and,  secondly,  an 
inflammatory  reaction,  associated  with  exudation  of  leucocytes.  How  far  the 
leucocytes  attack  and  destroy  the  bacilli  has  not  been  definitely  settled — 
Metschnikoff  claiming,  Baumgarten  denying,  an  active  phagocj^tosis. 

(3)  The  Degexeeatiox  of  Tubercle. —  (a)  Caseation. — At  the  central 
part  of  the  growth,  owing  to  the  direct  action  of  the  bacilli  or  their  products, 
a  process  of  coagulation  necrosis  goes  on  in  the  cells,  which  lose  their  outline, 
become  irregular,  no  longer  take  stains,  and  are  finally  converted  into  a 
homogeneous,  structureless  substance.  Proceeding  from  the  centre  outward, 
the  tubercle  may  be  gradually  converted  into  a  yellowish-gray  body,  in  which, 
however,  the  bacilli  are  still  abundant.  Xo  blood-vessels  are  found  in  them. 
Aggregated  together  these  form  the  cheesy  masses  so  common  in  tuberculosis, 
which  may  undergo  softening,  fibroid  limitation  (encapsulation),  or  calci- 
fication. 

(&)  Sclerosis. — "With  the  necrosis  of  the  cell  elements  at  the  centre  of  the 
tubercle,  hyaline  transformation  proceeds,  together  with  great  increase  in  the 
fibroid  elements ;  so  that  the  tubercle  is  converted  into  a  firm,  hard  structure. 
Often  the  change  is  rather  of  a  fibro-caseous  nature;  but  the  sclerosis  pre- 
dominates. In  some  situations,  as  in  the  peritonasum,  this  seems  to  be  the 
natural  transformation  of  tubercle,  and  it  is  by  no  means  rare  in  the  lungs. 

In  all  tubercles  two  processes  go  on:  the  one — caseation — destructive  and 
dangerous;  and  the  other — sclerosis — conservative  and  healing.  The  ulti- 
mate result  in  a  given  case  depends  upon  the  capabilities  of  the  body  to  restrict 
and  limit  the  growth  of  the  bacilli.  There  are  tissue-soils  in  which  the  baciUi 
are,  in  aU  probability,  killed  at  once — the  seed  lias  fallen  hy  the  wayside. 
There  are  others  in  which  a  lodgment  is  gained  and  more  or  less  damage  done, 
but  finally  the  day  is  with  the  conservative,-  protecting  forces — the  seed  has 
fallen  upon  stony  ground.  Thirdly,  there  are  tissue-soils  in  which  the  bacilli 
grow  luxuriantly,  caseation  and  softening,  not  limitation  and  sclerosis,  prevail, 
and  the  day  is  with  the  invaders — the  seed  has  fallen  upon  good  ground. 

The  action  of  the  bacilli  injected  directly  into  the  blood-vessels  illustrates 
many  points  in  the  histology  and  pathologv^  of  tuberculosis.  If  into  the  vein 
of  a  rabbit  a  pure  culture  of  the  bacilli  is  injected,  the  microbes  accumulate 
chiefly  va  the  liver  and  spleen.  The  animal  dies  usually  within  two  weeks, 
and  the  organs  apparently  show  no  trace  of  tubercles.  Microscopically,  in 
both  spleen  and  liver  the  young  tubercles  in  process  of  formation  are  very 
numerous,  and  karyokinesis  is  going  on  in  the  liver-cells.  After  an  injection 
of  a  more  dilute  culture,  or  one  whose  virulence  has  been  mitigated  by  age, 
instead  of  d}ring  within  a  fortnight  the  animal  survives  for  five  or  six  weeks', 
by  which  time  the  tubercles  are  apparent  in  the  spleen  and  liver,  and  often 
in  the  other  organs. 

(4)  The  diffused  Inflammatory  Tubercle.— This  is  most  frequently 
seen  in  the  lungs.     Only  a  great  master  like  Yirchow  could  have  won  the  pro- 


TUBERCULOSIS.  297 

fession  from  a  belief  in  the  unity  of  phthisis,  which  the  genius  of  Laennec  had 
on  anatomical  ground,  announced.  Here  and  there  a  teacher,  as  Wilson  Fox, 
protested,  but  the  heresy  prevailed,  and  we  repeated  the  striking  aphorism  of 
Niemeyer,  "  The  greatest  evil  which  can  happen  to  a  consumptive  is  that  he 
should  become  tuberculous."  It  was  thought  that  the  products  of  any  simple 
inflammation  might  become  caseous,  and  that  ordinary  catarrhal  pneumonia 
terminated  in  phthisis.  It  was  peculiarly  fitting  that  from  Germany,  in  which 
the  dualistic  heresy  arose,  the  truth  of  Laennec's  views  should  receive  incon- 
testable proof,  in  the  demonstration  by  Koch  of  the  etiological  unity  of  all  the 
various  processes  known  as  tuberculous  and  scrofulous. 

Infiltrated  tubercle  results  from  the  fusion  of  many  small  foci  of  infec- 
tion— so  small  indeed  that  they  may  not  be  visible  to  the  naked  eye,  but  which 
histologically  are  seen  to  be  composed  of  scattered  centres,  surrounded  by  areas 
in  which  the  air-cells  are  filled  with  the  products  of  exudation  and  of  the 
proliferation  of  the  alveolar  epithelium.  Under  the  influence  of  the  bacilli, 
caseation  takes  place,  usually  in  small  groups  of  lobules,  occasionally  in  an 
entire  lobe,  or  even  the  greater  part  of  a  lung.  In  the  early  stage  of  the 
process,  the  tissue  has  a  gray  gelatinous  appearance,  the  gi-ay  infiltration  of 
Laennec.  The  alveoli  contain  a  sero-fibrinous  fluid  with  cells,  and  the  septa 
are  also  infiltrated.  These  cells  accumulate  and  undergo  coagulation  necrosis, 
forming  areas  of  caseation,  the  infiltratioti  tuherculeuse  jaune  of  Laennec, 
the  scrofulous  or  cheesy  pneumonia  of  later  writers.  There  may  also  be  a 
diffuse  infiltration  and  caseation  without  any  special  foci,  a  wide-spread  tuber- 
culous pneumonia  induced  by  the  bacilli. 

After  all,  the  two  processes  are  identical.  As  Baumgarten  states :  "  There 
is  no  well-marked  difference  between  miliary  tubercle  and  chronic  caseous 
pneumonia.  Speaking  histologically,  miliary  tuberculosis  is  nothing  else  than 
a  chronic  caseous  miliary  pneumonia,  and  chronic  caseous  pneumonia  is  noth- 
ing but  a  tuberculosis  of  the  lungs." 

(5)  Secondary  Inflammatory  Processes. — (a)  The  irritation  caused 
by  the  bacilli  invariably  produces  an  inflammation  which  may,  as  has  been 
described,  be  limited  to  exudation  of  leucocytes  and  serum,  but  may  also  be 
much  more  extensive,  and  which  varies  with  varying  conditions.  We  flnd, 
for  example,  about  the  smaller  tubercles  in  the  lungs,  pneumonia — either 
catarrhal  or  fibrinous,  proliferation  of  the  connective-tissue  elements  in  the 
septa  (which  also  become  infiltrated  with  round  cells),  and  changes  in  the 
blood  and  lymph-vessels. 

(6)  In  processes  of  minor  intensity  the  inflammation  is  of  the  slow  reac- 
tive nature,  which  results  in  the  production  of  a  cicatricial  connective  tissue 
which  limits  and  restricts  the  development  of  the  tubercles  and  is  the  essential 
conservative  element  in  the  disease.  It  is  to  be  remembered  that  in  chronic 
pulmonary  tuberculosis  much  of  the  fibroid  tissue  which  is  present  is  not  in 
any  way  associated  with  the  action  of  the  bacilli. 

(c)  Suppuration.  Do  the  bacilli  themselves  induce  suppuration?  In 
so-called  cold  tuberculous  abscess  the  material  is  not  histologically  pus,  but 
a  debris  consisting  of  broken-down  cells  and  cheesy  material.  It  is  moreover 
sterile — that  is,  does  not  contain  the  usual  pus  organisms.  The  products  of 
the  tubercle  bacilli  are  probably  able  to  induce  suppuration,  as  in  joint  and 
bone  tuberculosis  pus  is  frequently  produced,  although  this  may  be  due  to  a 
21 


29g  SPECIFIC  INFECTIOUS  DISEASES. 

mixed  infection.  Koch  states  that  the  "  tuberculin  "  is  one  of  the  best  agents 
for  the  production  of  experimental  suppuration.  In  tuberculosis  of  the  lungs 
the  suppuration  is  largely  the  result  of  an  infection  with  pus  organisms. 

II.  Acute  Miliaet  Tuberculosis. 

The  modern  knowledge  of  this  remarkable  form  dates  from  the  statement 
of  Buhl  (1856),  that  miliary  tuberculosis  is  a  specific  infection  dependent  on 
the  presence  in  the  body  of  an  unencapsulated  yellow  tubercle,  or  a  tubercu- 
lous cavity  in  the  lung ;  and  that  it  bears  the  same  relation  to  the  primary  lesion 
as  pyaemia  does  to  a  focus  of  suppuration. 

Carl  Weigert  established  the  truth  of  this  brilliant  conception  by  demon- 
strating the  association  of  miliary  tuberculosis  with  tuberculosis  of  the  blood- 
vessels. There  are  two  groups  of  vessel  tubercle — the  tuberculous  periangitis 
in  which  there  is  invasion  of  the  adventitia^  and  the  endangitis  in  which  the 
tubercles  start  in  the  intima.  The  parts  most  frequently  affected  are  the 
pulmonary  veins  and  the  thoracic  duct,  less  often  the  jugular  vein,  the  supra- 
renal and  the  vena  cava  superior,  and  the  sinuses  of  the  dura  mater,  the  aorta, 
and  the  endocardium.  To  the  branches  of  the  pulmonary  veins  it  is  not 
uncommon  to  find  caseous  glands  adherent,  penetrating  the  walls  and  show- 
ing a  growth  of  miliary  tubercles  in  the  intima.  A  special  interest  belongs 
to  tuberculosis  of  the  thoracic  duct,  first  accurately  described  and  thoroughly 
studied  by  Sir  Astley  Cooper.  Benda  in  a  series  of  19  cases  of  vessel  tuber- 
culosis found  in  many  instances  an  enormous  number  of  bacilli,  particularly 
in  the  caseous  tubercles  of  the  thoracic  duct. 

Access  of  the  bacilli  to  the  blood  may  take  place  by  the  perforation  of  an 
extra-vascular  caseous  mass  into  the  lumen,  or  by  the  softening  and  ulcera- 
tion of  a  focus  of  tuberculous  endangitis.  The  bacilli  do  not  increase  in  the 
blood,  but  settle  in  the  different  organs,  producing  a  generalized  tuberculosis, 
of  which  Weigert  recognizes  three  t}^es  or  grades :  I.  The  acute  general  mil- 
iary tuberculosis,  in  which  the  various  organs  of  the  body  are  stuffed  with 
miliary  and  submiliary  nodules.  II.  A  second  form  characterized  by  a  small 
number  of  tubercles  in  one  or  many  organs.  III.  The  occurrence  of  numer- 
ous tuberculous  foci  widely  spread  throughout  the  body,  but  in  a  more  chronic 
form;  the  tubercles  are  larger  and  many  are  caseous.  It  is  the  chronic  gen- 
eralized tuberculosis  of  children.  Transitional  forms  between  these  groups 
occur.  In  the  first  variety,  which  we  are  here  considering,  there  is  an  erup- 
tion into  the  circulation  of  an  enormous  number  of  bacilli.  Benda  suggests 
in  explanation  of  the  profound  toxaemia  seen  in  certain  cases  (the  typhoid 
form)  that  in  addition  the  blood  is  surcharged  with  toxins  from  a  large  caseous 
focus  which  has  eroded  the  vessel. 

Clinical  Forms. 

The  cases  may  be  grouped  into  those  with  the  symptoms  of  an  acute  gen- 
eral infection — ^the  typhoid  form ;  cases  in  which  pulmonary  sjTnptoms  pre- 
dominate; and  cases  in  which  the  cerebral  or  cerebrospinal  symptoms  are 
marked — tuberculous  meningitis. 

Other  forms  have  been  recognized,  but  this  division  covers  a  large  majority 
of  the  cases. 


TUBERCULOSIS.  299 

Taking  any  series  of  cases  it  will  be  found  that  the  meningeal  form  of  acute 
tuberculosis  exceeds  in  numbers  the  cases  with  general  or  marked  pulmonary 
symptoms. 

1.  General  or  Typhoid  Form. — Symptoms. — The  patient  here  presents 
the  symptoms  of  a  profound  infection  with  few  if  any  local  signs.  The  cases 
simulate  and  are  frequently  mistaken  for  typhoid  fever.  After  a  period  of 
failing  health,  with  loss  of  appetite,  the  patient  becomes  feverish  and  weak. 
Occasionally  the  disease  sets  in  more  abruptly,  but  in  many  instances  the 
anamnesis  closely  resembles  that  of  typhoid  fever.  Nose-bleeding,  however, 
is  rare.  The  temperature  increases,  the  pulse  becomes  rapid  and  feeble,  the 
tongue  dry;  delirium  becomes  marked  and  the  cheeks  are  flushed.  The  pul- 
monary symptoms  may  be  very  slight;  usually  bronchitis  exists,  but  is  not 
more  severe  than  is  common  with  typhoid  fever.  The  pulse  is  seldom  dicrotic, 
but  is  rapid  in  proportion  to  the  pyrexia.  Perhaps  the  most  striking  feature 
of  the  temperature  is  the  irregularity;  and  if  seen  from  the  outset  there  is 
not  the  steady  ascent  noted  in  typhoid  fever.  There  is  usually  an  evening 
rise  to  103°,  sometimes  104°,  and  a  morning  remission  of  from  two  to  three 
degrees.  Sometimes  the  pyrexia  is  intermittent,  and  the  thermometer  may 
register  below  normal  during  the  early  morning  hours.  The  inverse  type  of 
temperature,  in  which  the  rise  takes  place  in  the  morning,  is  held  by  some 
writers  to  be  more  frequent  in  general  tuberculosis  than  in  other  diseases.  In 
rare  instances  there  may  be  little  or  no  fever.  On  two  occasions  I  have  had 
a  patient  admitted  to  my  wards  in  a  condition  of  profound  debility,  with  a 
history  of  illness  of  from  three  to  four  weeks'  duration,  with  rapid  pulse, 
flushed  cheeks,  dry  tongue,  and  very  slight  elevation  in  temperature,  in  whom 
(post  mortem)  the  condition  proved  to  be  general  tuberculosis.  In  one  in- 
stance there  was  tolerably  extensive.disease  at  the  right  apex.  Eeinhold,  from 
Baumler's  clinic,  has  recently  called  attention  to  these  afebrile  forms  of  acute 
tuberculosis.     In  9  of  52  cases  there  was  no  fever,  or  only  a  transient  rise. 

In  a  considerable  number  of  these  cases  the  respirations  are  increased 
in  frequency,  particularly  in  the  early  stage,  and  there  may  be  signs  of  diffuse 
bronchitis  and  slight  cyanosis.  Cheyne-Stokes  breathing  occurs  toward  the 
close. 

Active  delirium  is  rare.  More  commonly  there  are  torpor  and  dulness, 
gradually  deepening  into  coma,  in  which  the  patient  dies.  In  some  cases 
the  pulmonary  symptoms  become  more  marked;  in  others,  meningeal  or  cere- 
bral features  occur. 

Diagnosis. — The  differential  diagnosis  between  general  miliary  tubercu- 
losis without  local  manifestations  and  typhoid  fever  is  extremely  difficult.  A 
point  of  importance,  to  which  reference  has  already  been  made,  is  the  irregu- 
larity of  the  temperature  curve.  The  greater  frequency  of  the  respirations  and 
the  tendency  to  slight  cyanosis  is  much  more  common  in  tuberculosis.  There 
are  cases,  however,  of  typhoid  fever  in  which  the  initial  bronchitis  is  severe 
and  may  lead  to  dyspnoea  and  disturbed  oxygenation.  The  cough  may  be 
slight  or  absent.  Diarrhoea  is  rare  in  tuberculosis;  the  bowels  are  usually 
constipated;  but  diarrhoea  may  occur  and  persist  for  days.  In  certain  cases 
the  diagnosis  has  been  complicated  still  further  by  the  occurrence  of  blood 
in  the  stools.  Enlargement  of  the  spleen  occurs  in  general  tuberculosis,  but 
is  neither  so  early  nor  so  marked  as  in  typhoid  fever.    In  children,  however. 


300  SPECIFIC  INFECTIOUS  DISEASES. 

the  enlargement  may  be  considerable.  The  urine  ma}^  show  traces  of  albu- 
min, and  unfortunately  Ehrlich's  diazo-reaction,  which  is  so  constant  in 
typhoid  fever,  is  also  met  with  in  general  tuberculosis.  The  absence  of  the 
characteristic  roseola  is  an  important  feature.  Occasionally  in  acute  tubercu- 
losis reddish  spots  may  occur  and  for  a  time  cause  difficult}^,  but  they  do  not 
come  out  in  crops,  and  rarely  have  the  characters  of  the  true  tj'phoid  eruption. 
Herpes  is  perhaps  more  common  in  tuberculosis.  Toward  the  close,  petechige 
may  appear  on  the  skin,  particularly  about  the  wrists.  A  rare  event  is  jaun- 
dice, due  possibly  to  the  eruption  of  tubercles  in  the  liver.  It  is  to  be  remem- 
bered that  the  lesions  of  acute  tuberculosis  and  of  t}^hoid  fever  have  been 
demonstrated  in  the  same  body. 

A  negative  Widal  test  and  the  absence  of  typhoid  bacilli  in  blood-cultures 
may  be  of  decisive  importance  in  these  doubtful  cases.  In  very  rare  instances 
tubercle  bacilli  have  been  found  in  the  blood.  Leucocytosis  is  more  common 
in  miliary  tuberculosis  than  in  tj^phoid  fever,  in  which  leucopenia  is  the  rule. 
Careful  examination  of  the  eyes  may  show  choroidal  tubercles,  though  I  have 
never  known  a  diagnosis  made  on  their  presence  alone.  In  the  fluid  obtained 
by  lumbar  puncture  the  tubercle  bacilli  may  be  abundant,  even  when  there  is 
no  active  meningitis.  In  a  few  cases  the  bacilli  have  been  found  in  the  urine. 
Blood-cultures  have  been  occasionally  successful. 

2.  Pulmonary  Form. — Symptoms. — From  the  outset  the  pulmonary  sjonp- 
toms  are  marked.  The  patient  may  have  had  a  cough  for  months  or  for 
years  without  much  impairment  of  health,  or  he  may  be  known  to  be  the 
subject  of  chronic  pulmonary  tuberculosis.  In  other  instances,  particularly 
in  children,  the  affection  follows  measles  or  whooping-cough,  and  is  of  a  dis- 
tinctly broncho-pneumonic  type.  The  disease  begins  with  the  symptoms  of 
diffuse  bronchitis.  The  cough  is  marked,  the  expectoration  muco-purulent, 
occasionally  rusty.  Hsemoptv^sis  has  been  noted  in  a  few  instances.  From  the 
outset  dyspnoea  is  a  striking  feature  and  may  be  out  of  proportion  to  the 
intensity  of  the  physical  signs.  There  is  more  or  less  cyanosis  of  the  lips  and 
finger-tips,  and  the  cheeks  are  suffused.  Apart  from  emphysema  and  the  later 
stages  of  severe  pneumonia  I  know  of  no  other  pulmonary  condition  in  which 
the  cyanosis  is  so  marked.  The  physical  signs  are  those  of  bronchitis.  In 
children  there  may  be  defective  resonance  at  the  bases,  from  scattered  areas  of 
broncho-pneumonia;  or,  what  is  equally  suggestive,  areas  of  hyper-resonance. 
Indeed,  the  percussion  note,  particularly  in  the  front  of  the  chest,  in  some 
cases  of  miliary  tuberculosis,  is  full  and  clear,  and  it  will  be  noted  (post  mor- 
tem) that  the  lungs  are  unusually  voluminous.  This  is  probably  the  result 
of  more  or  less  wide-spread  acute  emphysema.  On  auscultatioia,  the  rales 
are  either  sibilant  and  sonorous  or  small,  fine,  and  crepitant.  There  may  be 
fine  crepitation  from  the  occurrence  of  tubercles  on  the  pleura  (Jiirgensen). 
In  children  there  may  be  high-pitched  tubular  breathing  at  the  bases  or  toward 
the  root  of  the  lung.  Toward  the  close  the  rales  may  be  larger  and  more 
mucous.  The  temperature  rises  to  102°  or  103°,  and  may  present  the  inverse 
type.  The  pulse  is  rapid  and  feeble.  In  the  very  acute  cases  the  spleen  is 
always  enlarged.  The  disease  may  prove  fatal  in  ten  or  twelve  davs,  or  may 
be  protracted  for  weeks  or  even  months. 

Diagnosis.— The  diagnosis  of  this  form  offers  less  difficulty  and  is  more 
frequently  made.     There  is  often  a  history  of  previous  cough,  or  the  patient 


TUBERCULOSIS.  301 

is  known  to  be  the  subject  of  local  disease  of  the  lung,  or  of  the  lymph-glands, 
or  of  the  bones.  In  children  these  symptoms  following  measles  or  Avhoop- 
ing-cough  indicate  in  the  majority  of  cases  acute  miliary  tuberculosis,  with 
or  without  broncho-pneumonia.  Occasionally  the  sputum  contains  tubercle 
bacilli. 

The  choroidal  tubercle  occurs  in  a  limited  number  of  cases  and  may  help 
the  diagnosis.  More  importajit  in  an  adult  is  the  combination  of  dyspnoea 
with  cyanosis  and  the  signs  of  a  diffuse  bronchitis.  In  some  instances  the 
occurrence  of  cerebral  symptoms  at  once  gives  a  clew  to  the  nature  of  the 
trouble. 

3.  Meningeal  Form  (Tuberculous  Meningitis,  Basilar  Meningitis) . — This 
affection,  which  is  also  known  as  acute  hydrocephalus  or  "  water  on  the 
brain,"  is  essentially  an  acute  tuberculosis  in  which  the  membranes  of  the 
brain,  sometimes  of  the  cord,  bear  the  brunt  of  the  attack.  Our  first  accurate 
knowledge  of  this  affection  dates  from  the  publication  of  Eobert  Whytt's 
Observations  on  the  Dropsy  of  the  Brain,  Edinburgh,  1768.  He  studied  20 
cases  and  divided  the  disease  into  three  stages,  according  to  the  condition  of 
the  pulse. 

Though  Guersant  had  as  early  as  1827  used  the  name  granular  menin- 
gitis for  this  form  of  inflammation  of  the  meninges,  it  was  not  until  1830 
that  Papavoine  demonstrated  the  nature  of  the  granules  and  noted  their 
occurrence  with  tubercles  in  other  parts. 

In  1833  and  1833,  W.  W.  Gerhard,  of  Philadelphia,  made  a  very  careful 
study  of  the  disease  in  the  Children's  Hospital  at  Paris,  and  his  publica- 
tions, more  than  those  of  any  other  author,  served  to  place  the  disease  on 
a  firm  anatomical  and  clinical  basis. 

There  are  several  special  etiological  factors  in  connection  with  this  form. 
It  is  much  more  common  in  children  than  in  adults.  It  is  rare  during  the 
first  year  of  life,  more  frequent  between  the  second  and  the  fifth  years.  In  a 
majority  of  the  cases  a  focus  of  old  tuberculous  disease  will  be  found,  com- 
monly in  the  bronchial  or  mesenteric  glands.  In  a  few  instances  the  affec- 
tion seems  to  be  primary  in  the  meninges.  It  is  very  difficult,  however,  in 
an  ordinary  post  mortem  to  make  an  exhaustive  search,  and  the  lesion  may 
be  in  the  bones,  sometimes  in  the  middle  ear,  or  in  the  genito-urinary  organs. 
In  those  instances  in  which  no  primary  focus  has  been  discovered  it  has  been 
suggested  that  the  bacilli  reach  the  meninges  through  the  cribriform  plate  of 
the  ethmoid  from  the  upper  part  of  the  nostrils,  but  this  is  not  probable. 

Morbid  Anatomy. — The  meninges  at  the  base  are  most  involved,  hence  the 
term  basilar  meningitis.  The  parts  about  the  optic  chiasm,  the  Sylvian  fis- 
sures, and  the  interpeduncular  space  are  affected.  There  may  be  only  slight 
turbidity  and  matting  of  the  membranes,  and  a  certain  stickiness  with  serous 
infiltration;  but  more  commonly  there  is  a  turbid  exudate,  fibrino-purulent 
in  character,  which  covers  the  structures  at  the  base,  surrounds  the  nerves, 
extends  into  the  Sylvian  fissures,  and  appears  on  the  lateral,  rarely  on  the 
upper,  surfaces  of  the  hemispheres.  The  tubercles  may  be  very  apparent, 
particularly  in  the  Sylvian  fissures,  appearing  as  small,  whitish  nodules  on 
the  membranes.  They  vary  much  in  number  and  size,  and  may  be  difficult 
to  find.  The  amount  of  exudate  bears  no  definite  relation  to  the  abundance 
of  tubercles.     The  arteries  of  the  anterior  and  posterior  perforated  spaces 


302  SPECIFIC  INFECTIOUS  DISEASES. 

should  be  carefully  withdrawn  and  searched,  as  upon  them  nodular  tubercles 
may  be  found  when  not  present  elsewhere.  In  doubtful  cases  the  middle  cere- 
bral arteries  should  be  very  carefully  removed,  spread  on  a  glass  plate  with 
a  black  background,  and  examined  with  a  lens.  The  tubercles  are  then  seen 
as  nodular  enlargements  on  the  smaller  arteries.  The  lateral  ventricles  are 
dilated  (acute  hydrocephalus)  and  contain  a  turbid  fluid;  the  epend}Tna  may 
be  softened,  and  the  septum  lucidum  and  fornix  are  usually  broken  doum. 
The  convolutions  are  often  flattened  and  the  sulci  obliterated  owing  to  the 
increased  intra-ventricular  pressure.  There  is  a  tuberculous  endarteritis  with 
the  formation  of  intimal  tubercles,  due  to  implantation  of  bacilli  from  the 
blood  (Hektoen).  Proliferation  in  the  adventitia,  with  invasion  of  the  media 
and  intima  are  common,  forming  nodular  circumscribed  tubercles.  The 
lumen  of  the  vessel  is  narrowed  and  thrombosis  may  result.  The  meninges 
are  not  alone  involved,  but  the  contiguous  cerebral  substance  is  more  or  less 
oedematous  and  infiltrated  with  leucoc}ies,  so  that  anatomically  the  condition 
is  in  reality  a  meningo-enceplialitis. 

There  are  instances  in  which  the  acute  process  is  associated  with  chronic 
meningeal  tuberculosis;  cases  which  may  for  months  present  the  clinical  pic- 
ture of  brain  tumor. 

Although  in  a  majority  of  instances  the  process  is  cerebral,  the  spinal 
meninges  may  also  be  involved,  particularly  those  of  the  cervical  cord.  There 
are  cases  indeed  in  which  the  sjTnptoms  are  chiefly  spinal.  A  sailor,  who  had 
fallen  on  the  deck  three  weeks  before  his  death,  was  admitted  to  the  Montreal 
General  Hospital.  He  presented  signs  of  meningitis,  chiefly  spinal,  which 
were  naturally  attributed  to  traumatism.  The  post  mortem  showed  absence 
of  tubercles  and  lymph  at  the  base  of  the  brain,  and  an  extensive  eruption 
of  miliary  tubercles  with  much  turbid  hTnph  over  the  entire  spinal  meninges. 
There  were  small  cheesy  masses  at  the  apices  of  the  lungs. 

Stmpto:ms. — Tuberculous  meningitis  presents  an  extremely  complex  clini- 
cal picture.     It  will  be  best  to  describe  the  form  found  in  children. 

Prodromal  s}Tnptoms  are  common.  The  child  may  have  been  in  failing 
health  for  some  weeks,  or  may  be  convalescent  from  measles  or  whooping- 
cough.  In  many  instances  there  is  a  history  of  a  fall.  The  child  gets  thin, 
is  restless,  peevish,  irritable,  loses  its  appetite,  and  the  disposition  may  com- 
pletely change.  Symptoms  pointing  to  the  disease  may  then  set  in,  either 
quite  suddenly  with  a  convulsion,  or  more  commonly  with  headache,  vomit- 
ing, and  fever,  three  essential  symptoms  of  the  onset  which  are  rarely  absent. 
The  pain  may  be  intense  and  agonizing.  The  child  puts  its  hand  to  its  head 
and  occasionally,  when  the  pain  becomes  worse,  gives  a  short,  sudden  cry,  the 
so-called  hydrocephalic  cry.  Sometimes  the  child  screams  continuously  until 
utterly  exhausted.  I  saw  in  West  Philadelphia  a  case  of  basilar  meningitis  in 
a  girl  of  thirteen,  who  for  three  days,  when  not  under  the  influence  of  a  pow- 
erful sedative  or  of  chloroform,  screamed  at  the  top  of  her  voice  so  as  to  be 
heard  a  square  or  more  away.  The  vomiting  is  without  apparent  cause,  and 
is  independent  of  taking  of  food.  Constipation  is  usually  present.  The  fever 
IS  slight,  but  gradually  rises  to  102°  or  103°.  The  pulse  is  at  flrst  rapid,  subse- 
quently irregular  and  slow.  The  respirations  are  rarelv  altered.  During 
sleep  the  child  is  restless  and  disturbed.  There  may  be  tsvitchings  of  the  mus- 
cles, or  sudden  startings;  or  the  child  may  wake  up  from  sleep  in  great  terror. 


TUBERCULOSIS.  303 

In  this  early  stage  the  pupils  are  usually  contracted.  These  are  the  chief 
symptoms  of  the  initial  stage,  or,  as  it  is  termed,  the  stage  of  irritation. 

In  the  second  period  of  the  disease  these  irritative  symptoms  subside ;  vom- 
iting is  no  longer  marked,  the  abdomen  becomes  retracted,  boat-shaped  or 
carinated.  The  bowels  are  obstinately  constipated,  the  child  no  longer  com- 
plains of  headache,  but  is  dull  and  apathetic,  and  when  roused  is  more  or  less 
delirious.  The  head  is  often  retracted  and  the  child  utters  an  occasional  cry. 
The  pupils  are  dilated  or  irregular,  and  a  squint  may  develop.  Sighing  res- 
piration is  common.  Convulsions  may  occur,  or  rigidity  of  the  muscles  of  one 
side  or  of  one  limb.  The  temperature  is  variable,  ranging  from  100°  to 
102.5°.  A  blotchy  erythema  is  not  uncommon  on  the  skin.  If  the  finger-nail 
is  drawn  across  the  skin  of  any  region  a  red  line  comes  out  quickly,  the 
so-called  tache  cerehrale,  which,  however,  has  no  diagnostic  significance. 

In  the  final  period,  or  stage  of  paralysis,  the  coma  increases  and  the  child 
can  not  be  roused.  Convulsions  are  not  infrequent,  and  there  are  spasmodic 
contractions  of  the  muscles  of  the  back  and  neck.  Spasms  may  occur  in  the 
limbs  of  one  side.  Optic  neuritis  and  paralysis  of  the  ocular  muscles  may  be 
present.  The  pupils  become  dilated,  the  eyelids  are  only  partially  closed,  and 
the  eyeballs  are  rolled  up  so  that  the  corneas  are  only  uncovered  in  part  by 
the  upper  eyelids.  Diarrhoea  may  occur,  the  pulse  becomes  rapid,  and  the 
child  may  sink  into  a  typhoid  state  with  dry  tongue,  low  delirium,  and  invol- 
untary passages  of  urine  and  fsces.  The  temperature  often  becomes  sub- 
normal, sinking  in  rare  instances  to  93°  or  94°.  In  some  cases  there  is  an 
ante-mortem  elevation  of  temperature,  the  fever  rising  to  106°.  The  entire 
duration  of  the  disease  is  from  a  fortnight  to  three  or  four  weeks.  A  leuco- 
cytosis  is  not  infrequently  present  throughout  the  disease. 

There  are  cases  of  tuberculous  meningitis  which  pursue  a  more  rapid 
course.  They  set  in  with  great  violence,  often  in  persons  apparently  in  good 
health,  and  may  prove  fatal  within  a  few  days.  In  these  instances,  more 
commonly  seen  in  adi^lts,  the  convex  surface  of  the  brain  is  usually  involved. 
There  are  again  instances  which  are  essentially  chronic  and  display  symptoms 
of  a  limited  meningitis,  sometimes  with  pronounced  psychical  symptoms,  and 
sometimes  with  those  of  cerebral  tumor. 

There  are  certain  features  which  call  for  special  comment. 

The  irregularity  and  slowness  of  the  pulse  in  the  early  and  middle  stages 
of  the  disease  are  points  upon  which  all  authors  agree.  Toward  the  close,  as 
the  heart's  action  becomes  weaker,  the  pulsations  are  more  frequent.  The 
temperature  is  usually  elevated,  but  there  are  instances  in  which  it  does  not 
rise  in  the  whole  course  of  the  disease  much  above  100°.  It  may  be  extremely 
irregular,  and  the  oscillations  are  often  as  much  as  three  or  four  degrees  in 
the  day.  Toward  the  close  the  temperature  may  sink  to  95°,  occasionally  to 
94°,  or  there  may  be  hyperpyrexia.  In  a  case  of  Baumler's  the  temperature 
rose  before  death  to  43.7°  C.\ll0.7°  F.). 

The  ocular  symptoms  of  the  disease  are  of  special  importance.  In  the 
early  stages  narrowing  of  the  pupils  is  the  rule.  Toward  the  close,  with  in- 
crease in  the  intra-cranial  pressure,  the  pupils  dilate  and  are  irregular. 
There  may  be  conjugate  deviation  of  the  eyes.  Of  ocular  palsies  the  third 
nerve  is  most  frequently  involved,  sometimes  with  paralysis  of  the  face,  limbs, 
and  hypoglossal  nerve  on  the  opposite  side  (syndrome  of  Weber),  due  to  a 


304  SPECIFIC  INFECTIOUS  DISEASES. 

lesion  limited  to  the  inferior  and  internal  part  of  the  crus.  The  changes  in 
the  retinse  are  very  important.  Neuritis  is  the  most  common.  According 
to  Gowers,  the  disk  at  first  becomes  full  colored  and  has  hazy  outlines, 
and  the  veins  are  dilated.  Swelling  and  striation  become  pronounced,  but 
the  neuritis  is  rarely  intense.  Of  26  cases  studied  by  Garlick,  in  6  the  condi- 
tion was  of  diagnostic  value.  The  tubercles  in  the  choroid  are  rare  and  much 
less  frequently  seen  during  life  than  post-mortem  figures  would  indicate. 
Thus  Litten  found  them  (post  mortem)  in  39  out  of  53  cases.  They  were 
present  in  only  1  of  the  26  cases  of  tuberculous  meningitis  examined  by  Gar- 
lick.     Heinzel  examined  with  negative  results  41  cases. 

Among  the  motor  symptoms  convulsions  are  most  common,  but  there  are 
other  changes  which  deserve  special  mention.  A  tetanic  contraction  of  one 
limb  may  persist  for  several  days,  or  a  cataleptic  condition.  Tremor  and  athe- 
toid  movements  are  sometimes  seen.  The  paralyses  are  either  hemiplegias 
or  monoplegias.  Hemiplegia  may  result  from  disturbance  in  the  cortical 
branches  of  the  middle  cerebral  artery,  occasionally  from  softening  in  the 
internal  capsule,  due  to  involvement  of  the  central  branches.  Of  monoplegias, 
that  of  the  face  is  perhaps  most  common,  and  if  on  the  right  side  it  may  occur 
with  aphasia.  In  two  of  my  cases  in  adults  aphasia  occurred.  Brachial  mono- 
plegia may  be  associated  with  it.  In  the  more  chronic  cases  the  symptoms 
persist  for  months,  and  there  may  be  a  characteristic  Jacksonian  epilepsy. 
Kernig's  sign  is  present  as  a  rule  (see  Cerebro-spinal  Fever). 

The  diagnosis  of  tuberculous  meningitis  is  rarely  difficult,  and  points 
upon  which  special  stress  is  to  be  laid  are  the  existence  of  a  tuberculous  focus 
in  the  body,  the  mode  of  onset  and  the  symptoms,  and  the  evidence  obtained 
on  lumbar  puncture.  The  fluid  withdrawn  is  usually  turbid,  often  sterile, 
but,  on  centrifugalizing,  the  bacilli  may  be  discovered.  The  cells  are  usually 
small  mononuclear  lymphocytes. 

The  prognosis  in  this  form  of  meningitis  is  always  most  serious.  I  have 
neither  seen  a  case  which  I  regarded  as  tuberculous  recover,  nor  have  I  seen 
post-mortem  evidence  of  past  disease  of  this  nature.  Cases  of  recovery  have 
been  reported  by  reliable  authorities,  but  they  are  extremely  rare,  and  there  is 
always  a  reasonable  doubt  as  to  the  correctness  of  the  diagnosis.  The  differ- 
ential features  and  treatment  will  be  considered  in  connection  with  acute 
meningitis. 

III.  Tuberculosis  of  the  Lymphatic  System. 

1.  Tuberculosis  of  the  Lymph-glands  {Scrofula). 
Scrofula  is  tubercle,  as  it  has  been  shown  that  the  bacillus  of  Koch  is  the 
essential  element.  Formerly  special  attention  was  given  to  different  types 
of  scrofula,  of  which  two  important  forms  were  recognized — the  sanguine,  in 
which  the  child  was  slightly  built,  tall,  with  small  limbs,  a  fine  clear  skin, 
soft  silky  hair,  and  was  mentally  very  bright  and  intelligent;  and  the  phleg- 
matic ij^e,  in  which  the  child  was  short  and  thick-set,  with  coarse  features 
muddy  complexion,  and  a  duU,  heavy  aspect.  It  is  not  yet  definitelv  settled 
whether  the  virus  which  produces  the  chronic  tuberculous  adenitis  or  ^scrofula 
differs  from  that  which  produces  tuberculosis  in  other  parts,  or  whether  it  is 
the  local  conditions  m  the  glands  which  account  for  the  slow  development  and 


TUBERCULOSIS.  305 

milder  course.  The  experiments  of  Arloing  would  indicate  that  the  virus  was 
attenuated  or  milder,  for  he  has  shown  that  the  caseous  material  of  a  lymph- 
gland  killed  guinea-pigs,  while  rabbits  escaped.  The  guinea-pig,  as  is  well 
known,  is  the  more  susceptible  animal  of  the  two.  The  observations  of  Lin- 
gard  are  still  more  conclusive,  as  showing  a  variation  in  the  virulence  of  the 
tubercle  bacillus.  Guinea-pigs  inoculated  with  ordinary  tubercle  showed 
lymphatic  infection  within  the  first  week,  and  the  animals  died  within  three 
months ;  infected  with  material  from  scrofulous  glands,  the  lymphatic  enlarge- 
ment did  not  appear  until  the  second  or  third  week,  and  the  animals  sur- 
vived for  six  or  seven  months.  He  showed,  moreover,  that  the  virulence  of  the 
infection  obtained  from  the  scrofulous  glands  increased  in  intensity  by  passing 
through  a  series  of  guinea-pigs.  In  a  certain  number  of  cases  the  infection  is 
with  the  bovine  germ,  but  exactly  in  what  proportion,  and  with  what  special 
clinical  features  have  not  yet  been  determined. 

Tuberculous  adenitis,  met  with  at  all  ages,  is  more  common  in  children 
than  in  adults;  and  may  occur  in  old  age. 

Tubercle  bacilli  are  ubiquitous ;  all  are  exposed  to  infection,  and  upon  the 
local  conditions,  whether  favorable  or  unfavorable,  depends  the  fate  of  those 
organisms  which  find  lodgment  in  our  bodies.  A  special  predisposing  factor 
in  lymphatic  tuberculosis  is  catarrh  of  the  mucous  membranes,  which  in  itself 
excites  slight  adenitis  of  the  neighboring  glands.  In  a  child  with  constantly 
recurring  naso-pharyngeal  catarrh,  the  bacilli  which  lodge  on  the  mucous 
membranes  find  in  all  probability  the  gateways  less  strictly  guarded  and  are 
taken  up  by  the  lymphatics  and  passed  to  the  nearest  glands.  The  impor- 
tance of  the  tonsils  as  an  infection-atrium  has  of  late  been  urged.  In  condi- 
tions of  health  the  local  resistance,  or,  as  some  would  put  it,  the  phagocytes, 
would  be  active  enough  to  deal  with  the  invaders,  but  the  irritation  of  a 
chronic  catarrh  weakens  the  resistance  of  the  lymph-tissue,  and  the  bacilli  are 
enabled  to  grow  and  gradually  to  change  a  simple  into  a  tuberculous  adenitis. 
The  frequent  association  of  tuberculous  adenitis  of  the  bronchial  glands  with 
whooping-cough  and  with  measles,  and  the  frequent  association  of  tubercle 
in  the  mesenteric  glands  in  children  with  intestinal  catarrh,  find  in  this  way 
a  rational  explanation.  After  all,  as  Yirchow  pointed  out,  an  increased  vul- 
nerability of  the  tissue,  however  brought  about,  is  the  important  factor  in  the 
disease. 

The  following  are  some  of  the  features  of  interest  in  tuberculous  ade- 
nitis : 

(a)  The  local  character  of  the  disease.  Thus,  the  glands  of  the  neck,  or 
at  the  bifurcation  of  the  bronchi,  or  those  of  the  mesentery,  may  be  alone 
involved. 

(&)  The  tendency  to  spontaneous  healing.  In  a  large  proportion  of  the 
cases  the  battle  which  ensues  between  the  bacilli  and  the  protective  forces  is 
long;  but  the  latter  are  finally  successful,  and  we  find  in  the  calcified  rem- 
nants in  the  bronchial  and  mesenteric  lymph-glands  evidences  of  victory. 
Too  often  in  the  bronchial  glands  a  truce  only  is  declared  and  hostilities  may 
break  out  afresh  in  the  form  of  an  acute  tuberculosis. 

(c)  The  tendency  of  tuberculous  adenitis  to  pass  on  to  suppuration.  The 
frequency  with  which,  particularly  in  the  glands  of  the  neck,  we  find  the  tuber- 
culous processes  associated  with  suppuration  is  a  special  feature  of  this  form 


306  SPECIFIC  INFECTIOUS  DISEASES. 

of  adenitis.  In  nearly  all  instances  the  pus  is  sterile.  Whether  the  suppura- 
tion is  excited  by  the  bacilli  or  by  their  products,  or  whether  it  is  the  result 
of  a  mixed  infection  with  pus  organisms,  which  are  subsequently  destroyed, 
has  not  been  settled. 

(d)  The  existence  of  an  unhealed  focus  of  tuberculous  adenitis  is  a  con- 
stant menace  to  the  organism.  It  is  safe  to  say  that  in  three-fourths  of  the 
instances  of  acute  tuberculosis  the  infection  is  derived  from  this  source.  On 
the  other  hand,  it  has  been  urged  that  scrofula  in  childhood  gives  a  sort  of 
protection  against  tuberculosis  in  adult  life.  We  certainly  do  meet  with  many 
persons  of  exceptional  bodily  vigor  who  in  childhood  had  eidarged  glands,  but 
the  evidence  which  Marfan  brings  forward  in  support  of  this  view  is  not  con- 
clusive. 

Clinical  Forms. — Gexeealized  Tubeeculous  Lymphadenitis. — In  excep- 
tional instances  we  find  diffuse  tuberculosis  of  nearly  all  the  lymph-glands  of 
the  body  with  little  or  no  involvement  of  other  parts.  The  most  extreme  cases 
of  it.  which  I  have  seen,  have  been  in  negro  patients.  Two  well-marked  cases 
occurred  at  the  Philadelphia  Hospital.  In  a  woman,  the  chart  from  April, 
1888,  until  March,  1889,  showed  persistent  fever,  ranging  from  101°  to  103°, 
occasionall}'  rising  to  104°.  On  December  16th  the  glands  on  the  right  side 
of  the  neck  were  removed.  After  an  attack  of  erysipelas,  on  February  17th, 
she  gradually  sank  and  died  ]\Iarch  5th.  The  lungs  presented  only  one  or  two 
puckered  spots  at  the  apices.  The  bronchial,  retro-peritoneal,  and  mesenteric 
glands  were  greatly  enlarged  and  caseous.  There  was  no  intestinal,  uterine, 
or  bone  disease.  The  continuous  high  fever  in  this  case  depended  apparently 
upon  the  tuberculous  adenitis,  which  was  much  more  extensive  than  was  sup- 
posed during  life.  In  these  instances  the  enlargement  is  most  marked  in  the 
retro-peritoneal,  bronchial,  and  mesenteric  glands,  but  may  be  also  present 
in  the  groups  of  external  glands.  Occurring  acutely,  it  presents  a  picture 
resembling  Hodgkin's  disease.  In  a  case  which  died  in  the  Montreal  General 
Hospital  this  diagnosis  was  made.  The  cervical  and  axillary  glands  were 
enormously  enlarged,  and  death  was  caused  by  infiltration  of  the  larjmx.  In 
infants  and  children  there  is  a  form  of  general  tuberculous  adenitis  in  which 
the  various  groups  of  glands  are  successiveh^,  more  rarely  simultaneously,  in- 
volved, and  in  which  death  is  caused  either  by  cachexia,  or  by  an  acute  infec- 
tion of  the  meninges. 

Local  Tuberculous  Adenitis. —  (a)  Cervical. — This  is  the  most  com- 
mon form  met  with  in  children.  It  is  seen  particularly  among  the  poor  and 
those  who  live  continuously  in  the  impure  atmosphere  of  badly  ventilated 
lodgings.  Children  in  foundling  hospitals  and  asjdums  are  specially  prone  to 
the  disease.  In  the  United  States  it  is  most  common  in  the  negro  race.  As 
already  stated,  it  is  often  met  with  in  catarrh  of  the  nose  and  throat,  or  chronic 
enlargement  of  the  tonsils ;  or  the  child  may  have  had  eczema  of  the  scalp  or 
a  purulent  otitis. 

The  submaxillary  glands  are  first  involved,  and  are  popularly  spoken  of 
as  enlarged  l-erneh.  They  are  usually  larger  on  one  side  than  on  the  other. 
As  they  increase  in  size,  the  individual  tumors  can  be  felt;  the  surface  is 
smooth  and  the  consistence  firm.  They  may  remain  isolated,  but  more  com- 
monly they  form  large,  knotted  masses,  over  which  the  skin  is,  as  a  rule,  freely 
movable.     In  many  cases  the  skin  ultimately  becomes  adherent,  and  inflam- 


TUBERCULOSIS.  307 

mation  and  suppuration  occur.  An  abscess  points  and,  unless  opened,  bursts, 
leaving  a  sinus  which  heals  slowly.  The  disease  is  frequently  associated  with 
coryza,  with  eczema  of  the  scalp,  ear,  or  lips,  and  with  conjunctivitis  or  kera- 
titis. Wlien  the  glands  are  large  and  growing  actively,  there  is  fever.  The 
subjects  are  usually  anaemic,  particularly  if  suppuration  has  occurred.  The 
progress  of  this  form  of  adenitis  is  slow  and  tedious.  Death,  however,  rarely 
follows,  and  many  aggravated  cases  in  children  ultimately  get  well.  Not  only 
the  submaxillary  group,  but  the  glands  above  the  clavicle  and  in  the  posterior 
cervical  triangle,  may  be  involved.  In  other  instances  the  cervical  and  axil- 
lary glands  are  involved  together,  forming  a  continuous  chain  which  extends 
beneath  the  clavicle  and  the  pectoral  muscle.  With  them  the  bronchial  glands 
may  also  be  enlarged  and  caseous.  Not  infrequently  the  enlargement  of  the 
supra-clavicular  and  axillary  group  of  glands  on  one  side  precedes  a  tubercu- 
lous pleurisy  or  pulmonary  tuberculosis. 

(h)  Tracheo-hronchial. — The  mediastinal  lymph-glands  constitute  filters 
in  which  lodge  the  various  foreign  particles  which  escape  the  normal  phago- 
cytes of  bronchi  and  lungs.  Among  these  foreign  particles,  and  probably 
attached  to  them,  tubercle  bacilli  are  not  uncommon,  and  we  find  tubercles  and 
caseous  matter  with  great  frequency  in  this  group.  ISTorthrup  found  them  in- 
volved in  every  one  of  127  cases  of  tuberculosis  at  the  New  York  Foundling 
Hospital.  This  tuberculous  adenitis  may,  in  the  bronchial  glands,  attain  the 
dimensions  of  a  tumor  of  large  size.  But  even  when  this  occurs  there  may 
be  no  pressure  sjrmptoms.  In  children  the  bronchial  adenitis  is  apt  to  be 
associated  with  suppuration.  The  effects  of  these  enlarged  glands  are  very 
varied,  and  for  full  details  the  reader  is  referred  to  the  elaborate  section  in 
the  TraiU  of  Barthez  and  Sannee  (tome  iii) .  It  is  sufficient  here  to  say  that 
there  are  instances  on  record  of  compression  of  the  superior  cava,  of  the  pulmo- 
nary artery,  and  of  the  azygos  vein.  The  trachea  and  bronchi,  though  often 
flattened,  are  rarely  seriously  compressed.  The  pneumogastric  nerve  may  be 
involved,  particularly  the  recurrent  laryngeal  branch.  More  important  really 
are  the  perforations  of  the  enlarged  and  softened  glands  into  the  bronchi  or 
trachea,  or  a  sort  of  secondary  cyst  may  be  formed  between  the  lung  and  the 
trachea.  Asphyxia  has  been  caused  by  blocking  of  the  larynx  by  a  case- 
ous gland  which  has  ulcerated  through  the  bronchus  (Voelcker),  and  Cyril 
Ogle  has  reported  a  case  in  which  the  ulcerated  gland  practically  occluded 
both  bronchi.  Perforations  of  the  vessels  are  much  less  common,  but  the  pul- 
monary artery  and  the  aorta  have  been  opened.  Perforation  of  the  oesophagus 
has  been  described  in  several  cases.  One  of  the  most  serious  effects  is  infec- 
tion of  the  lung  or  pleura  by  the  caseous  glands  situated  deep  along  the 
bronchi.  This  may,  as  is  often  clearly  seen,  be  by  direct  contact,  and  it  may 
be  difficult  to  determine  in  some  sections  where  the  caseous  bronchial  gland 
terminates  and  the  pulmonary  tissue  begins.  In  other  instances  it  takes  place 
along  the  root  of  the  lung  and  is  subpleural.  Among  other  sequences  may 
be  mentioned  diverticulum  of  the  oesophagus  following  adhesion  of  an  enlarged 
gland  and  its  subsequent  retraction;  and,  in  the  case  of  the  anterior  medi- 
astinal and  aortic  groups,  the  frequent  production  of  pericarditis,  either  by 
contact  or  by  rupture  of  a  softened  gland  into  the  sac. 

A  serious  danger  is  systemic  infection,  which  takes  place  through  the 
vessels. 


308  SPECIFIC  INFECTIOUS  DISEASES. 

(c)  Mesenteric;  Tales  mesenterica. — In  this  affection,  the  ahdominal 
scrofula  of  old  writers,  the  glands  of  the  mesentery  and  retro-peritonaeum  be- 
come enlarged  and  caseate ;  more  rarely  they  suppurate  or  calcify.  A  slight 
tuberculous  adenitis  is  extremely  common  in  children,  and  is  often  accidentally 
found  (post  mortem)  when  the  children  have  died  of  other  diseases.  It  may 
be  a  primary  lesion  associated  with  intestinal  catarrh,  or  it  may  be  secondary 
to  tuberculous  disease  of  the  intestines. 

The  statistics  of  abdominal  tuberculosis  show  a  great  variation  in  different 
localities.  The  small  percentage  in  New  York,  less  than  one  per  cent  of  all 
cases  (Bovaird  and  Mt.  Sinai  Hospital  figures),  contrasts  with  the  high  fig- 
ure, 18  per  cent,  for  England,  and  the  same  has  been  demonstrated  re- 
cently for  Scotland  by  John  Thomson,  3.57  for  Edinburgh  and  4.51  for 
Glasgow.  The  general  involvement  of  the  glands  interferes  seriously  with 
nutrition,  and  the  patients  are  puny,  wasted,  and  anaemic.  The  abdomen  is 
enlarged  and  tympanitic;  diarrhoea  is  a  constant  feature;  the  stools  are  thin 
and  offensive.  There  is  moderate  fever,  but  the  general  wasting  and  debility 
are  the  most  characteristic  features.  The  enlarged  glands  can  not  often  be 
felt,  owing  to  the  distended  condition  of  the  bowels.  These  cases  are  often 
spoken  of  as  consumption  of  the  bowels,  but  in  a  majority  of  them  the  intes- 
tines do  not  present  tuberculous  lesions.  In  a  considerable  number  of  the 
cases  of  tabes  mesenterica  the  peritonaeum  is  also  involved,  and  in  such  the 
abdomen  is  large  and  hard,  and  nodules  may  be  felt. 

In  adults  tuberculous  disease  of  the  mesenteric  glands  may  occur  as  a 
primary  affection,  or  in  association  with  pulmonary  disease.  Large  tumors 
may  exist  without  tuberculous  disease  in  the  intestines  or  in  any  other  part. 

2.  Tuberculosis  of  the  Serous  Membranes. 

General  Serous  Membrane  Tuberculosis  (Polyorrhomenitis) . — The 
serous  membranes  may  be  chiefly  involved,  simultaneously  or  consecutively, 
presenting  a  distinctive  and  readily  recognizable  clinical  type  of  tuberculosis. 
There  are  three  groups  of  cases.  First,  those  in  which  an  acute  tuberculosis 
of  the  peritonaeum  and  pleura  occurs  rapidly,  caused  by  local  disease  of  the 
tubes  in  women,  or  of  the  mediastinal  or  bronchial  lymph-glands.  Secondly, 
cases  in  which  the  disease  is  more  chronic,  with  exudation  into  both  perito- 
naeum and  pleurae,  the  formation  of  cheesy  masses,  and  the  occurrence  of  ulcer- 
ative and  suppurative  processes.  Thirdly,  there  are  cases  in  which  the  pleuro- 
peritoneal  affection  is  still  more  chronic,  the  tubercles  hard  and  fibroid,  the 
membranes  much  thickened,  and  with  little  or  no  exudate.  In  any  one  of 
these  three  forms  the  pericardium  may  be  involved  with  the  pleurae  and  peri- 
tonaeum. It  is  important  to  bear  in  mind  that  there  may  be  in  these  cases 
no  visceral  tuberculosis. 

Tuberculosis  oe  the  Pleura.— 1.  Acute  tuberculous  pleurisy.  It  is  dif- 
ficult in  the  present  state  of  our  knowledge  to  estimate  the  proportion  of 
instances  of  acute  pleurisy  due  to  tuberculosis  (see  Acute  Pleurisy).  The 
cases  are  rarely  fatal.  Here,  too,  there  are  three  groups  of  cases :  (a)  Acute 
tuberculous  pleurisy  with  subsequent  chronic  course,  (b)  Secondary  and  ter- 
minal forms  of  acute  pleurisy  (these  are  not  uncommon  in  hospital  practice). 
And  (c)  a  form  of  acute  tuberculous  suppurative  pleurisy.     A  considerable 


TUBERCULOSIS.  309 

number  of  the  purulent  pleurisies,  designated  as  latent  and  chronic,  are 
caused  by  tubercle  bacilli,  but  the  fact  is  not  so  widely  recognized  that  there 
is  an  acute,  ulcerative,  and  suppurative  disease  which  may  run  a  very  rapid 
course.  The  pleurisy  sets  in  abruptly,  with  pain  in  the  side,  fever,  cough,  and 
sometimes  with  a  chill.  There  may  be  nothing  to  suggest  a  tuberculous  pro- 
cess, and  the  subject  may  have  a  fine  physique  and  come  of  healthy  stock. 
2.  The  subacute  and  chronic  tuberculous  pleurisies  are  more  common.  The 
largest  group  of  cases  comprises  those  with  sero-fibrinous  effusion.  The  onset 
is  insidious,  the  true  character  of  the  disease  is  frequently  overlooked,  and  in 
almost  every  instance  there  are  tuberculous  foci  in  the  lungs  and  in  the  bron- 
chial glands.  These  are  cases  in  which  the  termination  is  often  in  pulmonary 
tuberculosis  or  general  miliary  tuberculosis.  In  a  few  cases  the  exudate 
becomes  purulent. 

And,  lastly,  there  is  a  chronic  adhesive  pleurisy,  a  primary  proliferative 
form  which  is  of  long  standing,  may  lead  to  very  great  thickening  of  the  mem- 
brane, and  sometimes  to  invasion  of  the  lung. 

Secondary  tuberculous  pleurisy  is  very  common.  The  visceral  layer  is 
always  involved  in  pulmonary  tuberculosis.  Adhesions  usually  form  and  a 
chronic  pleurisy  results,  which  may  be  simple,  but  usually  tubercles  are  scat- 
tered through  the  adhesions.  An  acute  tuberculous  pleurisy  may  result  from 
direct  extension.  The  fluid  may  be  sero-fibrinous  or  hasmorrhagic,  or  may 
become  purulent.  And,  lastl}^,  a  very  common  event  in  pulmonary  tubercu- 
losis is  the  perforation  of  a  superficial  spot  of  softening,  and  the  production 
of  pyo-pneumothorax. 

The  general  symptomatology  of  these  forms  will  be  considered  under  dis- 
ease of  the  pleura. 

Tuberculosis  of  the  Pericardium. — Miliary  tubercles  may  occur  as  a 
part  of  a  general  infection,  but  the  term  is  properly  limited  to  those  cases 
in  which,  either  as  a  primary  or  secondary  process,  there  is  extensive  disease 
of  the  membrane.  Tuberculosis  is  not  so  common  in  the  pericardium  as  in 
the  pleura  and  peritonaeum,  but  it  is  certainly  more  common  than  the  litera- 
ture would  lead  us  to  suppose.  George  Norris  found  82  instances  among 
1,780  post  mortems  in  tuberculous  subjects. 

We  may  recognize  four  groups  of  cases:  First,  those  in  which  the  condi- 
tion is  entirely  latent,  and  the  disease  is  discovered  accidentally  in  individuals 
who  have  died  of  other  affections  or  of  chronic  pulmonary  tuberculosis. 

A  second  group,  in  which  the  symptoms  are  those  of  cardiac  insufficiency 
following  the  dilatation  and  hypertrophy  consequent  upon  a  chronic  adhesive 
pericarditis.  The  symptoms  are  those  of  cardiac  dropsy,  and  suggest  either 
idiopathic  hypertrophy  and  dilatation,  or,  if  there  is  a  loud  blowing  systolic 
murmur  at  the  apex,  mitral  valve  disease,  either  insufficiency  or  stenosis. 
There  are  cases  of  adherent  pericardium  in  which  a  bruit  is  heard  which 
resembles  the  rumbling  presystolic  murmur  (T.  Fisher).  The  condition  of 
adherent  pericardium  is  usually  overlooked. 

In  a  third  group  the  clinical  picture  is  that  of  an  acute  tuberculosis,  either 
general  or  with  cerebro-spinal  manifestations,  which  has  had  its  origin  from 
the  tuberculous  pericardium  or  tuberculous  mediastinal  lymph-glands. 

A  fourth  group,  with  symptoms  of  acute  pericarditis,  includes  cases  in 
which  the  affection  is  acute  and  accompanied  with  more  or  less  exudation 


310  SPECIFIC  INFECTIOUS  DISEASES. 

of  a  sero-fibrinous,  ha>morrhagic,  or  purulent  character.     There  may  be  no 
suspicion  whatever  of  the  tuberculous  nature  of  the  trouble. 

Tuberculosis  of  the  Peritoneum. — In  connection  \nth  miliary  and 
chronic  pulmonary  tuberculosis  it  is  not  uncommon  to  find  the  peritonaeum 
studded  with  small  gray  granulations.  They  are  constantly  present  on  the 
serous  surface  of  tuberculous  ulcers  of  the  intestines.  Apart  from  these  con- 
ditions the  membrane  is  often  the  seat  of  extensive  tuberculous  disease,  which 
occurs  in  the  following  forms: 

(1)  Acute  miliary  tuherculosis  with  sero-fibrinous  or  bloody  exudation. 

(2)  Chronic  tuberculosis,  characterized  by  larger  growths,  which  tend  to 
caseate  and  ulcerate.  The  exudate  is  purulent  or  sero-purulent,  and  is  often 
sacculated. 

(3)  Chronic  fibroid  tuberculosis,  which  may  be  subacute  from  the  onset, 
or  which  may  represent  the  final  stage  of  an  acute  miliary  eruption.  The 
tubercles  are  hard  and  pigmented.  There  is  little  or  no  exudation,  and  the 
serous  surfaces  are  matted  together  by  adhesions. 

The  process  may  be  primary  and  local,  which  was  the  case  in  5  of  17 
post  mortems.  In  children  the  infection  appears  to  pass  from  the  intestines, 
and  in  adults  this  is  the  source  in  the  cases  associated  ^dth  chronic  phthisis. 
In  women  the  disease  extends  commonly  from  the  Fallopian  tubes.  In  at 
least  30  or  40  per  cent  of  the  instances  of  laparotomy  in  this  affection  reported 
by  gjTifecologists  the  infection  was  from  them.  The  prostate  or  the  sem- 
inal vesicles  may  be  the  starting-point.  In  many  cases  the  peritonaeum  is 
involved  with  the  pleura  and  pericardium,  particularly  with  the  former 
membrane. 

It  is  interesting  to  note  that  certain  morbid  conditions  of  the  abdominal 
organs  predispose  to  the  development  of  the  disease ;  thus  patients  with  cirrho- 
sis of  the  liver  very  often  die  of  an  acute  tuberculous  peritonitis.  The  fre- 
quency with  which  the  condition  is  met  with  in  operations  upon  ovarian 
tumors  has  been  commented  upon  by  gynaecologists.  Many  cases  have  fol- 
lowed trauma  of  the  abdomen.  A  very  interesting  feature  is  the  occurrence 
of  tuberculosis  in  hernial  sacs.  The  condition  is  not  very  uncommon.  In  a 
majority  of  the  instances  it  has  been  discovered  accidentally  during  the  oper- 
ation for  radical  cure  or  for  strangulation.  In  7  instances  the  sac  alone  was 
involved. 

It  is  generally  stated  that  males  are  attacked  oftener  than  females,  but 
in  the  collected  statistics  I  find  the  cases  to  be  twice  as  numerous  in  females 
as  in  males;  in  the  ratio,  indeed,  of  131  to  60. 

Tuberculous  peritonitis  occurs  at  all  ages.  It  is  common  in  children  asso- 
ciated with  intestinal  and  mesenteric  disease.  The  incidence  is  most  fre- 
quent between  the  ages  of  twenty  and  fort)^  It  may  occur  in  advanced  life. 
In  one  of  my  cases  the  patient  was  eighty-two  years  of  age.  Of  357  cases 
collected  by  me  from  the  literature,  there  were  under  ten  years,  27 ;  between 
ten  and  twenty,  75;  from  twenty  to  tliirty,  87;  between  thirty  and  fortv,  71; 
from  forty  to  fifty,  61 ;  from  fifty  to  sixty,  19 ;  from  sixty  to  seventy,  4 ; 
above  seventy,  2.  In  America  it  is  more  common  in  the  negro  than  in  the 
white  race.  More  blacks  than  whites,  77  to  70,  were  admitted  to  the  Johns 
Hopkins  Hospital  (Hamman). 

Sijmptoms.—ln  certain  special  features  the  tuberculous  varies  consider- 


TUBERCULOSIS.  311 

ably  from  other  forms  of  peritonitis.  It  presents  a  symptom-complex  of 
extraordinary  diversity. 

In  the  first  place,  the  process  may  be  latent  and  met  with  accidentally 
in  the  operation  for  hernia  or  for  ovarian  tumor.  The  acute  onset  is  not 
uncommon.  Four  cases  in  our  records  were  diagnosed  appendicitis,  two  acute 
cholecystitis,  and  six  had  symptoms  of  intestinal  obstruction,  in  two  of  these 
coming  on  with  great  abruptness  (Hamman).  The  cases  have  been  mistaken 
for  strangulated  hernia.  Other  cases  set  in  acutely  with  fever,  abdominal 
tenderness,  and  the  symptoms  of  ordinary  acute  peritonitis.  Cases  with  a 
slow  onset,  abdominal  tenderness,  tympanites,  and  low  continuous  fever  are 
often  mistaken  for  typhoid  fever. 

Ascites  is  frequent,  but  the  effusion  is  rarely  large.  It  is  sometimes  hsem- 
orrhagic.  In  this  form  the  diagnosis  may  rest  between  an  acute  miliary 
cancer,  cirrhosis  of  the  liver,  and  a  chronic  simple  peritonitis — conditions 
which  usually  offer  no  special  difficulties  in  differentiation.  A  most  impor- 
tant point  is  the  simultaneous  presence  of  a  pleurisy.  The  tuberculin  test 
may  be  used.  Tympanites  may  be  present  in  the  very  acute  cases,  when  it 
is  due  to  loss  of  tone  in  the  intestines,  owing  to  inflammatory  infiltration;  or 
it  may  occur  in  the  old,  long-standing  cases  when  universal  adhesion  has  taken 
place  between  the  parietal  and  visceral  layers.  Fever  is  a  marked  symptom 
in  the  acute  cases,  and  the  temperature  may  reach  103°  or  104°.  In  many 
instances  the  fever  is  slight.  In  the  more  chronic  cases  subnormal  tempera- 
tures are  common,  and  for  days  the  temperature  may  not  rise  above  97°,  and 
the  morning  record  may  be  as  low  as  95.5°.  An  occasional  symptom  is  pig- 
mentation of  the  skin,  which  in  some  cases  has  led  to  the  diagnosis  of  Addi- 
son's disease.  A  striking  peculiarity  of  tuberculous  peritonitis  is  the  fre- 
quency with  which  the  condition  either  simulates  or  is  associated  with  tumor. 
This  may  be : 

(a)  Omental,  due  to  puckering  and  rolling  of  this  membrane  until  it 
forms  an  elongated  firm  mass,  attached  to  the  transverse  colon  and  lying 
athwart  the  upper  part  of  the  abdomen.  This  cord-like  structure  is  found 
also  with  cancerous  peritonitis,  but  is  much  more  common  in  tuberculosis. 
Gairdner  has  called  special  attention  to  this  form  of  tumor,  and  in  children 
has  seen  it  undergo  gradual  resolution.  A  resonant  percussion  note  may 
sometimes  be  elicited  above  the  mass.  Though  usually  situated  near  the 
umbilicus,  the  omental  mass  may  form  a  prominent  tumor  in  the  right  iliac 
region. 

(&)  Sacculated  exudation,  in  which  the  effusion  is  limited  and  confined 
by  adhesions  between  the  coils,  the  parietal  peritonasum,  the  mesentery,  and 
the  abdominal  or  pelvic  organs.  This  encysted  exudate  is  most  common  in 
the  middle  zone,  and  has  frequently  been  mistaken  for  ovarian  tumor.  It  may 
occupy  the  entire  anterior  portion  of  the  peritonaBum,  or  there  may  be  a  more 
limited  saccular  exudate  on  one  side  or  the  other.  Within  the  pelvis  it  is 
associated  with  disease  of  the  Fallopian  tubes.  Eighteen  cases  in  the  gyneco- 
logical wards  (J.  H.  H.)  were  operated  upon  for  pyosalpinx  (Hamman). 

(c)  In  rare  cases  the  tumor  formations  may  be  due  to  great  retraction 
or  thickening  of  the  intestinal  coils.  The  small  intestine  is  found  short- 
ened, the  walls  enormously  thickened,  and  the  entire  coil  may  form  a  firm 
knot  close  against  the  spine,  giving  on  examination  the  idea  of  a  solid  mass. 


312  SPECIFIC  INFECT lOVS  DISEASES. 

Not  the  small  intestine  only,  but  the  entire  Ijowel  from  the  duodenum  to  the 
rectum,  has  been  found  forming  such  a  hard  nodular  tumor. 

(d)  Mesenteric  glands,  which  occasionally  form  very  large,  tumor-like 
masses,  more  commonly  foimd  in  children  than  in  adults.  This  condition 
may  be  confined  to  the  abdominal  glands.  Ascites  may  coexist.  The  condi- 
tion must  be  distinguished  from  that  in  children,  in  which,  with  ascites  or 
tjTapanites — sometimes  both — there  can  be  felt  irregular  nodular  masses,  due 
to  large  caseous  formations  between  the  intestinal  coils.  'No  doubt  in  a  con- 
siderable number  of  cases  of  the  so-called  tabes  mesenterica,  particularly  in 
those  with  enlargement  and  hardness  of  the  abdomen — the  condition  which 
the  French  call  carreau — there  is  involvement  also  of  the  peritonaeum. 

The  diagnosis  of  these  peritoneal  tumors  is  sometimes  very  difficult.  The 
omental  mass  is  a  less  frequent  source  of  error  than  any  other ;  but,  as  already 
mentioned,  a  similar  condition  may  occur  in  cancer.  The  most  important 
problem  is  the  diagnosis  of  the  saccular  exudation  from  ovarian  tumor.  In 
fully  one-third  of  the  recorded  cases  of  laparotomy  in  tuberculous  peritonitis, 
the  diagnosis  of  cystic  ovarian  disease  had  been  made.  The  most  suggestive 
points  for  consideration  are  the  history  of  the  patient  and  the  evidence  of 
old  tuberculous  lesions.  The  physical  condition  is  not  of  much  help,  as  in 
many  instances  the  patients  have  been  robust  and  well  nourished.  Irregular 
febrile  attacks,  gastro-intestinal  disturbance,  and  pains  are  more  common 
in  tuberculous  disease.  Unless  inflamed  there  is  usually  not  much  fever  with 
ovarian  cysts.  The  local  signs  are  very  deceptive,  and  in  certain  cases  have 
conformed  in  every  particular  to  those  of  cystic  disease.  The  outlines  in  sac- 
cular exudation  are  rarely  so  well  defined.  The  position  and  form  may  be 
variable,  owing  to  alterations  in  the  size  of  the  coils  of  which  in  parts  the 
walls  are  composed.  Nodular  cheesy  masses  may  sometimes  be  felt  at  the 
periphery.  Depression  of  the  vaginal  wall  is  mentioned  as  occurring  in 
encysted  peritonitis :  but  it  is  also  found  in  ovarian  tumor.  Lastly,  the  con- 
dition of  the  Fallopian  tubes,  of  the  lungs  and  the  pleurse,  should  be  thor- 
oughly examined.  The  association  of  salpingitis  with  an  Hi-defined  anoma- 
lous mass  in  the  abdomen  should  arouse  suspicion,  as  should  also  involvement 
of  the  pleura,  the  apex  of  one  lung,  or  a  testis  in  the  male. 

IV.  Pulmonary  Tubeeculosis  {Phthisis,  Consumption). 

Three  clinical  groups  may  be  conveniently  recognized:  (1)  tuberculo- 
pneumonicplLt]iisis—AQ\\ie^\ii\Aii%;  (2)  chronic  ulcerative  pUMsis;  and  (3) 
fibroid  phthisis. 

According  to  the  mode  of  infection  there  are  two  distinct  t}-pes  of  lesions : 
(a)  When  the  bacilli  reach  the  limgs  through  the  blood-vessels  or  lym- 
phatics the  primary  lesion  is  usually  in  the  tissues  of  the  alveolar  walls,  in 
the  capillary  vessels,  the  epithelium  of  the  air-cells,  and  in  the  connective- 
tissue  framework  of  the  septa.  The  irritation  of  the  bacilli  produces,  within 
a  few  days,  the  small,  gray  miliary  nodules,  involving  several  alveoli  and  con- 
sisting largely  of  round,  cuboidal,  uninuclear  epithelioid  cells.  Depending 
upon  the  number  of  bacilli  which  reach  the  lung  in  this  way,  either  a  localized 
or  a  general  tuberculosis  is  excited.  The  tubercles  may  be  uniformlv  scat- 
tered through  both  lungs  and  form  a  part  of  a  general  miliary  tuberculo- 


TUBERCULOSIS.  313 

sis,  or  they  may  be  confined  to  the  lungs,  or  even  in  great  part  to  one  lung. 
The  changes  which  the  tubercles  undergo  have  already  been  referred  to.  The 
further  stages  may  be:  (1)  Arrest  of  the  process  of  cell  division,  gradual 
sclerosis  of  the  tubercle,  and  ultimately  complete  fibroid  transformation. 
(2)  Caseation  of  the  centre  of  the  tubercle,  extension  at  the  periphery  by 
proliferation  of  the  epithelioid  and  lymphoid  cells,  so  that  the  individual 
tubercles  or  small  groups  become  confiuent  and  form  diffuse  areas  which 
undergo  caseation  and  softening.  (3)  Occasionally  as  a  result  of  intense 
infection  of  a  localized  region  through  the  blood-vessels  the  tubercles  are 
thickly  set.  The  intervening  tissue  becomes  acutely  inflamed,  the  air-cells 
are  filled  with  the  products  of  a  desquamative  pneumonia,  and  many  lobules 
are  involved. 

(&)  When  the  bacilli  reach  the  lung  through  the  bronchi — inhalation  or 
aspiration  tuberculosis — the  picture  differs.  The  smaller  bronchi  and  bron- 
chioles are  more  extensively  affected;  the  process  is  not  confined  to  single 
groups  of  alveoli,  but  has  a  more  lobular  arrangement,  and  the  tuberculous 
masses  from  the  outset  are  larger,  more  diffuse,  and  may  in  some  cases  involve 
an  entire  lobe  or  the  greater  part  of  a  lung.  It  is  in  this  mode  of  infection 
that  we  see  the  characteristic  peri-bronchial  granulations  and  the  areas  of 
the  so-called  nodular  broncho-pneumonia.  These  broncho-pneumonic  areas, 
with  on  the  one  hand  caseation,  ulceration,  and  cavity  formation,  and  on  the 
other  sclerosis  and  limitation,  make  up  the  essential  elements  in  the  anatom- 
ical picture  of  tuberculous  phthisis. 

1.  Acute  Pneumonic  Tuberculosis  of  the  Lungs. 

This  form,  known  also  by  the  name  of  galloping  consumption,  is  met  with 
both  in  children  and  adults.  In  the  former  many  of  the  cases  are  mistaken 
for  simple  broncho-pneumonia. 

Two  types  may  be  recognized,  the  pneumonic  and  hroncho-pneumonic. 

The  Pneumonic  Form. — In  the  pneumonic  form  one  lobe  may  be  involved, 
or  in  some  instances  an  entire  lung.  The  organ  is  heavy,  the  affected  portion 
airless ;  the  pleura  is  usually  covered  with  a  thin  exudate,  and  on  section  the 
picture  resembles  closely  that  of  ordinary  hepatization.  The  following  is  an 
extract  from  the  post-mortem  report  of  a  case  in  which  death  occurred  twenty- 
nine  days  after  the  onset  of  the  illness,  having  all  the  characters  of  an  acute 
pneumonia:  "Left  lung  weighs  1,500  grammes  (double  the  weight  of  the 
other  organ)  and  is  heavy  and  airless,  crepitant  only  at  the  anterior  margins. 
Section  shows  a  small  cavity  the  size  of  a  walnut  at  the  apex,  about  which 
are  scattered  tubercles  in  a  consolidated  tissue.  The  greater  part  of  the  lung 
presents  a  grayish-white  appearance  due  to  the  aggregation  of  tubercles  which 
in  some  places  have  a  continuous,  uniform  appearance,  in  others  are  sur- 
rounded by  an  injected  and  consolidated  lung-tissue.  Toward  the  margins  of 
the  lower  lobe  strands  of  this  firm  reddish  tissue  separate  angemic,  dry  areas. 
There  are  in  the  right  lung  three  or  four  small  groups  of  tubercles  but  no 
caseous  masses.  The  bronchial  glands  are  not  tuberculous."  Here  the  intense 
local  infection  was  due  to  the  small  focus  at  the  apex  of  the  lung,  probably  an 
aspiration  process. 

Only  the  most  careful  inspection  may  reveal  the  presence  of  miliary  tuber- 
cles, or  the  attention  may  be  arrested  by  the  detection  of  tubercles  in  the  other 


314  SPECIFIC  INFECTIOUS  DISEASES. 

lung  or  in  the  bronchial  glands.  The  process  may  involve  only  one  lobe. 
ThS-e  may  be  older  areas  which  are  of  a  peculiarly  yellowish-white  color  and 
distinctly  caseous.  The  most  remarkable  picture  is  presented  by  cases  of  this 
kind  in  which  the  disease  lasts  for  some  months.  A  lobe  or  an  entire  lung 
may  be  enlarged,  firm,  airless  throughout,  and  converted  into  a  dr}^,  yellowish- 
white,  cheesy  substance.  Cases  are  met  with  in  which  the  entire  kmg  from 
apex  to  base  is  in  this  condition,  with  perhaps  only  a  small,  narrow  area  of 
air-containing  tissue  on  the  margin.  More  commonly,  if  the  case  has  lasted 
for  two  or  three  months,  rapid  softening  has  taken  place  at  the  apex  with 
extensive  cavity  formation. 

Males  are  much  more  frequently  attacked  than  females.  Of  my  series  of 
15  cases,  11  were  in  males.  The  onset  was  acute  in  13,  with  a  chill  in  9.  Ba- 
cilli were  found  in  the  sputum  in  one  case  as  early  as  the  fourth  day.  Fraenkel 
and  Troje  believe  that  the  cases  are  of  bronchogenous  origin,  due  to  infection 
from  a  small  focus  somewhere  in  the  lung.  They  found  tubercle  bacilli  alone 
in  11  of  their  13  cases.  Tendeloo  reports  a  fatal  case  on  the  sixth  day,  and 
regards  the  infection  as  sometimes  hematogenous. 

Symptoms. — The  attack  sets  in  abruptly  with  a  chill,  usually  in  an  indi- 
vidual who  has  enjoyed  good  health,  although  in  many  cases  the  onset  has 
been  preceded  by  exposure  to  cold,  or  there  have  been  debilitating  circum- 
stances. The  temperature  rises  rapidly  after  the  chill,  there  are  pain  in  the 
side,  and  cough,  with  at  first  mucoid,  subsequently  rusty-colored  expectora- 
tion which  may  contain  tubercle  bacilli.  The  dyspnoea  may  become  extreme 
and  the  patient  may  have  suffocative  attacks.  The  physical  examination  shows 
involvement  of  one  lobe  or  of  one  lung,  with  signs  of  consolidation,  dulness,  in- 
creased fremitus,  at  first  feeble  or  suppressed  vesicular  murmur,  and  subse- 
quently well-marked  bronchial  breathing.  The  upper  or  lower  lobe  may  be 
involved,  or  in  some  cases  the  entire  lung. 

At  this  time,  as  a  rule,  no  suspicion  enters  the  mind  of  the  practitioner 
that  the  case  is  anything  but  one  of  frank  lobar  pneumonia.  Occasionally 
there  may  be  suspicious  circumstances  in  the  history  of  the  patient  or  in  his 
family;  but,  as  a  rule,  no  stress  is  laid  upon  them  in  view  of  the  intense  and 
characteristic  mode  of  onset.  Between  the  eighth  and  tenth  day,  instead 
of  the  expected  crisis,  the  condition  becomes  aggravated,  the  temperature  is 
irregular,  and  the  pulse  more  rapid.  There  may  be  sweating,  and  the  expec- 
toration becomes  muco-purulent  and  greenish  in  color — a  point  of  special 
importance,  to  which  Traube  called  attention.  Even  in  the  second  or  third 
week,  with  the  persistence  of  these  symptoms,  the  physician  tries  to  console 
himself  with  the  idea  that  the  case  is  one  of  unresolved  pneumonia,  and  that 
all  will  yet  be  well.  Gradually,  however,  the  severity  of  the  sjmptoms,  the 
presence  of  physical  signs  indicating  softening,  the  existence  of  elastic  tissue 
and  tubercle  bacilli  in  the  sputa  present  the  mournful  proofs  that  the  case  is 
one  of  acute  pneumonic  phthisis.  Death  may  occur  on  the  sixth  day,  as  in 
a  case  of  Tendeloo.  The  earliest  death  in  my  series  was  on  the  thirteenth  day. 
A  majority  of  the  cases  drag  on,  and  death  does  not  occur  until  the  third 
month.  In  a  few  cases,  even  after  a  stormy  onset  and  active  course,  the  symp- 
toms subside  and  the  patient  passes  into  the  chronic  stage. 

Diagnosis. — Waters,  of  Liverpool,  who  gave  an  admirable  description  of 
these  cases,  called  attention  to  the  difficulty  in  distinguishing  them  from  ordi- 


TUBERCULOSIS.  315 

nary  pneumonia.  Certainly  the  mode  of  onset  affords  no  criterion  whatever. 
A  healthy,  robust-looking  young  Irishman,  a  cab-driver,  who  had  been  kept 
waiting  on  a  cold,  blustering  night  until  three  in  the  morning,  was  seized  the 
next  afternoon  with  a  violent  chill,  and  the  folloAving  day  was  admitted  to 
my  wards  at  the  University  Hospital,  Philadelphia.  He  was  made  the  sub- 
ject of  a  clinical  lecture  on  the  fifth  day,  when  there  was  absent  no  single 
feature  in  history,  symptoms,  or  physical  signs  of  acute  lobar  pneumonia  of 
the  right  upper  lobe.  It  was  not  until  ten  days  later,  when  bacilli  were  found 
in  his  expectoration,  that  we  were  made  aware  of  the  true  nature  of  the  case. 
I  know  of  no  criterion  by  which  cases  of  this  kind  can  be  distinguished  in  the 
early  stage.  A  point  to  which  Traube  called  attention,  and  which  is  also 
referred  to  as  important  by  Herard  and  Cornil,  is  the  absence  of  breath-sounds 
in  the  consolidated  region ;  but  this,  I  am  sure,  does  not  hold  good  in  all  cases. 
The  tubular  breathing  may  be  intense  and  marked  as  early  as  the  fourth  day; 
and  again,  how  common  it  is  to  have,  as  one  of  the  earliest  and  most  suggestive 
symptoms  of  lobar  pneumonia,  suppression  or  enfeeblement  of  the  vesicular 
murmur !  In  many  cases,  however,  there  are  suspicious  circumstances  in  the 
onset:  the  patient  has  been  in  bad  health,  or  may  have  had  previous  pulmo- 
nary trouble,  or  there  are  recurring  chills.  Careful  examination  of  the  sputa 
and  a  study  of  the  physical  signs  from  day  to  day  can  alone  determine  the 
true  nature  of  the  case.  In  one  of  my  cases  the  bacilli  were  found  on  the 
fourth  day.  A  point  of  some  moment  is  the  character  of  the  fever,  which 
in  true  pneumonia  is  more  continuous,  particularly  in  severe  cases,  whereas 
in  this  form  of  tuberculosis  remissions  of  1.5°  or  2°  are  not  infrequent. 

Acute  tuberculous  broncho-pneumonia  is  more  common,  particularly  in 
children,  and  forms  a  majority  of  the  cases  of  phthisis  florida,  or  "  galloping 
consumption."  It  is  an  acute  caseous  broncho-pneumonia,  starting  in  the 
smaller  tubes,  which  become  blocked  with  a  cheesy  substance,  while  the  air- 
cells  of  the  lobule  are  filled  with  the  products  of  a  catarrhal  pneumonia.  In 
the  early  stages  the  areas  have  a  grayish-red,  later  an  opaque-white,  caseous 
appearance.  By  the  fusion  of  contiguous  masses  an  entire  lobe  may  be  ren- 
dered nearly  solid,  but  there  can  usually  be  seen  between  the  groups  areas  of 
crepitant  air  tissue.  This  is  not  an  uncommon  picture  in  the  acute  phthisis 
of  adults,  but  it  is  still  more  frequent  in  children.  The  following  is  an  ex- 
tract from  the  post-mortem  report  of  a  case  on  a  child  aged  four  months, 
who  died  in  the  sixth  week  of  illness :  "  On  section,  the  right  upper  lobe 
is  occupied  with  caseous  masses  from  5  to  13  mm.  in  diameter,  separated 
from  each  other  by  an  intervening  tissue  of  a  deep-red  color.  The  bronchi  are 
filled  with  cheesy  substance.  The  middle  and  lower  lobes  are  studded  with 
tubercles,  many  of  which  are  becoming  caseous.  Toward  the  diaphragmatic 
surface  of  the  lower  lobe  there  is  a  small  cavity  the  size  of  a  marble.  The 
left  lung  is  more  crepitant  and  uniformly  studded  with  tubercles  of  all  sizes, 
some  as  large  as  peas.  The  bronchial  glands  are  very  large,  and  one  contains 
a  tuberculous  abscess." 

There  is  a  form  of  tuberculous  aspiration  pneumonia,  to  which  Baumler 
has  called  attention,  occurring  as  a  sequence  of  haemoptysis,  and  due  to  the 
aspiration  of  blood  and  the  contents  of  pulmonary  cavities  into  the  finer  tubes. 
There  are  fever,  dyspnoea,  and  signs  of  a  diffuse  broncho-pneumonia.  Some 
of  these  cases  run  a  very  rapid  course,  and  are  examples  of  galloping  consump- 


316  SPECIFIC  INFECTIOUS  DISEASES, 

tion  following  liEcmoptysis.  This  accident  may  occur  not  only  early  in  the 
disease,  but  may  follow  haemorrhage  in  a  well-marked  pulmonary  tuberculosis. 

In  'children  the  enlarged  bronchial  glands  usually  surround  the  root  of 
the  lung,  and  even  pass  deeply  into  the  substance,  and  the  lobules  are  often 
involved  by  direct  contact. 

In  other  cases  the  caseous  broncho-pneumonia  involves  groups  of  alveoli 
or  lobules  in  different  portions  of  the  lungs,  more  commonly  at  both  apices, 
forming  areas  from  1  to  3  cm.  in  diameter.  The  size  of  the  mass  depends 
largely ''upon  that  of  the  bronchus  involved.  There  are  cases  which  probably 
should  come  in  this  category,  in  which,  with  a  history  of  an  acute  illness  of 
from  four  to  eight  weeks,  the  lungs  are  extensively  studded  with  large  gray 
tubercles,  ranging  in  size  from  5  to  10  mm.  In  some  instances  there  are 
cheesy  masses  the  size  of  a  cherry.  All  of  these  are  grayish-white  in  color, 
distinctly  cheesy,  and  between  the  adjacent  ones,  particularly  in  the  lower 
lobe,  there  may  be  recent  pneumonia,  or  the  condition  of  lung  which  has  been 
termed  splenization.  In  a  case  of  this  kind  at  the  Philadelphia  Hospital  death 
took  place  about  the  eighth  week  from  the  abrupt  onset  of  the  illness  with 
haemorrhage.  There  were  no  extensive  areas  of  consolidation,  but  the  cheesy 
nodules  were  uniformly  scattered  throughout  both  lungs.  Xo  softening  had 
taken  place. 

Secondary  infections  are  not  uncommon;  but  Prudden  was  able  to  show 
that  the  tubercle  bacillus  could  produce  not  only  distinct  tubercle  nodules, 
but  also  the  various  kinds  of  exudative  pneumonia,  the  exudates  varpng  in 
appearance  in  different  cases,  which  phenomena  occurred  absolutely  without 
the  intervention  of  other  organisms.  The  fact  that  these  latter  had  not  sub- 
sequently crept  in  was  shown  by  cultures  at  the  autopsy  on  the  affected  animal. 

Symptoms. — The  s}Tnptoms  of  acute  broncho-pneumonic  phthisis  are  very 
variable.  In  adults  the  disease  may  attack  persons  in  good  health,  but  over- 
worked or  "  run  down "'  from  anj^  cause.  Haemorrhage  initiates  the  attack 
in  a  few  cases.  There  may  be  repeated  chills;  the  temperature  is  high,  the 
pulse  rapid,  and  the  respirations  are  increased.  The  loss  of  flesh  and  strength 
is  very  striking. 

The  physical  signs  may  at  first  be  uncertain  and  indefinite,  but  finally 
there  are  areas  of  impaired  resonance,  usually  at  the  apices;  the  breath- 
sounds  are  harsh  and  tubular,  with  numerous  rales.  The  sputa  may  early 
show  elastic  tissue  and  tubercle  bacilli.  In  the  acute  cases,  within  three  weeks, 
the  patient  may  be  in  a  marked  tj-phoid  state,  with  delirium,  dry  tongue,  and 
high  fever.  Death  may  occur  within  three  weeks.  In  other  cases  the  onset 
is  severe,  with  high  fever,  rapid  loss  of  fiesh  and  strength,  and  signs  of  exten- 
sive unilateral  or  bilateral  disease.  Softening  takes  place;  there  are  sweats, 
chills,  and  progressive  emaciation,  and  all  the  features  of  phthisis  florida. 
Six  or  eight  weeks  later  the  patient  may  begin  to  improve,  the  fever  lessens, 
the  general  s^Tnptoms  abate,  and  a  case  which  looks  as  if  it  would  certainly 
terminate  fatally  within  a  few  weeks  drags  on  and  becomes  chronic. 

In  children  the  disease  most  commonly  follows  the  infectious  diseases, 
particularly  measles  and  whooping-cough.*  'The  profession  is  gradually  recog- 
nizing the  fact  that  a  majority  of  all  such  cases  are  tuberculous.     At  least 


■  Tussis  convulsiva  vestibulum  tabis  "  (Willis). 


TUBERCULOSIS.  317 

three  groups  of  these  tuberculous  broncho-pneumonias  may  be  recognized.  In 
the  first  the  child  is  taken  ill  suddenly  while  teething  or  during  convales- 
cence from  fever;  the  temperature  rises  rapidly,  the  cough  is  severe,  and 
there  may  be  signs  of  consolidation  at  one  or  both  apices  with  rales.  Death 
may  occur  within  a  few  days,  and  the  lung  shows  areas  of  broncho-pneumonia, 
with  perhaps  here  and  there  scattered  opaque  grayish-yellow  nodules.  Macro- 
scopically  the  affection  does  not  look  tuberculous,  but  histologically  miliary 
granulations  and  bacilli  may  be  found.  Tubercles  are  usually  present  in  the 
bronchial  glands,  but  the  appearance  of  the  broncho-pneumonia  may  be  ex- 
ceedingly deceptive,  and  it  may  require  careful  microscopical  examination  to 
determine  its  tuberculous  character.  The  second  group  is  represented  by  the 
case  of  the  child  previously  quoted,  which  died  at  the  sixth  week  with  the 
ordinary  symptoms  of  severe  broncho-pneumonia.  And  the  third  group  is 
that  in  which,  during  the  convalescence  from  an  infectious  disease,  the  child 
is  taken  ill  with  fever,  cough,  and  shortness  of  breath.  The  severity  of  the 
symptoms  abates  within  the  first  fortnight ;  but  there  is  loss  of  flesh,  the  gen- 
eral condition  is  bad,  and  the  physical  examination  shows  the  presence  of 
scattered  rales  throughout  the  lungs,  and  here  and  there  areas  of  defective 
resonance.  The  child  has  sweats,  the  fever  becomes  hectic  in  character,  and 
in  many  cases  the  clinical  picture  gradually  passes  into  that  of  chronic 
phthisis. 

2.  Chronic  Ulcerative  Tuberculosis  of  the  Lungs. 

Under  this  heading  may  be  grouped  the  great  majority  of  cases  of  pul- 
monary tuberculosis,  in  which  the  lesions  proceed  to  ulceration  and  softening, 
and  ultimately  produce  the  well-known  picture  of  chronic  phthisis.  At  first 
a  strictly  tuberculous  affection,  it  ultimately  becomes,  in  a  majority  of  cases, 
a  mixed  disease,  many  of  the  most  prominent  symptoms  of  which  are  due  to 
septic  infection  from  purulent  foci  and  cavities. 

Morbid  Anatomy. — Inspection  of  the  lungs  in  a  case  of  chronic  phthisis 
shows  a  remarkable  variety  of  lesions,  comprising  nodular  tubercles,  diffuse 
tuberculous  infiltration,  caseous  masses,  pneumonic  areas,  cavities  of  various 
sizes,  with  changes  in  the  pleura,  bronchi,  and  bronchial  glands. 

1.  The  Distribution  op  the  Lesions. — For  years  it  has  been  recognized 
that  the  most  advanced  lesions  are  at  the  apices,  and  that  the  disease  pro- 
gresses downward,  usually  more  rapidly  in  one  of  the  lungs.  This  general 
statement,  which  has  passed  current  in  the  text-books  ever  since  the  masterly 
description  of  Laennec,  has  been  carefully  elaborated  by  Kingston  Fowler, 
who  finds  that  the  disease  in  its  onward  progress  through  the  lungs  follows, 
in  a  majority  of  the  cases,  distinct  routes.  In  the  upper  lobe  the  primary 
lesion  is  not,  as  a  rule,  at  the  extreme  apex,  but  from  an  inch  to  an  inch  and 
a  half  below  the  summit  of  the  lung,  and  nearer  to  the  posterior  and  external 
borders.  The  lesion  here  tends  to  spread  downward,  probably  from  inhala- 
tion of  the  virus,  and  this  accounts  for  the  frequent  circumstance  that  exami- 
nation behind,  in  the  supra-spinous  fossa,  will  give  indications  of  disease  before 
any  evidences  exist  at  the  apex  in  front.  Anteriorly  this  initial  focus  corre- 
sponds to  a  spot  Just  below  the  centre  of  the  clavicle,  and  the  direction  of 
extension  in  front  is  along  the  anterior  aspect  of  the  upper  lobe,  along  a  line 
running  about  an  inch  and  a  half  from  the  inner  ends  of  the  first,  second, 


3^3  SPECIFIC  INFECTIOUS  DISEASES. 

and  third  interspaces.  A  second  less  common  site  of  the  primary  lesion  in 
the  apex  "  corresponds  on  the  chest  wall  with  the  first  and  second  interspaces 
below  the  outer  third  of  the  clavicle."  The  extension  is  doT\Tiward,  so  that 
the  outer  part  of  the  upper  lobe  is  chiefly  involved. 

In  the  middle  lobe  of  the  right  lung  the  affection  usually  follows  disease 
of  the  upper  lobe  on  the  same  side.  In  the  involvement  of  the  lower  lobe 
the  first  secondary  infiltration  is  about  an  inch  to  an  inch  and  a  half  below 
the  posterior  extremity  of  its  apex,  and  corresponds  on  the  chest  wall  to  a 
spot  opposite  the  fifth  dorsal  spine.  This  involvement  is  of  the  greatest  im- 
portance clinically,  as  "  in  the  great  majority  of  cases,  when  the  physical  signs 
of  the  disease  at  the  apex  are  sufficiently  definite  to  allow  of  the  diagnosis  of 
phthisis  being  made,  the  lower  lobe  is  already  affected.''  Examination,  there- 
fore, should  be  made  carefully  of  this  posterior  apex  in  all  suspicious  cases. 
In  this  situation  the  lesion  spreads  downward  and  laterally  along  the  line 
of  the  interlobular  septa,  a  line  which  is  marked  by  the  vertebral  border 
of  the  scapula,  when  the  hand  is  placed  on  the  opposite  scapula  and  the 
elbow  raised  above  the  level  of  the  shoulder.  Once  present  in  an  apex,  the 
disease  usually  extends  in  time  to  the  opposite  upper  lobe;  but  not,  as  a 
rule,  until  the  apex  of  the  lower  lobe  of  the  lung  first  affected  has  been 
attacked. 

Of  427  cases  above  mentioned,  the  right  apex  was  involved  in  172,  the 
left  in  130,  both  in  11]. 

Lesions  of  the  base  may  be  primary,  though  this  is  rare.  Percy  Kidd 
makes  the  proportion  of  basic  to  apical  phthisis  1  to  500,  a  smaller  number 
than  existed  in  my  series.  In  very  chronic  cases  there  may  be  arrested  lesions 
at  the  apex  and  more  recent  lesions  at  the  base. 

2.  Summary  of  the  Lesioivts  in  CHEOisric  Ulceeative  Phthisis. — 
(a)  Miliary  Tubercles. — They  have  one  of  two  distributions:  (1)  A  dissemi- 
nation due  to  aspiration  of  tuberculous  material,  the  tubercles  being  situated 
in  the  air-cells  or  the  walls  of  the  smaller  bronchi;  (2)  the  distribution  due 
to  dissemination  of  tubercle  bacilli  by  the  IjTnph  current,  the  tubercles  being 
scattered  about  the  old  foci  in  a  radial  manner — ^the  secondary  crop  of  Laen- 
nec.  Much  more  rarely  there  is  a  scattered  dissemination  from  infection  here 
and  there  of  the  smaller  vessels,  the  tubercles  then  being  situated  in  the  vessel 
walls.  Sometimes,  in  cases  with  cavity  formation  at  the  apex,  the  greater 
part  of  the  lower  lobes  presents  many  groups  of  firm,  sclerotic,  miliary  tuber- 
cles, which  may  indeed  form  the  distinguishing  anatomical  feature — a  chronic 
miliary  tuberculosis. 

(6)  Tuberculous  Bronclio-pneumonia. — In  a  large  proportion  of  the  cases 
of  chronic  phthisis  the  terminal  bronchiole  is  the  point  of  origin  of  the  process, 
consequently  we  find  the  smaller  bronchi  and  their  alveolar  territories  blocked 
with  the  accumulated  products  of  inflammation  in  all  stages  of  caseation. 
At  an  early  period  a  cross-section  of  an  area  of  tuberculous  broncho-pneumonia 
gives  the  most  characteristic  appearance.  The  central  bronchiole  is  seen  as 
a  small  orifice,  or  it  is  plugged  with  cheesy  contents,  while  surrounding  it  is 
a  caseous  nodule,  the  so-called  peribronchial  tubercle.  The  longitudinal  sec- 
tion has  a  somewhat  dendritic  or  foliaceous  appearance.  The  condition  of  the 
picture  depends  much  upon  the  slowness  or  rapidity  with  which  the  process 
has  advanced.     The  following  changes  may  occur: 


TUBERCULOSIS.  319 

Ulceration. — When  the  caseation  takes  place  rapidly  or  ulceration  occurs 
i'n  the  bronchial  wall,  the  mass  may  break  down  and  form  a  small  cavity. 

Sclerosis. — In  other  instances  the  process  is  more  chronic,  and  fibroid 
changes  gradually  produce  a  sclerosis  of  the  affected  area.  The  sclerosis  may 
be  confined  to  the  margin  of  the  mass,  forming  a  limiting  capsule,  within 
which  is  a  uniform,  firm,  cheesy  substance,  in  which  lime  salts  are  often 
deposited.  This  represents  the  healing  of  one  of  these  areas  of  caseous 
broncho-pneumonia.  It  is  only,  however,  when  complete  fibroid  transforma- 
tion or  calcification  has  occurred  that  we  can  really  speak  of  healing.  In 
many  instances  the  colonies  of  miliary  tubercles  about  these  masses  show 
that  the  virus  is  still  active  in  them.  Subsequently,  in  ulcerative  processes, 
these  calcareous  bodies — lung-stones,  as  they  are  sometimes  called — may  be 
expectorated. 

(c)  Pneumonia. — An  important  though  secondary  place  is  occupied  by 
inflammation  of  the  alveoli  surrounding  the  tubercles,  which  become  filled  with 
epithelioid  cells.  The  consolidation  may  extend  for  some  distance  about 
the  tuberculous  foci  and  unite  them  into  areas  of  uniform  consolidation. 
Although  in  some  instances  this  inflammatory  process  may  be  simple,  in 
others  it  is  undoubtedly  specific.  It  is  excited  by  the  tubercle  bacilli  and  is 
a  manifestation  of  their  action.  It  may  present  a  very  varied  appearance; 
in  some  instances  resembling  closely  ordinary  red  hepatization,  in  others 
being  more  homogeneous  and  infiltrated,  the  so-called  infiltration  tuberculeuse 
of  Laennec.  In  other  cases  the  contents  of  the  alveoli  undergo  fatty  degen- 
eration, and  appear  on  the  cut  surface  as  opaque  white  or  yellowish-white 
bodies.  In  early  phthisis  much  of  the  consolidation  is  due  to  this  pneumonic 
infiltration,  which  may  surround  for  some  distance  the  smaller  tuberculous 
foci. 

{d)  Cavities. — A  vomica  is  a  cavity  in  the  lung  tissue,  produced  by  necro- 
sis and  ulceration.  The  process  usually  begins  in  the  wall  of  the  bronchus  in 
a  tuberculous  area.  Dilatation  is  produced  by  retained  secretion,  and  necrosis 
and  ulceration  of  the  wall  occur  with  gradual  destruction  of  the  contiguous 
tissues.  By  extension  of  the  necrosis  and  ulceration  the  cavity  increases,  con- 
tiguous ones  unite,  and  in  an  affected  region  there  may  be  a  series  of  small 
excavations  communicating  with  a  bronchus.  In  nearly  all  instances  the  pro- 
cess extends  from  the  bronchi,  though  it  is  possible  for  necrosis  and  softening 
to  take  place  in  the  centre  of  a  caseous  area  without  primary  involvement  of 
the  bronchial  wall.     Three  forms  of  cavities  may  be  recognized. 

The  fresh  ulcerative,  seen  in  acute  phthisis,  in  which  there  is  no  limiting 
membrane,  but  the  walls  are  made  up  of  softened,  necrotic,  and  caseous 
masses.  A  small  vomica  of  this  sort,  situated  just  beneath  the  pleura,  may 
rupture  and  cause  pneumothorax.  In  cases  of  acute  tuberculo-pneumonic 
phthisis  they  may  be  large,  occupying  the  greater  portion  of  the  upper  lobe. 
In  the  chronic  ulcerative  phthisis,  cavities  of  this  sort  are  invariably  present 
in  those  portions  of  the  lung  in  which  the  disease  is  advancing.  At  the 
apex  there  may  be  a  large  old  cavity  with  well-defined  walls,  while  at  the 
anterior  margin  of  the  upper  lobes,  or  in  the  apices  of  the  lower  lobes,  there 
are  recent  ulcerating  cavities  communicating  with  the  bronchi. 

Cavities  with  Well-defined  Walls. — A  majority  of  the  cavities  in  the 
chronic  form  of  phthisis  have  a  well-defined  limiting  membrane,  the  inner 


320  SPECIFIC  INFECTIOUS  DISEASES. 

surface  of  which  constantly  produces  pus.  The  walls  are  crossed  by  trabec- 
ulse  wliich  represent  remnants  of  bronchi  and  blood-vessels.  Even  the  vomicas 
with  the  well-defined  walls  extend  gradually  by  a  slow  necrosis  and  destruc- 
tion of  the  contiguous  lung  tissue.  The  contents  are  usually  purulent,  sim- 
ilar in  character  to  the  gra3dsh  nummular  sputa  coughed  up  by  phthisical 
patients.  Not  infrequently  the  membrane  is  vascular  or  it  may  be  haemor- 
rhagic.  Occasionally,  when  gangrene  has  occurred  in  the  wall,  the  contents 
are\orribly  foetid.  These  cavities  may  occupy  the  greater  portion  of  the 
apex,  forming  an  irregular  series  which  communicate  with  each  other  and 
with' the  bronchi,  or  the  entire  upper  lobe  except  the  anterior  margin  may 
be  excavated,  forming  a  thin-walled  cavity.  In  rare  instances  the  process  has 
proceeded  to  total  excavation  of  the  lung,  not  a  remnant  of  which  remains, 
except  perhaps  a  narrow  strip  at  the  anterior  margin.  In  a  case  of  this  kind, 
in  a  young  girl,  the  cavity  held  40  fluid  ounces,  in  another  43  ounces. 

Quiescent  Cavities. — When  quite  small  and  surrounded  by  dense  cicatricial 
tissue  communicating  with  the  bronchi  they  form  the  cicatrices  fistuleuses  of 
Laennec.  Occasionally  one  apex  may  be  represented  by  a  series  of  these  small 
cavities,  surrounded  by  dense  fibrous  tissue.  The  lining  membrane  of  these 
old  cavities  may  be  quite  smooth,  almost  like  a  mucous  membrane.  Cavities 
of  any  size  do  not  heal  completely. 

Cases  are  often  seen  in  which  it  has  been  supposed  that  a  cavity  has  healed ; 
but  the  signs  of  excavation  are  notoriously  uncertain,  and  there  may  be  pec- 
toriloquy and  cavernous  sounds  with  gurgling  resonant  rales  in  an  area  of 
consolidation  close  to  a  large  bronchus. 

In  the  formation  of  vomica  the  blood-vessels  gradually  become  closed  by 
an  obliterating  inflammation.  They  are  the  last  structures  to  yield  and  may 
be  completely  exposed  in  a  cavity,  even  when  the  circulation  is  still  going  on 
in  them.  Unfortunately,  the  erosion  of  a  large  vessel  which  has  not  yet  been 
obliterated  is  by  no  means  infrequent,  and  causes  profuse  and  often  fatal  haem- 
orrhage. Another  common  event  is  the  formation  of  aneurisms  on  the  arte- 
ries running  in  the  walls  of  cavities.  These  may  be  small,  bunch-like  dilata- 
tions, or  they  may  form  sacs  the  size  of  a  walnut  or  even  larger.  Rasmussen, 
Douglas  Powell,  and  others  have  called  attention  to  their  importance  in  haem- 
optysis, under  which  section  they  are  dealt  with  more  fully. 

And,  finally,  about  cavities  of  all  sorts,  the  connective  tissue  grows,  tend- 
ing to  limit  their  extent.  The  thickening  is  particularly  marked  beneath  the 
pleura,  and  in  chronic  cases  an  entire  apex  may  be  converted  into  a  mass  of 
fibrous  tissue,  enclosing  a  few  small  cavities. 

(e)  Pleura. — Practically,  in  all  cases  of  chronic  phthisis  the  pleura  is  in- 
volved. Adhesions  take  place  which  may  be  thin  and  readily  torn,  or  dense 
and  firm,  uniting  layers  of  from  2  to  5  mm.  in  thickness.  This  pleurisy  may 
be  simple,  but  in  many  cases  it  is  tuberculous,  and  miliary  tubercles  or  case- 
ous masses  are  seen  in  the  thickened  membrane.  Effusion  is  not  at  all  infre- 
quent, either  serous,  purulent,  or  hfemorrhagic.  Pneumothorax  is  a  common 
accident. 

(/)  Changes  in  the  smaller  Ironclii  control  the  situation  in  the  early  stages 
of  tuberculous  phthisis,  and  play  an  important  role  throughout  the  disease. 
The  process  very  often  begms  m  the  walls  of  the  smaller  tubes  and  leads  to 
caseation,  distention  with  products  of  inflammation,  and  broncho-pneumonia 


TUBERCULOSIS.  321 

of  the  lobules.  In  many  cases  the  visible  implication  of  the  bronchus  is  an 
extension  upward  of  a  process  which  has  begun  in  the  smallest  bronchiole. 
This  involvement  weakens  the  wall,  leading  to  bronchiectasis,  not  an  uncom- 
mon event  in  phthisis.  The  mucous  membrane  of  the  larger  bronchi,  which  is 
usually  involved  in  a  chronic  catarrh,  is  more  or  less  swollen,  and  in  some 
instances  ulcerated.  Besides  these  specific  lesions,  they  may  be  the  seat,  espe- 
cially in  children,  of  inflammation  due  to  secondary  invasion,  most  frequently 
by  the  micrococcus  lanceolatus,  with  the  production  of  a  broncho-pneumonia. 

(g)  The  bronchial  glands,  in  the  more  acute  cases,  are  swollen  and 
oedematous.  Miliary  tubercles  and  caseous  foci  are  usually  present.  In  cases 
of  chronic  phthisis  the  caseous  areas  are  common,  calcification  may  occur, 
and  not  infrequently  purulent  softening. 

(h)  Changes  in  the  other  Organs. — Of  these,  tuberculosis  is  the  most  com- 
mon. In  my  series  of  autopsies  the  brain  presented  tuberculous  lesions  in  31, 
the  spleen  in  33,  the  liver  in  12,  the  kidneys  in  32,  the  intestines  in  65,  and 
the  pericardium  in  7.  Other  groups  of  lymphatic  glands  besides  the  bron- 
chial may  be  affected. 

Amyloid  change  is  frequent  in  the  liver,  spleen,  kidneys,  and  mucous  mem- 
brane of  the  intestines.  The  liver  is  often  the  seat  of  extensive  fatty  infiltra- 
tion, which  may  cause  marked  enlargement.  The  intestinal  tuberculosis 
occurs  in  advanced  cases  and  is  responsible  in  great  part  for  the  troublesome 
diarrhoea. 

Endocarditis  is  not  very  uncommon,  and  was  present  in  12  of  my  post 
mortems  and  in  27  of  Percy  Kidd's  500  cases.  Tubercle  bacilli  have  been 
found  in  the  vegetations.  Tubercles  may  be  present  on  the  endocardium,, 
particularly  of  the  right  ventricle. 

The  larynx  is  frequently  involved,  and  ulceration  of  the  vocal  cords  and 
destruction  of  the  epiglottis  are  not  at  all  uncommon. 

Modes  of  Onset. — We  have  already  seen  that  tuberculosis  of  the  lungs 
may  occur  as  the  chief  part  of  a  general  infection,  or  may  set  in  with  symp- 
toms which  closely  simulate  acute  pneumonia.  In  the  ordinary  type  of  pul- 
monary tuberculosis  the  invasion  is  gradual  and  less  striking,  but  presents 
an  extraordinarily  diverse  picture,  so  that  the  practitioner  is  often  led  into 
error.     Among  the  most  characteristic  modes  of  onset  are  the  following : 

(a)  Latent  Types. — It  is  probable  that  many  slight,  ill-defined  ailments 
are  due  to  a  local  unrecognized  tuberculosis  of  the  lung.  In  the  history  of 
cases. of  phthisis  such  attacks  are  not  infrequently  mentioned. 

The  disease  makes  considerable  progress  before  there  are  serious  symp- 
toms to  arouse  the  attention  of  the  patient.  In  workingmen  the  disease  may 
even  advance  to  excavation  of  an  apex  before  they  seek  advice.  It  is  not  a 
little  remarkable  how  slight  the  lung  symptoms  may  have  been. 

The  symptoms  may  be  masked  by  the  existence  of  serious  disease  in  other 
organs,  as  in  the  peritonaeum,  intestines,  or  bones. 

(b)  With  Symptoms  of  Dyspepsia  and  Ancemia. — The  gastric  mode  of 
onset  is  very  common,  and  the  early  manifestations  may  be  great  irritability 
of  the  stomach  with  vomiting  or  a  type  of  acid  dyspepsia  with  eructations. 
In  young  girls  (and  in  children)  with  this  dyspepsia  there  is  very  frequently 
a  pronounced  chloro-ansemia,  and  the  patient  complains  of  palpitation  of  the 
heart,  increasing  weakness,  slight  afternoon  fever,  and  amenorrhoea. 

22 


322  SPECIFIC  INFECTIOUS  DISEASES. 

(c)  In  a  considerable  number  of  cases  the  onset  of  pulmonaiT  tiTljercnlo- 
sis  is  with  symptoms  which  suggest  malarial  fever.  The  patient  has  repeated 
paroxysms  of  chills,  fevers,  and  sweats,  which  may  recur  with  great  regular- 
ity. In  districts  in  which  intermittents  prevail  there  is  no  more  common 
m'^istake  than  to  confound  the  initial  rigors  of  pulmonary  tuberculosis  with 
malaria. 

(d)  Onset  with  Pleurisy. — The  first  symptoms  may  be  a  dry  pleurisy  over 
an  apex,  with  persistent  friction  murmur.  In  other  instances  the  pulmonary 
sjTuptoms  have  followed  an  attack  of  pleurisy  with  effusion.  The  exudate 
gradually  disappears,  but  the  cough  persists  and  the  patient  becomes  fever- 
ish, and  gradually  signs  of  disease  at  one  apex  become  manifest.  About  one- 
third  of  all  cases  of  pleurisy  with  effusion  subsequently  have  pulmonary 
tuberculosis. 

(e)  With  Laryngeal  Symptoms. — The  primary  localization  may  be  in  the 
lar}Tix,  though  in  a  majority  of  the  instances  in  which  huskiness  and  larjoi- 
geal  symptoms  are  the  first  noticeable  features  of  the  disease  there  are  doubt- 
less foci  already  existing  in  the  lung.  The  group  of  cases  in  which  for  many 
months  throat  and  lar}Tix  s3^nptoms  precede  the  graver  manifestations  of  pul- 
monary phthisis  is  a  very  important  one. 

(/)  Onset  with  Haemoptysis. — Frequently  the  very  first  s}anptom  of  the 
disease  is  a  brisk  haemorrhage  from  the  lungs,  following  which  the  pulmonary 
symptoms  may  come  on  with  great  rapidity.  In  other  cases  the  hasmoptysis 
recurs,  and  it  may  be  months  before  the  sjTaptoms  become  well  established. 
In  a  majority  of  these  cases  the  local  tuberculous  lesion  exists  at  the  date  of 
the  haemoptysis. 

(g)  With  Tuberculosis  of  the  Cervico-axiUary  Glands. — Preceding  the 
onset  of  pulmonary  phthisis  for  months,  or  even  for  years,  the  Ijanph-glands 
of  the  neck  or  of  the  neck  and  axilla  of  one  side  may  be  enlarged.  These  cases 
are  by  no  means  infrequent,  and  they  are  of  importance  because  of  the  latency 
of  the  pulmonary  lesions,  l^owadays,  when  operative  interference  is  so  com- 
mon, it  is  well  to  bear  in  mind  that  in  such  patients  the  corresponding  apex  of 
the  lung  may  be  extensively  involved. 

(h)  And,  lastl}^  in  by  far  the  largest  number  of  all  cases  the  onset  is  with 
a  bronchitis,  or,  as  the  patient  expresses  it,  a  neglected  cold.  There  has  been, 
perhaps,  a  liability  to  catch  cold  easily  or  the  patient  has  been  subject  to  naso- 
pharjmgeal  catarrh;  then,  following  some  unusual  exposure,  a  cough  begins, 
which  may  be  frequent  and  very  irritating.  The  examination  of  the  lungs 
may  reveal  localized  moist  sounds  at  one  apex  and  perhaps  wheezing  bronchitic 
rales  in  other  parts.  In  a  few  cases  the  early  s3Tnptoms  are  often  suggestive 
of  asthma  with  marked  wheezing  and  diffuse  piping  rales. 

Symptoms. — In  discussing  the  symptoms  it  is  usual  to  divide  the  disease 
into  three  periods :  the  first  embracing  the  time  of  the  growth  and  develop- 
ment of  the  tubercles;  the  second,  when  they  soften;  and  the  third,  when 
there  is  a  formation  of  cavities.  Unfortunately,  these  anatomical  stages 
can  not  be  satisfactorily  correlated  with  corresponding  clinical  periods,  and 
we  often  find  that  a  patient  in  the  third  stage  with  a  well-marked  cavity  is  in 
a  far  better  condition  and  has  greater  prospects  of  recovery  than  a  patient  in 
the  first  stage  with  diffuse  consolidation.  It  is  therefore  better  perhaps  to 
disregard  them  altogether. 


TUBERCULOSIS.  323 

1.  Local  Symptoms. — Pain  in  the  chest  may  be  early  and  troublesome 
or  absent  throughout.  It  is  usually  associated  with  pleurisy,  and  may  be 
sharp  and  stabbing  in  character,  and  either  constant  or  felt  only  during  cough- 
ing. Perhaps  the  commonest  situation  is  in  the  lower  thoracic  zone,  though 
in  some  instances  it  is  beneath  the  scapula  or  referred  to  the  apex.  The 
attacks  may  recur  at  long  intervals.  Intercostal  neuralgia  occasionally  occurs 
in  the  course  of  ordinary  phthisis. 

Cough  is  one  of  the  earliest  sjnnptoms,  and  is  present  in  the  majority  of 
cases  from  beginning  to  end.  There  is  nothing  peculiar  or  distinctive  about 
it.  At  first  dry  and  hacking,  and  perhaps  scarcely  exciting  the  attention  of 
the  patient,  it  subsequently  becomes  looser,  more  constant,  and  associated  with 
a  glairy,  muco-purulent  expectoration.  In  the  early  stages  of  the  disease  the 
cough  is  bronchial  in  its  origin.  When  cavities  have  formed  it  becomes  more 
paroxysmal,  and  is  most  marked  in  the  morning  or  after  a  sleep.  Cough  is 
not  a  constant  symptom,  however,  and  a  patient  may  present  himself  with 
well-marked  excavation  at  one  apex  who  will  declare  that  he  has  had  little  or  no 
cough.  So,  too,  there  may  be  well-marked  physical  signs,  dulness  and  moist 
sounds,  without  either  expectoration  or  cough.  In  well-established  cases  the 
nocturnal  paroxysms  are  most  distressing  and  prevent  sleep.  The  cough  may 
be  of  such  persistence  and  severity  as  to  cause  vomiting,  and  the  patient 
becomes  rapidly  emaciated  from  loss  of  food — Morton's  cough  (Phthisiologia, 
1689,  p.  101).  The  laryngeal  complications  give  a  peculiarly  husky  quality 
to  the  cough,  and  when  erosion  and  ulceration  have  proceeded  far  in  the  vocal 
cords  the  coughing  becomes  much  less  effective. 

Sputum. — This  varies  greatly  in  amount  and  character  at  the  different 
stages  of  ordinary  phthisis.  There  are  cases  with  well-marked  local  signs 
at  one  apex,  with  slight  cough  and  moderately  high  fever,  without  from  day 
to  day  a  trace  of  expectoration.  So,  also,  there  are  instances  with  the  most 
extensive  consolidation  (caseous  pneumonia),  and  high  fever,  but  without 
enough  expectoration  to  enable  an  examination  for  bacilli  to  be  made.  In  the 
early  stage  of  pulmonary  tuberculosis  the  sputum  is  chiefly  catarrhal  and  has 
a  glairy,  sago-like  appearance,  due  to  the  presence  of  alveolar  cells  which  have 
undergone  the  myeline  degeneration.  There  is  nothing  distinctive  or  peculiar 
in  this  form  of  expectoration,  which  may  persist  for  months  without  indicat- 
ing serious  trouble.  The  earliest  trace  of  characteristic  sputum  may  show  the 
presence  of  small  grayish  or  greenish-gray  purulent  masses.  These,  when 
coughed  up,  are  always  suggestive  and  should  be  the  portions  picked  out 
for  microscopical  examination.  As  softening  comes  on,  the  expectoration 
becomes  more  profuse  and  purulent,  but  may  still  contain  a  considerable 
quantity  of  alveolar  epithelium.  Finally,  when  cavities  exist,  the  sputa 
assume  the  so-called  nummular  form;  each  mass  is  isolated,  flattened, 
greenish-gray  in  color,  quite  airless,  and,  when  spat  into  water,  sinks  to 
the  bottom. 

By  the  microscopical  examination  of  the  sputum  we  determine  whether 
the  process  is  tuberculous,  and  whether  softening  has  occurred.  For  tubercle 
hacilli  the  Ehrlich-Weigert  method  is  the  best.  The  bacilli  are  seen  as  elon- 
gated, slightly  curved,  red  rods,  sometimes  presenting  a  beaded  appearance. 
They  are  frequently  in  groups  of  three  or  four,  but  the  number  varies  consid- 
erably.   Only  one  or  two  may  be  found  in  a  preparation,  or,  in  some  instances. 


324  SPECIFIC  INFECTIOUS  DISEASES. 

they  are  so  abundant  that  the  entire  field  is  occupied.  Eepeated  examinations 
may  be  necessary. 

The  continued  presence  of  tubercle  bacilli  in  the  sputum  is  an  infallible  in- 
dication of  the  existence  of  tuberculosis. 

One  or  two  may  possibly  be  due  to  accidental  inhalation.  A  number  may 
come  from  a  spot  of  softening  3  by  3  cm.  In  the  nummular  sputa  of  later 
stages  the  bacilli  are  very  abundant. 

Elastic  tissue  may  be  derived  from  the  bronchi,  the  alveoli,  or  from  the 
arterial  coats ;  and  naturally  the  appearance  of  the  tissue  will  vary  with  the 
locality  from  which  it  comes.  In  the  examination  for  this  it  is  not  necessary 
to  boil  the  sputum  with  caustic  potash.  For  years  I  have  used  a  simple  plan 
which  was  shown  to  me  at  the  London  Hospital  by  Sir  Andrew  Clark.  This 
method  depends  upon  the  fact  that  in  almost  all  instances  if  the  sputum  is 
spread  in  a  sufficiently  thin  layer  the  fragments  of  elastic  tissue  can  be  seen 
with  the  naked  eye.  The  thick,  purulent  portions  are  placed  upon  a  glass 
plate  15  X  15  cm.  and  flattened  into  a  thin  layer  by  a  second  glass  plate 
10  X  10  cm.  In  this  compressed  grayish  layer  between  the  glass  slips  any 
fragments  of  elastic  tissue  show  on  a  black  background  as  grayish-yellow 
spots  and  can  either  be  examined  at  once  under  a  low  power  or  the  uppermost 
piece  of  glass  is  slid  along  until  the  fragment  is  exposed,  when  it  is  picked 
out  and  placed  upon  the  ordinary  microscopic  slide.  Fragments  of  bread 
and  collections  of  milk-globules  may  also  present  an  opaque  white  appearance, 
but  with  a  little  practice  they  can  readily  be  recognized.  Fragments  of  epi- 
thelium from  the  tongue,  infiltrated  with  micrococci,  are  still  more  deceptive, 
but  the  microscope  at  once  shows  the  difference. 

The  bronchial  elastic  tissue  forms  an  elongated  network,  or  two  or  three 
long,  narrow  fibres  are  found  close  together.  From  the  blood-vessels  a  some- 
what similar  form  may  be  seen  and  occasionalh''  a  distinct  sheeting  is  found 
as  if  it  had  come  from  the  intima  of  a  good-sized  artery.  The  elastic  tissue 
of  the  alveolar  wall  is  quite  distinctive;  the  fibres  are  branched  and  often 
show  the  outline  of  the  arrangement  of  the  air-cells.  The  elastic  tissue  from 
bronchi  or  alveoli  indicates  extensive  erosion  of  a  tube  and  softening  of  the 
lung-tissue. 

Another  occasional  constituent  of  the  sputum  is  blood,  which  may  be  pres- 
ent as  the  chief  characteristic  of  the  expectoration  in  haemoptysis  or  may 
simply  tinge  the  sputum.  In  chronic  cases  with  large  cavities,  in  addition  to 
bacteria,  various  forms  of  fungi  may  be  found,  of  which  the  aspergillus  is  the 
most  important.     Sarcinge  may  also  occur. 

Calcareous  Fragments. — Formerly  a  good  deal  of  stress  was  laid  upon  their 
presence  in  the  sputum,  and  Morton  described  a  phthisis  a  calculis  in  pulmoni- 
bus  generatis.  Bayle  also  described  a  separate  form  of  phthisie  calculeuse. 
The  size  of  the  fragments  varies  from  a  small  pea  to  a  large  cherry. 
As  a  rule,  a  single  one  is  ejected;  sometimes  large  numbers  are  coughed 
up  in  the  course  of  the  disease.  They  are  formed  in  the  lung  by  the  calcifica- 
tion of  caseous  masses,  and  it  is  said  also  occasionally  in  obstructed  bronchi. 
They  may  come  from  the  bronchial  glands  by  ulceration  into  the  bronchi,  and 
there  is  a  case  on  record  of  suffocation  in  a  child  from  this  cause. 

The  daily  amount  of  expectoration  varies.  In  rapidly  advancing  cases, 
with  much  cough,  it  may  reach  as  high  as  500  cc.  in  the  day.    In  cases  with 


TUBERCULOSIS.  325 

large  cavities  the  chief  amount  is  brought  up  in  the  morning.  The  expectora- 
tion of  tuberculous  j)atients  usually  has  a  heavy,  sweetish  odor,  and  occasion- 
ally it  is  fetid,  owing  to  decomposition  in  the  cavities. 

HEMOPTYSIS. — One  of  the  most  famous  of  the  Hippocratic  axioms  says, 
"  From  a  spitting  of  blood  there  is  a  spitting  of  pus,"  The  older  writers 
thought  that  the  phthisis  was  directly  due  to  the  inflammatory  or  putrefactive 
changes  caused  by  the  haemorrhage  into  the  lung.  Morton,  however,  in  his 
interesting  section.  Phthisis  ah  HcBmoptoe,  rather  doubted  this  sequence. 
Laennec  and  Louis^  and  later  in  the  century  Traube,  regarded  the  hgemoptysis 
as  an  evidence  of  existing  disease  of  the  lung.  From  the  accurate  views  of 
Laennec  and  Louis  the  profession  was  led  away  by  Graves,  and  particularly  by 
Niemeyer,  who  held  that  the  blood  in  the  air-cells  set  up  an  inflammatory 
process,  a  common  termination  of  which  was  caseation.  Since  Koch's  dis- 
covery we  have  learned  that  many  cases  in  which  the  physical  examination  is 
negative  show,  either  during  the  period  of  haemorrhage  or  immediately  after  it, 
tubercle  bacilli  in  the  sputa,  so  that  opinion  has  veered  to  the  older  view, 
and  we  now  regard  the  appearance  of  haemoptysis  as  an  indication  of  existing 
disease.  In  young,  apparently  healthy  persons,  cases  of  haemoptysis  may  be 
divided  into  three  groups.  In  the  first  the  bleeding  has  come  on  without 
premonition,  without  overexertion  or  injury,  and  there  is  no  family  history  of 
tuberculosis.  The  physical  examination  is  negative,  and  the  examination  of 
the  expectoration  at  the  time  of  the  haemorrhage  and  subsequently  shows  no 
tubercle  bacilli.  Such  instances  are  not  uncommon,  and,  though  one  may 
suspect  strongly  the  presence  of  some  focus  of  tuberculosis,  yet  the  individuals 
may  retain  good  health  for  many  years,  and  have  no  further  trouble.  Of  the 
386  cases  of  haemoptysis  noted  by  Ware  in  private  practice,  62  recovered,  and 
pulmonary  disease  did  not  subsequently  occur. 

In  a  second  group  individuals  in  apparently  perfect  health  are  suddenly 
attacked,  perhaps  after  a  slight  exertion  or  during  some  athletic  exercises. 
The  physical  examination  is  also  negative,  but  tubercle  bacilli  are  found  some- 
times in  the  bloody  sputa,  more  frequently  a  few  days  later. 

In  a  third  set  of  cases  the  individuals  have  been  in  failing  health  for  a 
month  or  two,  but  the  symptoms  have  not  been  urgent  and  perhaps  not  noticed 
by  the  patients.  The  physical  examination  shows  the  presence  of  well-marked 
tuberculous  disease,  and  there  are  both  tubercle  bacilli  and  elastic  tissue  in  the 
sputa. 

A  very  interesting  systematic  study  of  the  subject  of  haemoptysis,  particu- 
larly in  its  relation  to  the  question  of  tuberculosis,  has  been  completed  in  the 
Prussian  army  by  Franz  Strieker.  During  the  five  years  1890-95  there  were 
900  cases  admitted  to  the  hospitals,  which  is  a  percentage  of  0.045  of  the 
strength  (1,728,505).  Of  the  cases,  in  480  the  haemorrhage  came  on  with- 
out recognizable  cause.  Of  these,  417  cases,  86  per  cent,  were  certainly  or 
probably  tuberculous.     In  only  221,  however,  was  the  evidence  conclusive. 

In  a  second  group  of  213  cases  the  haemorrhage  came  on  during  the  mili- 
tary exercise,  and  of  these  75  patients  were  shown  to  be  tuberculous. 

In  118  cases  the  hemorrhage  followed  certain  special  exercises,  as  in  the 
gymnasium  or  in  riding  or  in  consequence  of  swimming.  In  24  cases  it 
occurred  during  the  exercise  of  the  voice  in  singing  or  in  giving  command  or  in 
the  use  of  wind  instruments.    A  very  interesting  group  is  reported  of  24  cases 


326  SPECIFIC  INFECTIOUS  DISEASES. 

in  which  the  haBmorrhage  followed  trauma,  either  a  fall  or  a  blow  upon  the 
thorax.  In  7  of  these  tuberculosis  was  positively  present,  and  in  6  other 
cases  there  was  a  strong  probability  of  its  existence. 

Among  the  conclusions  which  Strieker  draws  the  following  are  the  most 
important:  namely,  that  soldiers  attacked  with  hsemoptysis  without  special 
cause  are  in  at  least  86.8  per  cent  tuberculous.  In  the  cases  in  which  the 
ha3mopt3^sis  follows  the  special  exercises,  etc.,  of  military  service,  at  least  74.4 
per  cent  are  tuberculous.  In  the  cases  which  come  on  during  swimming  or 
as  a  consequence  of  direct  injury  to  the  thorax  about  one-half  are  not  associ- 
ated with  tuberculosis. 

Haemoptysis  occurs  in  from  60  to  80  per  cent  of  all  cases  of  pulmonary 
tuberculosis.     It  is  more  frequent  in  males  than  in  females. 

In  a  majority  of  all  eases  the  bleeding  recurs.  Sometimes  it  is  a  special 
feature  throughout  the  disease,  so  that  a  hsemorrhagic  form  has  been  recog- 
nized. The  amount  of  blood  brought  up  varies  from  a  couple  of  drachms  to 
a  pint  or  more.  In  69  per  cent  of  4,125  cases  of  hgemoptysis  at  the  Brompton 
Hospital  the  amount  brought  up  was  under  half  an  ounce. 

A  distinction  may  be  drawn  between  the  haemoptysis  early  in  the  disease 
and  that  which  occurs  in  the  later  periods.  In  the  former  the  bleeding  is 
usually  slight,  is  apt  to  recur,  and  fatal  haemorrhage  is  very  rare.  In  these 
cases  the  bleeding  is  usually  from  small  areas  of  softening  or  from  early 
erosions  in  the  bronchial  mucosa.  In  the  later  periods,  after  cavities  have 
formed,  the  bleeding  is,  as  a  rule,  more  profuse  and  is  more  apt  to  be  fatal. 
Single  large  haemorrhages,  proving  quickly  fatal,  are  very  rare,  except  in  the 
advanced  stages  of  the  disease.  In  these  cases  the  bleeding  comes  either  from 
an  erosion  of  a  good-sized  vessel  in  the  wall  of  a  cavity  or  from  the  rupture 
of  an  aneurism  of  the  pulmonary  artery. 

The  bleeding,  as  a  rule,  sets  in  suddenly.  Without  any  warning  the  patient 
may  notice  a  warm  salt  taste  and  the  mouth  fills  with  blood.  It  may  come 
up  with  a  slight  cough.  The  total  amoimt  may  not  be  more  than  a  few 
drachms,  and  for  a  day  or  two  the  patient  may  spit  up  small  quantities.  When 
a  large  vessel  is  eroded  or  an  aneurism  bursts,  the  amount  of  blood  brought 
up  is  large,  and  in  the  course  of  a  short  time  a  pint  or  two  may  be  expec- 
torated. Fatal  haemorrhage  may  occur  into  a  very  large  cavity  without  any 
blood  being  coughed  up.  The  character  of  the  blood  is,  as  a  rule,  distinctive. 
It  is  frothy,  mixed  with  mucus,  generally  bright  red  in  color,  except  when 
large  amounts  are  expectorated,  and  then  it  may  be  dark.  The  sputum  may 
remain  blood-tinged  for  some  days,  or  there  are  brownish-black  streaks  in  it, 
or  friable  nodules  consisting  entirely  of  blood-corpuscles  may  be  coughed  up. 
Blood  moulds  of  the  smaller  bronchi  are  sometimes  expectorated. 

The  microscopical  examination  of  the  sputum  in  tuberculous  cases  is  most 
important.  If  carefully  spread  out,  there  may  be  noted,  even  in  an  apparently 
pure  hemorrhagic  mass,  little  portions  of  mucus  from  which  bacilli  or  elastic 
tissue  may  be  obtained. 

Dyspnoea  is  not  a  common  accompaniment  of  ordinary  phthisis.  The 
greater  part  of  one  lung  may  be  diseased  and  local  trouble  exist  at  the  other 
apex  without  any  shortness  of  breath.  Even  in  the  paroxysms  of  very  high 
fever  the  respirations  may  not  be  much  increased.  Dyspnoea  occurs  (1)  with 
the  rapid  extension  in  both  lungs  of  a  broncho-pneumonia;   (2)   with  the 


TUBERCULOSIS.  327 

occurrence  of  miliary  tuberculosis;  (3)  sometimes  with  pneumothorax;  (4) 
in  old  cases  with  much  emphysema,  and  it  may  be  associated  with  cyanosis; 
(5)  and,  lastly,  in  long-standing  cases,  with  contracted  apices  or  great  thicken- 
ing of  the  pleura,  the  right  heart  is  enlarged,  and  the  dyspnoea  may  be  cardiac. 

3.  General  Symptoms. — Fever. — To  get  a  correct  idea  of  the  tempera- 
ture range  in  pulmonary  tuberculosis  it  is  necessary,  as  Ringer  pointed  out, 
to  make  tolerably  frequent  observations.  The  usual  8  a.  ^.  and  8  p.  m.  record 
is,  in  a  majority  of  the  cases,  very  deceptive,  giving  neither  the  minimum  ilor 
maximum.  The  former  usually  occurs  between  3  and  6  a.  m.,  and  the  latter 
between  3  and  6  p.  m. 

A  recognition  of  various  forms  of  fever,  viz.,  of  tuberculization,  of  ulcera- 
tion, and  of  absorption,  emphasizes  the  anatomical  stages  of  growth,  soften- 
ing and  cavity  formation ;  but  practically  such  a  division  is  of  little  use,  as  in 
a  majority  of  cases  these  processes  are  going  on  together. 

Fever  is  the  most  important  initial  symptom  and  throughout  the  entire 
course  the  thermometer  is  the  most  trustworthy  guide  as  to  the  progress  of  the 
affection.  With  pyrexia  a  patient  loses  in  weight  and  strength,  and  the  local 
disease  usually  progresses.  The  periods  of  apyrexia  are  those  of  gain  in  weight 
and  strength  and  of  limitation  of  the  local  lesion.  It  by  no  means  necessarily 
follows  that  a  patient  with  tuberculosis  has  pyrexia.  There  may  be  quite 
extensive  disease  without  coexisting  fever.  On  one  occasion  I  had  18  instances 
of  chronic  phthisis  under  observation,  of  whom  10  were  practically  free  from 
fever.  But  in  the  early  stage,  when  tubercles  are  developing  and  caseous  areas 
are  in  process  of  formation  and  when  softening  is  in  progress,  fever  is  a  con- 
stant symptom.  There  are  a  few  rare  cases  in  which  little  or  no  fever  is 
present  at  the  outset  even  with  advancing  lesions. 

Two  types  of  fever  are  seen — the  remittent  and  the  intermittent.  These 
may  occur  indifferently  in  the  early  or  in  the  late  stages  of  the  disease  or 
may  alternate  with  each  other,  a  variability  which  depends  upon  the  fact 
that  phthisis  is  a  progressive  disease  and  that  all  stages  of  lesions  may  be 
found  in  a  single  lung.  Special  stress  should  be  laid  upon  the  fact,  particu- 
larly in  malarial  regions,  that  tuberculosis  ma}''  set  in  with  a  fever  typically 
intermittent  in  character — a  daily  chill,  with  subsequent  fever  and  sweat. 
In  Montreal,  where  malaria  is  practically  unknown,  this  was  always  regarded 
as  a  suggestive  symptom;  but  in  Philadelphia  and  Baltimore,  where  ague 
prevails,  many  cases  of  early  tuberculosis  are  treated  for  ague.  These  are 
often  cases  that  pursue  a  rapid  course.  The  fever  of  onset — tuberculization 
— ^may  be  almost  continuous,  "with  slight  daily  exacerbations ;  and  at  any  time 
during  the  course  of  chronic  phthisis,  if  there  is  rapid  extension,  the  remis- 
sions become  less  marked. 

A  remittent  fever,  in  which  the  temperature  is  constantly  above  normal 
but  drops  two  or  three  degrees  toward  morning,  is  not  uncommon  in  the 
middle  and  later  stages  and  is  usually  associated  with  softening  or  extension 
of  the  disease.  Here,  too,  a  simple  morning  and  evening  register  may  give 
an  entirely  erroneous  idea  as  to  the  range  of  the  fever.  With  breaking  down 
of  the  lung-tissue  and  formation  of  cavities,  associated  as  these  processes 
always  are  with  suppuration  and  with  more  or  less  systemic  contamination, 
the  fever  assumes  a  characteristically  intermittent  or  hectic  type.  For  a  large 
part  of  the  day  the  patient  is  not  only  afebrile,  but  the  temperature  is  sub- 


328 


SPECIFIC  INFECTIOUS  DISEASES. 


normal.  In  the  annexed  two-hourly  chart,  from  a  case  of  chronic  tuberculosis 
of  the  lungs,  it  will  be  seen  that  from  10  p.  m.  to  8  a.  m.  or  noon,  the  tem- 
perature continuously  fell  and  went  as  low  as  95°.  A  slow  rise  then  took 
place  through  the  late  morning  and  early  afternoon  hours  and  reached  its 
maximum  between  6  and  10  p.  m.    As  shown  in  the  chart,  there  were  in  the 


Chart  XII. — Three  Days.    Chronic  Tuberculosis. 

three  days  about  forty-three  hours  of  p}Texia  and  twenty-nine  hours  of  apy- 
rexia.  The  rapid  fall  of  the  temperature  in  the  early  morning  hours  is  usually 
associated  with  sweating.  This  hectic,  as  it  is  called,  which  is  a  t}^ical  fever 
of  septic  infection,  is  met  with  when  the  process  of  cavity  formation  and 
softening  is  advanced  and  extending. 

A  continuous  fever  with  remissions  of  not  more  than  a  degree,  occurring 
in  the  course  of  pulmonary  tuberculosis,  is  suggestive  of  acute  pneumonia. 
When  a  two-hourly  chart  is  made,  the  remissions  even  in  acute  tuberculous 
pneumonia  are  usually  well  marked.  A  continued  fever,  such  as  is  seen  in 
the  first  week  of  typhoid,  or  in  some  cases  of  inflammation  of  the  lung,  is 
rare  in  tuberculosis. 

Sweating. — Drenching  perspirations  are  common  in  phthisis  and  consti- 
tute one  of  the  most  distressing  features  of  the  disease.     They  occur  usually 


TUBERCULOSIS.  329 

with  the  drop  in  the  fever  in  the  early  morning  hours,  or  at  any  time  in  the 
day  when  the  patient  sleeps.  They  may  come  on  early  in  the  disease,  but  are 
more  persistent  and  frequent  after  cavities  have  formed.  Some  patients  escape 
altogether. 

The  pulse  is  increased  in  frequency,  especially  when  the  fever  is  high.  It 
is  often  remarkably  full,  though  soft  and  compressible.  Pulsation  may  some- 
times be  seen  in  the  capillaries  and  in  the  veins  on  the  back  of  the  hand. 

Emaciation  is  a  pronounced  feature,  from  which  the  two  common  names 
of  the  disease  have  been  derived.  The  loss  of  weight  is  gradual  but,  if  the 
disease  is  extending,  progressive.  The  scales  give  one  of  the  best  indications 
of  the  progress  of  the  case. 

3.  Physical  Signs. — (a)  Inspection. — The  shape  of  the  chest  is  often 
suggestive,  though  it  is  to  be  remembered  that  the  disease  may  be  met  with 
in  chests  of  any  build.  Practically,  however,  in  a  considerable  proportion 
of  cases  the  thorax  is  long  and  narrow,  with  very  wide  intercostal  spaces,  the 
ribs  more  vertical  in  direction  and  the  costal  angle  very  narrow.  The  scap- 
ulae are  "^^  winged,"  a  point  noted  by  Hippocrates.  Another  type  of  chest 
which  is  very  common  is  that  which  is  flattened  in  the  antero-posterior  diam- 
eter. The  costal  cartilages  may  be  prominent  and  the  sternum  depressed. 
Occasionally  the  lower  sternum  forms  a  deep  concavity,  the  so-called  funnel 
breast  (TricJiter-Brust) .  Inspection  gives  valuable  information  in  all  stages 
of  the  disease.  Special  examination  should  be  made  of  the  clavicular  regions 
to  see  if  one  clavicle  stands  out  more  distinctly  than  the  other,  or  if  the  spaces 
above  or  below  it  are  more  marked.  Defective  expansion  at  one  apex  is  an 
early  and  important  sign.  The  condition  of  expansion  of  the  lower  zone  of 
the  thorax  may  be  well  estimated  by  inspection.  The  condition  of  the  prge- 
cordia  should  also  be  noted,  as  a  wide  area  of  impulse,  particularly  in  the 
second,  third,  and  fourth  interspaces,  often  results  from  disease  of  the  left 
apex.  From  a  point  behind  the  patient,  looking  over  the  shoulders,  one  can 
often  better  estimate  the  relative  expansion  of  the  apices. 

(h)  Palpation. — Deficiency  in  expansion  at  the  apices  or  bases  is  perhaps 
best  gauged  by  placing  the  hands  in  the  subclavicular  spaces  and  then  in  the 
lateral  regions  of  the  chest  and  asking  the  patient  to  draw  slowly  a  full  breath. 
Standing  behind  the  patient  and  placing  the  thumbs  in  the  supraclavicular 
and  the  fingers  in  the  infraclavicular  spaces  one  can  judge  accurately  as  to 
the  relative  mobility  of  the  two  sides.  Disease  at  an  apex,  though  early  and 
before  dulness  is  at  all  marked,  may  be  indicated  by  deficient  expansion.  On 
asking  the  patient  to  count,  the  tactile  fremitus  is  increased  wherever  there  is 
local  growth  of  tubercle  or  extensive  caseation.  In  comparing  the  apices  it 
is  important  to  bear  in  mind  that  normally  the  fremitus  is  stronger  over  the 
right  than  the  left.  So  too  at  the  base,  when  there  is  consolidation  of  the 
lung,  the  fremitus  is  increased;  whereas,  if  there  is  pleural  effusion,  it  is 
diminished  or  absent.  In  the  later  stages,  when  cavities  form,  the  tactile 
fremitus  is  usually  much  exaggerated  over  them.  When  the  pleura  is  greatly 
thickened  the  fremitus  may  be  somewhat  diminished. 

(c)  Percussion. — Tubercles,  inflammatory  products,  fibroid  changes,  and 

cavities  produce  important  changes  in  the  pulmonary  resonance.    There  may 

be  localized  disease,  even  of  some  extent,  without  inducing  much  alteration, 

as  when  the  tubercles   are  scattered  there  is  air-containing  tissue  between 

23 


330  SPECIFIC  INFECTIOUS  DISEASES. 

them.  One  of  the  earliest  and  most  valuable  signs  is  defective  resonance 
upon  and  above  a  clavicle.  In  a  considerable  proportion  of  all  cases  of  phthi- 
sis the  dulness  is  first  noted  in  these  regions.  The  comparison  between  the 
two  sides  should  be  made  also  Avhen  the  breath  is  held  after  a  full  inspiration, 
as  the  defective  resonance  may  then  be  more  clearly  marked.  In  the  early 
stages  the  percussion  note  is  usually  higher  in  pitch,  and  it  may  require  an 
experienced  ear  to  detect  the  difference.  In  recent  consolidation  from  case- 
ous pneumonia  the  percussion  note  often  has  a  tubular  or  tympanitic  quality. 
A  wooden  dulness  is  rarely  heard  except  in  old  cases  with  extensive  fibroid 
change  at  the  apex  or  base.  Over  large,  thin-walled  cavities  at  the  apex  the 
so-called  cracked-pot  sound  may  be  obtained.  In  thin  subjects  the  percus- 
sion should  be  carefully  practised  in  the  supraspinous  fossae  and  the  inter- 
scapular space,  as  they  correspond  to  very  important  areas  early  involved  in 
the  disease.  In  cases  with  numerous  isolated  cavities  at  the  apex,  without 
much  fibroid  tissue  or  thickening  of  the  pleura,  the  percussion  note  may  show 
little  change,  and  the  contrast  between  the  signs  obtained  on  auscultation  and 
percussion  is  most  marked.  In  the  direct  percussion  of  the  chest,  particularly 
in  thin  patients  over  the  pectorals,  one  frequently  sees  the  phenomenon  known 
as  myoidcema,  a  local  contraction  of  the  muscle  causing  bulging,  which  per- 
sists for  a  variable  period  and  gradually  subsides.  It  has  no  special  signifi- 
cance. 

(d)  Auscultation. — Feeble  breath-sounds  are  among  the  most  character- 
istic early  signs,  since  not  as  much  air  enters  the  tubes  and  vesicles  of  the 
affected  area.  It  is  well  at  first  always  to  compare  carefully  the  correspond- 
ing points  on  the  two  sides  of  the  chest  without  asking  the  patient  either  to 
draw  a  deep  breath  or  to  cough.  With  early  apical  disease  the  inspiration 
on  quiet  breathing  may  be  scarcely  audible.  Expiration  is  usually  prolonged. 
On  the  other  hand,  there  are  cases  in  which  the  earliest  sign  is  a  harsh,  rude, 
respiratory  murmur.  On  deep  breathing  it  is  frequently  to  be  noted  that 
inspiration  is  jerking  or  wavy,  the  so-called  "  cog-wheel "  rhythm ;  which, 
however,  is  by  no  means  confined  to  tuberculosis.  With  extension  of  the 
disease  the  inspiratory  murmur  is  harsh,  and,  when  consolidation  occurs, 
whiffing  and  bronchial.  With  these  changes  in  the  character  of  the  murmur 
there  are  rales,  due  to  the  accompanying  bronchitis.  They  may  be  heard  only 
on  deep  inspiration  or  on  coughing,  and  early  in  the  disease  are  often  crack- 
ling in  character.  When  softening  occurs  they  are  louder  and  have  a  bub- 
bling, sometimes  a  characteristic  clicking  quality.  These  "  moist  sounds,"  as 
they  are  called,  when  associated  with  change  in  the  percussion  resonance  are 
extremely  suggestive.  When  cavities  form,  the  rales  are  louder,  more  gur- 
gling, and  resonant  in  quality.  When  there  is  consolidation  of  any  extent 
the  breath-sounds  are  tubular,  and  in  the  large  excavations  loud  and  cavern- 
ous, or  have  an  amphoric  quality.  In  the  unaffected  portions  of  the  lobe 
and  in  the  opposite  lung  the  breath-sounds  may  be  harsh  and  even  puerile. 
The  vocal  resonance  is  usually  increased  in  all  stages  of  the  process,  and 
bronchophony  and  pectoriloquy  are  met  with  in  the  regions  of  consolidation 
and  over  cavities.  Pleuritic  friction  may  be  present  at  any  stage  and,  as  men- 
tioned before,  occurs  very  early.  There  are  cases  in  which  it  is  a  marked 
feature  throughout.  When  the  lappet  of  lung  over  the  heart  is  involved  there 
may  be  a  pleuro-pericardial  friction,  and  when  this  area  is  consolidated  there 


TUBERCULOSIS.  331 

may  be  curious  clicking  rales  synchronous  with  the  heart-beat,  due  to  the  com- 
pression by  the  heart  of  this  portion  with  expulsion  of  air  from  it.  An 
interesting  auscultatory  sign,  met  most  commonly  in  phthisis,  is  the  so-called 
cardio-respiratory  murmur,  a  whiffing  systolic  bruit  due  to  the  propulsion  of 
air  out  of  the  tubes  by  the  impulse  of  the  heart.  It  is  best  heard  during 
inspiration  and  in  the  antero-lateral  regions  of  the  chest. 

A  systolic  murmur  is  frequently  heard  in  the  subclavian  artery  on  either 
side,  the  pulsation  of  which  may  be  very  visible.  The  murmur  is  in  all  prob- 
ability due  to  pressure  on  the  vessels  by  the  thickened  pleura. 

The  signs  of  cavity  may  be  here  briefly  enumerated. 

(a)  When  there  is  not  much  thickening  of  the  pleura  or  condensation 
of  the  surrounding  lung-tissue,  the  percussion  sound  may  be  full  and  clear, 
resembling  the  normal  note.  More  commonly  there  is  defective  resonance 
or  a  tympanitic  quality  which  may  at  times  be  purely  amphoric.  The  pitch 
of  the  percussion  note  changes  over  a  cavity  when  the  mouth  is  opened  or 
closed  (Wintrich's  sign),  or  it  may  be  brought  out  more  clearly  on  change 
of  position.  The  cracked-pot  sound  is  obtainable  only  over  tolerably  large 
cavities  with  thin  walls.  It  is  best  elicited  by  a  j&rm,  quick  stroke,  the  patient 
at  the  time  having  the  mouth  open.  In  those  rare  instances  of  almost  total 
excavation  of  one  lung  the  percussion  note  may  be  amphoric  in  quality,  (h) 
On  auscultation  the  so-called  cavernous  sounds  are  heard :  ( 1 )  Various  grades 
of  modified  breathing — blowing  or  tubular,  cavernous  or  amphoric.  There 
may  be  a  curiously  sharp  hissing  sound,  as  if  the  air  was  passing  from  a 
narrow  opening  into  a  wide  space.  In  very  large  cavities  both  inspiration 
and  expiration  may  be  typically  amphoric.  (2)  There  are  coarse  bubbling 
rales  which  have  a  resonant  quality,  and  on  coughing  may  have  a  metallic 
or  ringing  character.  On  coughing  they  are  often  loud  and  gurgling.  In 
very  large  thin-walled  cavities,  and  more  rarely  in  medium-sized  cavities, 
surrounded  by  recent  consolidation,  the  rales  may  have  a  distinctly  amphoric 
echo,  simulating  those  of  pneumothorax.  There  are  dry  cavities  in  which  no 
rales  are  heard.  (3)  The  vocal  resonance  is  greatly  intensified,  and  whispered 
pectoriloquy  is  clearly  heard.  In  large  apical  cavities  the  heart-sounds  are 
well  heard,  and  occasionally  there  may  be  an  intense  systolic  murmur,  prob- 
ably always  transmitted  to,  and  not  produced,  as  has  been  supposed,  in  the 
cavity  itself.  In  large  excavations  of  the  left  apex  the  heart  impulse  may 
cause  gurgling  sounds  or  clicks  synchronous  with  the  systole.  They  may 
even  be  loud  enough  to  be  heard  at  a  little  distance  from  the  chest  wall.  A 
large  cavity  with  smooth  walls  and  thin  fluid  contents  may  give  the  succus- 
sion  sound  when  the  trunk  is  abruptly  shaken  (Walshe),  and  even  the  coin 
sound  may  be  obtained. 

Pseudo-cavernous  signs  may  be  caused  by  an  area  of  consolidation  near  a 
large  bronchus.  The  condition  may  be  most  deceptive — the  high-pitched  or 
tympanitic  percussion  note,  the  tubular  or  cavernous  breathing,  and  the  reso- 
nant rales,  simulate  closely  those  of  cavity. 

3.  Complications  of  Pulmonary  Tuberculosis. 

(1)  In  the  Respiratory  System. — The  larynx  is  rarely  spared  in  chronic 
pulmonary  tuberculosis.  The  first  symptom  may  be  huskiness  of  the  voice. 
There  are  pain,  particularly  in  swallowing,  and  a  cough  which  is  often  wheez- 


332  SPECIFIC  INFECTIOUS  DISEASES. 

ing,  and  iu  the  later  stages  very  ineffectual.  Aphonia  and  dysphagia  are  the 
two  most  distressing  s}Tnptoms  of  the  laryngeal  involvement.  When  the  epi- 
glottis is  seriously  diseased  and  the  ulceration  extends  to  the  lateral  wall  of 
the  pharynx,  the  pain  in  swallowing  may  be  very  intense,  or,  owing  to  the 
imperfect  closure  of  the  glottis,  there  may  be  coughing  spells  and  regurgita- 
tion of  food  through  the  nostrils.  Bronchitis  and  tracheitis  are  almost  invari- 
able accompaniments. 

Pneumonia  is  a  not  infrequent  terminal  complication  of  chronic  phthisis. 
It  may  run  a  perfectly  normal  course,  while  in  other  instances  resolution  may 
be  delayed,  and  one  is  in  doubt,  in  spite  of  the  abruptness  of  the  onset,  as 
to  the  presence  of  a  simple  or  a  tuberculous  pneumonia. 

Emphysema  of  the  uninvolved  portions  of  the  lung  is  a  common  feature, 
rare!}'  producing  any  special  s3Tiiptoms.  There  are,  however,  cases  of  chronic 
tuberculosis  in  which  emphysema  dominates  the  picture,  and  in  which  the 
condition  comes  on  slowly  during  a  period  of  many  years.  (General  subcu- 
taneous emphysema,  which  has  been  met  with  in  a  few  rare  cases,  is  due  either 
to  perforation  of  the  trachea  or  to  the  rupture  of  a  cavity  closely  adherent  to 
the  chest  wall.) 

Gangrene  of  the  lung  is  an  occasional  event  in  chronic  pulmonary  tuber- 
culosis, due  in  almost  all  instances  to  sphacelus  in  the  walls  of  the  cavity, 
rarely  in  the  lung-tissue  itself. 

Complications  in  the  Pleura. — A  dry  pleurisy  is  a  very  common  accom- 
paniment of  the  early  stages  of  tuberculosis.  It  is  always  a  conservative,  use- 
ful process.  In  some  cases  it  is  very  extensive,  and  friction  murmurs  may 
be  heard  over  the  sides  and  back.  The  cases  with  dry  pleurisy  and  adhesions 
are  of  course  much  less  liable  to  the  dangers  of  pneumothorax.  Pleurisy 
with  effusion  more  commonly  precedes  than  occurs  in  the  course  of  pulmonary 
tuberculosis.  Still,  it  is  common  enough  to  meet  with  cases  in  which  a  sero- 
fibrinous effusion  arises  in  the  course  of  the  chronic  disease.  There  are  cases 
in  which  it  is  a  special  feature,  and  it  often,  I  think,  favors  chronicity.  A 
patient  may  during  a  period  of  four  or  five  years  have  signs  of  local  disease 
at  one  apex  with  recurring  effusion  in  the  same  side.  Owing  to  adhesions  in 
different  parts  of  the  pleura,  the  effusion  may  be  encapsulated.  H^emorrhagic 
effusions,  which  are  not  uncommon  in  connection  with  tuberculous  pleurisy, 
are  comparatively  rare  in  chronic  phthisis.  Chyliform  or  milk}^  exudates  are 
sometimes  found.  Purulent  effusions  are  not  frequent  apart  from  pneumo- 
thorax. An  empyema,  however,  may  occur  in  the  course  of  the  disease  or  as 
a  sequence  of  a  sero-fibrinous  exudate.  Pneumothorax  is  an  extremely  com- 
mon complication.  Of  49  eases  at  the  Johns  Hopkins  Hospital,  23  were 
tuberculous  (Emerson).  It  may  prove  fatal  in  twenty-four  hours.  '  In  other 
mstances  a  pyo-pneumothorax  follows  and  the  patient  lingers  for  weeks  or 
months.  In  a  third  group  of  cases  it  seems  to  have  a  beneficial  effect  on  the 
course  of  the  disease. 

(2)  Symptoms  referable  to  other  Organs.— (a)  Cardio-vascular.— 
The  retraction  of  the  left  upper  lobe  exposes  a  large  area  of  the  heart.  In 
thm-chested  subjects  there  may  be  pulsation  in  the  second,  third,  and  fourth 
interspaces  close  to  the  sternum.  Sometimes  with  much  retraction  of  the 
left  upper  lobe  the  heart  is  drawn  up.  A  systolic  murmur  over  the  pulmo- 
nary area  is  common  in  aU  stages  of  phthisis.     Apical  murmurs  are  also  not 


TUBERCULOSIS.  333 

infrequent  and  may  be  extremely  rough  and  harsh  without  necessarily  indi- 
cating that  endocarditis  is  present.  The  association  of  heart-disease  with 
phthisis  is  not,  however,  very  uncommon.  As  already  mentioned,  there  were 
13  instances  of  endocarditis  in  216  autopsies.  The  arterial  tension  is  usually 
low  in  phthisis  and  the  capillary  resistance  lessened  so  that  the  pulse  is  often 
full  and  soft  even  in  the  later  stages  of  the  disease.  The  capillary  pulse  is 
not  infrequently  met  with,  and  pulsation  of  the  veins  in  the  back  of  the  hand 
is  occasionally  to  be  seen. 

(h)  Blood  Glandular  System. — The  early  anasmia  has  already  been  noted. 
It  is  often  more  apparent  than  real,  a  chloro-ansemia,  and  the  blood-count 
rarely  sinks  below  two  millions  per  cubic  millimetre. 

The  blood-plates  are,  as  a  rule,  enormiously  increased  and  are  seen  in  the 
withdrawn  blood  as  the  so-called  Schultze's  granule  masses.  Without  any 
significance,  they  are  of  interest  chiefly  from  the  fact  that  every  few  years 
some  tyro  announces  their  discovery  as  a  new  diagnostic  sign  of  phthisis. 
The  leucocytes  are  greatly  increased,  particularly  in  the  later  stages. 

(c)  Gastro-intestinal  System. — The  tongue  is  usually  furred,  but  may 
be  clean  and  red.  Small  aphthous  ulcers  are  sometimes  distressing.  A  red 
line  on  the  gums,  a  symptom  to  which  at  one  time  much  attention  was  paid 
as  a  special  feature  of  phthisis,  occurs  in  other  cachectic  states.  Extensive 
tuberculous  disease  of  the  pharynx,  associated  with  a  similar  affection  of  the 
larynx,  may  interfere  seriously  with  deglutition  and  prove  a  very  distressing 
^nd  intractable  symptom.  H.  M.  Hayes  has  studied  the  saliva  and  finds  a 
marked  impairment  in  its  digestive  powers. 

Tuberculosis  of  the  stomach  is  rare.  Ulceration  may  occur  as  an  acci- 
dental complication  and  multiple  catarrhal  ulcers  are  not  uncommon.  Inter- 
stitial and  parenchymatous  changes  in  the  mucosa  are  common  (possibly  asso- 
ciated with  the  venous  stasis)  and  lead  to  atrophy,  but  these  can  not  always 
be  connected,  with  the  symptoms,  and  they  may  be  found  when  not  expected. 
On  the  other  hand,  when  the  gastric  symptoms  have  been  most  persistent  the 
mucosa  may  show  very  little  change.  It  is  impossible  always  to  refer  the 
anorexia,  nausea,  and  vomiting  of  consumption  to  local  conditions.  The 
hectic  fever  and  the  neurotic  influences,  upon  which  Immermann  lays  much 
stress,  must  be  taken  into  account,  as  they  play  an  important  role.  The  organ 
is  often  dilated,  and  to  muscular  insufficiency  alone  may  be  due  some  of  the 
cases  of  dyspepsia.  The  condition  of  the  gastric  secretion  is  not  constant, 
and  the  reports  are  discordant.  In  the  early  stages  there  may  be  superacidity ; 
later,  a  deflciency  of  acid. 

Anorexia  is  often  a  marked  symptom  at  the.  onset ;  there  may  be  positive 
loathing  of  food,  and  even  small  quantities  cause  nausea.  Sometimes,  with- 
out any  nausea  or  distress  after  eating,  the  feeding  of  the  patient  is  a  daily 
battle.  When  practicable,  Debove's  forced  alimentation  is  of  great  benefit 
in  such  cases.  Nausea  and  vomiting,  though  occasionally  troublesome  at  an 
early  period,  are  more  marked  in  the  later  stages.  The  latter  may  be  caused 
by  the  severe  attacks  of  coughing.  S.  H.  Habershon  refers  to  four  different 
causes  the  vomiting  in  phthisis:  (1)  central,  as  from  tuberculous  menin- 
gitis; (3)  pressure  on  the  vagi  by  caseous  glands;  (3)  stimulation  from  the 
peripheral  branches  of  the  vagus,  either  pulmonary,  pharyngeal,  or  gastric; 
and  (4)  mechanical  causes. 


334  SPECIFIC  INFECTIOUS  DISEASES. 

Of  the  intestinal  symptoms  diarrhoea  is  the  most  serious.  It  may  come 
on  early,  but  is  more  usually  a  s^Tnptom  of  the  later  stages^  and  is  associ- 
ated with  ulceration,  particularly  of  the  large  bowel.  Extensive  ulceration 
of  the  ileum  may  exist  without  any  diarrhoea.  The  associated  catarrhal 
condition  may  account  in  part  for  it,  and  in  some  instances  the  amyloid  degen- 
eration of  the  mucous  membrane. 

(d)  Nervous  System.-^{1)  Focal  lesions  due  to  the  development  of  coarse 
tubercles  and  areas  of  tuberculous  meningo-encephalitis.  Aphasia,  for  in- 
stance, may  result  from  the  growth  of  meningeal  tubercles  in  the  fissure  of 
Sylvius,  or  even  hemiplegia  may  occur.  The  solitary  tubercles  are  more  com- 
mon in  the  chronic  phthisis  of  children.  (2)  Basilar  meningitis  is  an  occa- 
sional complication.  It  may  be  confined  to  the  brain,  though  more  commonly 
it  is  a  (3)  cerebro-spinal  meningitis,  which  may  come  on  in  persons  without 
well-marked  local  signs  in  the  chest.  Twice  have  I  known  strong,  robust 
men  brought  into  hospital  with  signs  of  cerebro-spinal  meningitis,  in  whom 
the  existence  of  pulmonary  disease  was  not  discovered  until  the  post  mortem. 
(4)  Periplieral  neuritis,  which  is  not  common,  may  cause  an  extensor  paraly- 
sis of  the  arm  or  leg,  more  commonly  the  latter,  with  foot-drop.  It  is  usually 
a  late  manifestation.  (5)  Mental  sjnnptoms.  It  was  noted,  even  by  the 
older  writers,  that  consumptives  had  a  peculiarly  hopeful  temperament,  and 
the  spes  pMliisica  forms  a  curious  characteristic  of  the  disease.  Patients 
with  extensive  cavities,  high  fever,  and  too  weak  to  move  will  often  make 
plans  for  the  future  and  confidently  expect  to  recover. 

Apart  from  tuberculosis  of  the  brain,  there  is  sometimes  in  chronic  phthi- 
sis a  form  of  insanity  not  unlike  that  which  occurs  in  the  convalescence  from 
acute  affections. 

(e)  A  remarkable  hypertrophy  of  the  mammary  gland  may  occur  in  pul- 
monary tuberculosis,  most  commonly  in  males.  It  may  be  only  on  the  affected 
side.  It  is  a  chronic  interstitial,  non-tuberculous  mammitis  (Allot).  Mas- 
titis adolescentium,  not  very  uncommon,  is  not  necessarily  suggestive  of  pul- 
monary tuberculosis. 

(/)  Genito-urinary  System. — The  urine  presents  no  special  peculiarities 
in  amount  or  constituents.  Fever,  however,  has  a  marked  influence  upon  it. 
Albumin  is  met  with  frequently  and  may  be  associated  with  the  fever,  or  is 
the  result  of  definite  changes  in  the  kidneys.  In  the  latter  case  it  is  more 
abundant  and  more  curd-like.  Amyloid  disease  of  the  kidneys  is  not  uncom- 
mon. Its  presence  is  shown  by  albumin  and  tube-casts,  and  sometimes  by  a 
great  increase  in  the  amount  of  urine.  In  other  instances  there  is  drops}^,  and 
the  patients  have  aU  the  characteristic  features  of  chronic  Bright's  disease. 

Pus  in  the  urine  may  be  due  to  disease  of  the  bladder  or  of  the  pelves 
of  the  kidneys.  In  some  instances  the  entire  urinary  tract  is  involved.  In 
pulmonary  phthisis,  however,  extensive  tuberculous  disease  is  rarely  found 
in  the  urinary  organs.  Bacilli  may  occasionally  be  detected  in  the  pus. 
Haematuna  is  not  a  very  common  symptom.  It  may  occur  occasionally  as  a 
result  of  congestion  of  the  kidneys,  and  pass  off  leaving  the  urine  albuminous. 
In  other  instances  it  results  from  disease  of  the  pelvis  or  of  the  bladder,  and 
is  associated  either  with  early  tuberculosis  of  the  mucous  membranes  or  more 
commonly  with  ulceration.  In  any  medical  clinic  the  routine  inspection  of 
the  testes  for  tubercle  will  save  two  or  three  mistakes  a  year. 


TUBERCULOSIS.  335 

{g)  Cutaneous  System. — The  skin  is  often  dry  and  harsh.  Local  tuber- 
cles occasionally  occur  on  the  hands.  There  may  be  pigmentary  staining, 
the  chloasma  phthisicorum,  which  is  more  common  when  the  peritonaeum  is 
involved.  Upon  the  chest  and  back  the  brown  stains  of  pityriasis  versicolor 
are  very  frequent.  The  hair  of  the  head  and  beard  may  become  dry  and 
lanky.  The  terminal  phalanges,  in  chronic  cases,  become  clubbed  and  the 
nails  incurvated — the  Hippocratic  fingers.  A  remarkable  and  unusual  com- 
plication is  general  emphysema,  which  may  result  from  ulceration  of  an 
adherent  lung  or  perforation  of  the  larynx. 

Diagnosis. — The  early  diagnosis  of  pulmonary  tuberculosis  is  of  such  vital 
importance  to  the  patient  that  every  possible  means  should  be  taken  to  recog- 
nize the  disease  before  it  has  made  much  headway.  The  truth  is,  a  majority 
of  the  cases  come  before  us  when  the  lesion  is  already  advanced,  as  indi- 
cated by  the  physical  signs.  The  following  points  should  be  specially 
attended  to : 

1.  General  Features. — Failing  health,  loss  in  weight  and  anaemia,  with 
slight  cough,  particularly  at  night,  are  rarely  absent.  It  is  usually  for  these 
symptoms  that  the  patient  or  his  friends  seek  relief.  Or  there  has  been  a 
slight  haemoptysis. 

2.  The  Local  Examination. — In  very  many  cases  the  physical  signs  are 
quite  well  marked,  deficient  expansion,  the  prominence  of  one  clavicle,  the 
changes  in  the  percussion  note,  the  changes  in  the  respiratory  murmur,  and 
the  clicking  rales.  In  other  instances  the  physical  signs  are  indefinite,  and 
it  is  not  possible  to  say  after  the  most  careful  examination  that  there  is  a 
suspicious  focus  in  either  lung. 

3.  Examination  of  the  Sputum. — Bacilli  and  elastic  tissue  may  be  pres- 
ent without  definite  physical  signs.  They  may  come  from  a  very  small  focus 
not  discoverable  on  examination.  In  a  great  majority  of  early  cases  repeated 
inspection  of  the  sputum  is  the  most  important  diagnostic  measure.  It  is 
very  often  difficult  to  get  the  sputum  in  incipient  cases. 

4.  Tuberculin  may  be  given  or  the  ophthalmic  reaction  tested. 

5.  The  agglutination  and  serum  diagnosis,  as  practised  by  Arloing  and 
Courmont,  may  turn  out  to  be  of  great  service  in  doubtful  cases. 

4.  Fibroid  Phthisis. 

In  their  monograph  on  Fibroid  Diseases  of  the  Lung  (1894)  Clark,  Had- 
ley  and  Chaplin  make  the  following  classification:  1.  Pure  fibroid;  fibroid 
phthisis — a  condition  in  which  there  is  no  tubercle.  2.  Tuberculo-fibroid  dis- 
ease— a  condition  primarily  tuberculous,  but  which  has  run  a  fibroid  course. 
3.  Fibro-tuberculous  disease — a  condition  primarily  fibroid,  but  which  has 
become  tuberculous.  The  tuberculo-fibroid  form  may  come  on  gradually  as  a 
sequence  of  a  chronic  tuberculous  broncho-pneumonia,  or  follow  a  chronic 
tuberculous  pleurisy.  In  other  instances  the  process  supervenes  upon  an  ordi- 
nary ulcerative  phthisis.  The  disease  becomes  limited  to  one  apex,  the  cavity 
is  surrounded  by  layers  of  dense  fibrous  tissue,  the  pleura  is  thickened,  and 
the  lower  lobe  is  gradually  invaded  by  the  sclerotic  change.  Ultimately  a 
picture  is  produced  little  if  at  all  different  from  the  condition  known  as 
cirrhosis  of  the  lungs.  It  may  even  be  difficult  to  say  that  the  process  is 
tuberculouSj  but  in  advanced  cases  the  bacilli  are  usually  present  in  the  walls 


336  SPECIFIC  INFECTIOUS  DISEASES. 

of  the  cavity  at  the  apex,  or  old,  encapsulated  caseous  areas  are  present,  or 
there  may  be  tubercles  at  the  apex  of  the  other  lung  and  in  the  bronchial 
glands.  Dilatation  of  the  bronchi  is  present;  the  right  ventricle,  sometimes 
the  entire  heart,  is  hypertropliied. 

The  disease  is  chronic,  lasting  from  ten  to  twenty  or  more  years,  during 
which  time  the  patient  may  have  fair  health. 

The  chief  symptoms  are  cough,  often  paroxysmal  in  character  and  most 
marked  in  the  morning,  and  dyspnoea  on  exertion.  The  expectoration  is  puru- 
lent, and  in  some  instances,  when  the  bronchiectasis  is  extensive,  fetid.  There 
is  rarely  any  fever. 

The  physical  signs  are  very  characteristic.  The  chest  is  sunken  and  the 
shoulder  lower  on  the  affected  side;  the  heart  is  often  drawn  over  and  dis- 
placed. If  the  left  lung  is  involved  there  may  be  an  unusually  large  area  of 
cardiac  pulsation  in  the  third,  fourth,  and  fifth  interspaces.  Heart-murmurs 
are  common.  There  are  dulness  over  the  affected  side  and  deficient  tactile 
fremitus.  At  the  apex  there  may  be  well-marked  cavernous  sounds;  at  the 
base,  distant  bronchial  breathing.  The  condition  may  persist  for  years.  In 
some  cases  the  other  lung  becomes  involved,  or  the  patient  has  repeated  attacks 
of  hffimopt3^sis,  in  one  of  which  he  dies.  As  a  result  of  the  chronic  suppura- 
tion, amj'loid  degeneration  of  the  liver,  spleen,  and  intestines  may  take  place ; 
dropsy  frequently  supervenes  from  failure  of  the  right  heart. 

A  more  detailed  account  is  found  under  Cirrhosis  of  the  Lung,  with  which 
this  form  is  clinically  identical. 

Concurrent  Infections  in  Pulmonary  Tuberculosis. — It  has  long  been 
known  that  in  pulmonary  tuberculosis  organisms  other  than  the  specific  bacilli 
are  present,  particularly  Micrococcus  lanceolatus,  Streptococcus  pyogenes,  and 
Staphylococcus  aureus;  less  frequently  Bacillus  pyocyaneus. 

A  majority  of  all  cases  of  pulmonary  tuberculosis  are  combined  infec- 
tions; streptococci  and  pneumococci  may  be  found  in  the  sputa,  and  the 
former  have  been  isolated  from  the  blood.  Prudden,  who  has  very  carefully 
studied  this  question,  arrives  at  the  following  conclusions:  The  pulmonary 
lesions  of  tuberculosis  are  subject  to  variations  depending  largely  on  the  dif- 
ferent modes  of  distribution  of  the  bacilli,  whether  by  the  blood-vessels  or 
through  the  bronchi,  and  also  whether  a  concurrent  infection  with  other 
organisms  has  taken  place.  The  pneumonia  complicating  tuberculosis  may 
be  the  direct  result  of  the  tubercle  bacillus  or  its  toxins,  or  it  may  follow 
secondary  infection  with  other  germs,  particularly  the  Streptococcus  pyogenes, 
the  Micrococcus  lanceolatus,  and  the  Staphylococcus  pyogenes.  The  frequency 
of  this  secondary  infection  and  the  relative  significance  of  these  germs  are 
not  yet  fully  decided.  The  introduction  of  the  tubercle  bacilli  into  the  lungs 
of  a  rabbit  through  the  trachea  induces  the  various  phases  of  pulmonary  tuber- 
culosis, but  cavity  formation  is  rare.  If,  on  the  other  hand,  into  the  lungs 
of  a  rabbit  which  are  the  seat  of  extensive  consolidation  the  Streptococcus 
pyogenes  h  mtroduced,  then  cavities  form  rapidly,  and  the  anatomical  picture 
IS  very  simHar  to  that  of  chronic  ulcerative  tuberculosis  in  man.  It  is  very 
probable  that  in  man,  too,  the  effect  of  contamination  with  these  pus  organ- 
isms is  a  very  important  one  in  hastening  necrosis  and  softening,  and  also 
m  the  chronic  cases  they  doubtless  produce  in  large  amounts  the  toxins  which 
are  responsible  for  many  of  the  symptoms  of  the  disease. 


TUBERCULOSIS.  337 

Diseases  associated  with  Pulmonary  Tuberculosis. — Lobar  pneumonia  is 
a  not  uncommon  cause  of  death.  It  is  met  with,  most  frequently  indeed,  as 
a  terminal  event  in  the  chronic  cases.  It  may,  however,  occur  early,  and  be 
difficult  to  distinguish  from  an  acute  caseous  pneumonia.  The  sputa  in  the 
latter  are  rarely  rusty,  while  the  fever  in  the  former  is  more  continuous  and 
higher,  but  in  many  cases  it  is  impossible  to  differentiate  between  the  two 
conditions. 

The  association  of  tuberculosis  and  typhoid  fever  has  already  been  dis- 
cussed (page  90). 

Erysipelas  not  infrequently  attacks  old  poitrinaires  in  hospital  wards  and 
almshouses.  There  are  instances  in  which  the  attack  seems  to  be  beneficial, 
as  the  cough  lessens  and  the  symptoms  ameliorate.  It  may,  however,  prove 
fatal. 

The  eruptive  fevers,  particularly  measles,  frequently  precede,  but  rarely 
occur  in  the  course  of  pulmonary  tuberculosis.  In  the  revaccination  of  a 
tuberculous  subject  the  vesicles  run  a  normal  course. 

Fistula  in  ano  is  associated  with  phthisis  in  an  interesting  manner.  In 
a  majority  of  such  cases  it  is  a  tuberculous  process.  The  general  affection  may 
progress  rapidly  after  an  operation.  The  question  is  considered  in  tubercu- 
losis of  the  alimentary  canal. 

Heart-disease. — Cardiac  hypoplasia  seems  uncommon  in  tuberculosis, 
though  it  was  much  referred  to  by  the  older  writers.  It  was  present  in  only 
3  cases  in  1,764  autopsies  on  tuberculous  patients  (JSTorris).  Rokitansky 
taught  that  there  was  an  antagonism  between  valvular  lesions  and  aneurisms 
and  tuberculosis.  All  forms  of  congenital  heart-disease  predispose  to  it,  par- 
ticularly stenosis  of  the  pulmonary  artery.  Mitral  stenosis,  on  the  other  hand, 
has  a  distinctly  inhibitory  influence.  The  two  conditions  are  rarely  found 
associated.  Endocarditis  has  already  been  referred  to.  A  terminal  acute 
tuberculosis,  particularly  of  the  serous  membranes,  is  not  at  all  uncommon 
in  cardio-vascular  diseases. 

In  chronic  and  arrested  phthisis  arteriosclerosis  and  phleho-sclerosis  are 
not  uncommon.  Ormerod  noted  30  cases  of  chronic  renal  disease  in  100 
post  mortems. 

The  .association  of  tuberculosis  with  chronic  arthritis,  upon  which  cer- 
tain writers  lay  stress,  finds  its  explanation  in  the  lowered  resistance  of  these 
patients,  and  the  greater  liability  to  infection  in  the  institutions  in  which  so 
many  of  them  live. 

Peculiarities  of  Pulmonary  Tuberculosis  at  the  Extremes  of  Life. — (a) 
Old  Age. — It  is  remarkable  how  common  tuberculosis  is  in  the  aged,  partic- 
ularly in  institutions.  McLachlan  noted  145  cases  in  which  tuberculosis  was 
the  cause  of  death  in  old  persons  in  Chelsea  Hospital.  All  were  over  sixty 
years  of  age.  The  experience  at  the  Salpetriere  is  the  same.  Laennec  met 
with  a  case  in  a  person  over  ninety-nine  years  of  age. 

At  the  Philadelphia  Hospital,  in  the  bodies  of  aged  persons  sent  over 
from  the  almshouse  it  was  extremely  common  to  find  either  old  or  recent 
tuberculosis.  A  patient  died  under  my  care  at  the  age  of  eighty-two  with 
extensive  peritoneal  tuberculosis.  Pulmonary  tuberculosis  in  the  aged  is 
usually  latent  and  runs  a  slow  course.  The  physical  signs  are  often  masked 
by  emphysema  and  by  the  coexisting  chronic  bronchitis.     The  diagnosis  may 


338  SPECIFIC  INFECTIOUS  DISEASES. 

depend  entirely  upon  the  discovery  of  the  bacilli  and  elastic  tissue.  Contrary 
to  the  opinion  which  was  held  some  years  ago,  tuberculosis  is  by  no  means 
uncommon  with  senile  emphysema.  Some  of  the  cases  of  tuberculosis  in 
the  aged  are  instances  of  quiescent  disease  which  may  have  dated  from  an 
early  period. 

(h)  Infants. — The  occurrence  of  acute  tuberculosis  in  children  has 
already  been  mentioned,  and  also  the  fact  that  the  disease  is  occasionally  con- 
genital. Leroux  has.  analyzed  the  statistics  of  the  late  Prof.  Parrot,  em- 
bracing 219  cases  in  children  under  three  years.  Of  these  there  were  from 
one  day  to  three  months,  23 ;  from  three  to  six  months,  46 ;  from  six  to  twelve 
months,  53  (a  total  of  111  under  one  year)  ;  and  from  one  to  three  years,  108. 
Pulmonary  cavities  were  present  in  57  of  the  cases,  and  in  only  50  was  the 
pulmonary  lesion  the  sole  manifestation.  At  the  St.  Petersburg  Foundling 
Asylum,  in  the  ten  years  ending  1884,  there  were  416  cases  of  tuberculosis 
in  16,581  autopsies.  The  observations  of  jSTorthrup,  at  the  New  York 
Foundling  Hospital,  are  of  special  interest  in  connection  with  the  mode  of 
infection.  Of  125  cases  of  tuberculosis  on  the  records  of  this  institution, 
in  34  the  ravages  were  extensive,  the  seat  of  the  primary  affection  was  not 
clear,  and  the  bronchial  glands  were  large  and  cheesy.  In  20  cases  of  general 
tuberculosis  there  were  cheesy  masses  in  the  bronchial  glands  and  in  the  lungs. 
In  42  cases  of  general  tuberculosis  the  only  cheesy  masses  were  in  the  bronchial 
hmph-glands.  In  9  cases  the  tubercles  were  limited  to  the  bronchial  nodes 
and  the  lungs;  the  latter  containing  only  discrete  miliary  bodies,  while  the 
bronchial  glands  showed  advanced  caseation.  In  13  cases  there  was  tuber- 
culosis of  the  bronchial  nodes  only.  In  most  of  these  cases  the  patients  died 
of  infectious  diseases.  These  figures  are  very  suggestive,  and  point,  as  already 
noted,  to  infection  through  the  bronchial  passages  as  the  most  common  method, 
even  in  children.  Of  500  autopsies  in  children  at  the  Munich  Pathological 
Institute,  in  150  (30  per  cent)  tuberculosis  was  present  and  in  over  92  per 
cent  the  lungs  were  involved  (Miiller). 

Modes  of  Death  in  Pulmonary  Tuberculosis. —  (a)  Bij  asthenia,  a  gradual 
failure  of  the  strength.  The  end  is  usually  peaceable  and  quiet,  occasion- 
ally disturbed  by  paroxysms  of  cough.  Consciousness  is  often  retained  until 
near  the  close. 

(6)  By  asphyxia,  as  ia  some  cases  of  acute  miliary  tuberculosis  and  in 
acute  pneumonic  phthisis.  In  chronic  phthisis  it  is  rarely  seen,  even  when 
pneumothorax  develops. 

(c)  By  syncope.  This  is  not  common.  I  have  known  it  to  happen  once 
or  twice  ia  patients  who  insisted  upon  going  about  when  in  the  advanced 
stages  of  the  disease.  There  may  be,  but  not  necessarily,  fatty  degeneration 
of  the  heart.  Eapid  s}Ticope  may  follow  hasmorrhage  or  may  be  due  to  throm- 
bosis or  emboHsm  of  the  pulmonary  artery,  or  to  pneumothorax. 

(d)  From  hcemorrhage.  The  fatal  bleeding  in  chronic  phthisis  is  due 
to  erosion  of  a  large  vessel  or  rupture  of  an  aneurism  in  a  pulmonary  cavity, 
most  commonly  the  latter.  Of  26  cases  analyzed  by  S.  West,  in  11  the  fatal 
haemoptysis  was  due  to  aneurism,  and  of  35  cases  collected  by  Percy  Kidd, 
aneurism  was  present  in  30.  In  a  case  of  Curtin's,  at  the  Philadelphia  Hos- 
pital, the  bleeding  proved  fatal  before  hemoptysis  occurred,  as  the  eroded 
vessel  opened  into  a  capacious  cavity. 


TUBERCULOSIS.  339 

(e)  With  cerebral  symptoms.  Coma  may  be  due  to  meningitis,  less  often 
to  urgemia.  Death  in  convulsions  is  rare.  The  hsemorrhagic  pachy-menin- 
gitis  which  occurs  in  some  cases  of  phthisis  occasionally  causes  loss  of  con- 
sciousness, but  is  rarely  a  direct  cause  of  death.  In  one  of  my  cases,  death 
resulted  from  thrombosis  of  the  cerebral  sinuses  with  symptoms  of  meningitis. 

Y.  Tuberculosis  of  the  Alimentary  Caxal. 

(a)  Lips. — Tuberculosis  of  the  lip  is  very  rare.  It  occurs  occasionally  in 
the  form  of  an-  ulcer,  either  alone  or  more  commonly  in  association  with  laryn- 
geal or  pulmonary  disease.  Two  cases  are  reported  and  the  literature  is 
analyzed  in  Verneuil's  Etudes.*  The  ulcer  is  usually  very  sensitive  and  may 
be  mistaken  for  a  chancre  or  an  epithelioma.  The  diagnosis  may  be  made  in 
cases  of  doubt  by  inoculation  or  the  examination  of  a  portion  for  tubercle 
bacilli. 

(&)  Tongue. — The  disease  begins  by  an  aggregation  of  small  granular 
bodies  on  the  edge  or  dorsum.  Ulceration  proceeds,  leaving  an  irregular  sore 
with  a  distinct  but  uneven  margin,  and  a  rough,  often  caseous  base.  The 
disease  extends  slowly  and  may  form  an  ulcer  of  considerable  size.  I  have 
known  it  to  be  mistaken  for  epithelioma  and  the  tongue  to  be  excised.  It  is 
rarely  met  with  except  when  other  organs  are  involved.  The  glands  of  the 
angle  of  the  jaw  are  not  enlarged  and  the  sore  does  not  yield  to  iodide  of 
potassium,  which  are  points  of  distinction  between  the  tuberculous  and  the 
syphilitic  ulcer.  In  doubtful  cases  the  inoculation  test  should  be  made,  or  a 
portion  excised  for  microscopical  examination. 

(c)  The  salivary  glands  belong  to  that  small  group  of  organs  of  the  body 
which  seem  to  possess  an  immunity;  a  very  few  cases  have  been  reported. 

(d)  Tubercles  of  the  hard  or  soft  palate  nearly  always  follow  extension  of 
the  disease  from  neighboring  parts. 

(e)  Tuberculosis  of  the  Tonsils. — In  7  of  45  consecutive  cases  in  children 
from  three  months  to  fifteen  years  A.  Latham  demonstrated,  by  inoculation, 
the  presence  of  tuberculosis  of  the  tonsils  either  in  organs  removed  by  oper- 
ation or  post  mortem.  The  observation  is  of  interest  in  connection  with  the 
views  of  Schlenker,  who  claims  that  the  majority  of  the  cases  of  tuberculous 
cervical  glands  result  from  infection  with  tubercle  bacilli  which  gain  admis- 
sion by  way  of  the  tonsil.  A  large  number  of  his  cases  of  tuberculous  cervical 
adenitis  were  definitely  of  a  descending  variety  and  associated  with  tubercu- 
losis of  these  glands.  The  majority  also  had  pulmonary  tuberculosis,  and  he 
regards  surface  infection  of  the  tonsil  by  tuberculous  food  and  sputum  far 
more  common  than  infection  by  way  of  the  circulation.  The  disease  may 
occur  as  a  superficial  ulceration.  More  commonly  there  is  an  infiltration  of 
the  tonsil  with  miliary  tubercles,  which  produces  a  greater  or  less  hypertrophy 
which  it  is  practically  impossible  to  distinguish  from  an  ordinary  enlargement 
of  the  tonsil  without  a  microscopical  examination.  Hugh  Walsham's  observa- 
tions on  the  frequency  of  infection  of  the  tonsils  in  pulmonary  tuberculosis 
have  been  referred  to. 

(/)  Pharynx. — In  extensive  laryngeal  tuberculosis  an  eruption  of  miliary 
granules  on  the  posterior  wall  of  the  pharjmx  is  not  very  uncommon.     In 

*  Tome  iii,  Fasc.  I. 


340  SPECIFIC  INFECTIOUS  DISEASES. 

chronic  phthisis  an  ulcerative  pharjTigitis,  due  to  extension  of  the  disease 
from  the  epiglottis  and  lar}Tix,  is  one  of  the  most  distressing  of  complica- 
tions, rendering  deglutition  acutely  painful.  Adenoids  of  the  naso-pharjTix 
may  be  tuberculous,  as  shown  by  Lermo3'ez.  Macroscopically,  they  do  not 
differ  from  the  ordinary  vegetations  found  in  this  situation. 

(g)  A  few  instances  occur  in  the  literature  of  tuberculosis  of  the  (esoph- 
agus. The  condition  is  a  pathological  curiosity,  except  in  the  slight  exten- 
sion from  the  lar}Tix,  which  is  not  infrequent ;  but  in  a  case  in  my  wards  de- 
scribed by  Flexner  the  ulcer  perforated  and  caused  purulent  pleurisy.  The 
condition  has  been  fully  considered  by  Claribel  Cone,  who  has  described  a 
second  case  from  the  Jolins  Hopkins  Hospital  (Bulletin,  Xovember,  1897). 

{li)  Stomach. — Many  cases  are  reported  which  are  doubtful.  Primary 
disease  is  unknown.  Marfan  was  able  to  collect  only  about  a  dozen  authentic 
cases.  Perforation  of  the  stomach  occurred  six  times,  thrice  by  a  tuberculous 
gland.  In  Oppolzer's  case  an  rdcer  of  the  colon  perforated  the  organ.  In 
Musser's  case  there  was  a  large  tuberculous  ulcer  3  X  14  inches  in  extent. 
Three  cases  have  been  described  from  my  wards  by  Alice  Hamilton  (J.  H.  H. 
Bulletin,  April,  1897). 

{i)  Intestines. — The  tubercles  may  be  (1)  primary  in  the  mucous  mem- 
brane, or  more  commonly  (2)  secondary  to  disease  of  the  lungs,  or  in  rare 
cases  the  affection  may  (3)  pass  from  the  peritongeuni. 

(1)  Primary  intestinal  tuberculosis  occurs  most  frequently  in  children, 
in  whom  it  may  be  associated  with  enlargement  and  caseation  of  the  mesen- 
teric glands,  or  with  peritonitis.  As  stated  on  page  292,  there  is  great  dis- 
crepancy in  the  statistics  on  this  point — German  4  per  cent,  American  1  per 
cent,  English  18  per  cent — and  the  question  needs  careful  study.  Biedert 
gives  16  cases  in  3,104  instances  of  tuberculosis  in  children.  In  adults  pri- 
mary intestinal  tuberculosis  is  rare,  occurring  in  but  1  instance  in  1,000 
autopsies  upon  tuberculous  adults  at  the  Munich  Pathological  Institute;  but 
now  and  then  cases  occur  in  which  the  disease  sets  in  with  irregular  diar- 
rhoea, moderate  fever,  and  colick\'  pains.  In  a  few  cases  hsemorrhage  has 
been  the  initial  symptom.  Eegarded  at  first  as  a  chronic  catarrh,  it  is  not 
until  the  emaciation  becomes  marked  or  the  signs  of  disease  appear  in  the 
lungs  that  the  true  nature  is  apparent.  Still  more  deceptive  are  the  cases  in 
which  the  tuberculosis  begins  in  the  cfficum  and  there  are  symptoms  of  appen- 
dicitis— tenderness  in  the  right  iliac  fossa,  constipation,  or  an  irregular  diar- 
rhoea and  fever.  These  signs  may  gradually  disappear,  to  recur  again  in  a 
few  weeks  and  still  further  complicate  the  diagnosis.  Fatal  hsemorrhage  has 
occurred  in  several  of  my  cases.  Perforation  may  occur  with  the  formation 
of  a  pericsecal  abscess,  or  perforation  into  the  peritoneum  may  take  place,  or 
in  very  rare  instances  there  is  partial  healing  with  great  thickening  of  the 
walls  and  narrowing  of  the  lumen. 

(2)  Secondary  involvement  of  the  bowels  is  very  common  in  chronic  pul- 
monary tuberculosis,  e.g.,  in  566  of  the  1,000  Municli  autopsies  in  tuber- 
culosis .just  referred  to.  In  only  three  of  these  cases  were  the  lungs  not 
involved.  The  lesions  are  chiefly  in  the  ileum,  cascum,  and  colon.  The  affec- 
tion begins  in  the  solitary  and  agminated  glands  or  on  the  surface  of  or 
within  the  mucosa.  The  caseation  and  necrosis  lead  to  ulceration,  which 
may  be  very  extensive  and  involve  the  greater  portion  of  the  mucosa  of  the 


TUBERCULOSIS.  341 

large  and  small  bowels.  In  the  ileum  the  Peyer's  patches  are  chiefly  involved 
and  the  ulcers  may  be  ovoid,  but  in  the  jejunum  and  colon  they  are  usually 
round  or  transverse  to  the  long  axis.  The  tuberculous  ulcer  has  the  follow- 
ing characters:  (a)  It  is  irregular,  rarely  ovoid  or  in  the  long  axis,  more 
frequently  girdling  the  bowel;  (&)  the  edges  and  base  are  infiltrated,  often 
caseous;  (c)  the  submucosa  and  muscularis  are  usually  involved;  and  {d) 
on  the  serosa  may  be  seen  colonies  of  young  tubercles  or  a  well-marked  tuber- 
culous Ijrmphangitis.  Perforation  and  peritonitis  are  not  uncommon  events 
in  the  secondary  ulceration.  Stenosis  of  the  bowel  from  cicatrization  may 
occur ;  the  strictures  may  be  multiple. 

Localized  chronic  tuberculosis  of  the  iho-coBcal  region  is  of  great  impor- 
tance. The  caecum  may  present  a  chronic  hyperplastic  tuberculosis,  which  not 
uncommonly  extends  into  the  appendix.  As  a  consequence  of  the  changes 
produced  a  definite  tumor-like  mass  is  formed  in  the  right  iliac  fossa.  This 
varies  in  size,  is  usually  elongated  in  a  vertical  direction,  hard,  slightly  mov- 
able, or  bound  down  by  adhesions  and  very  sensitive  to  pressure.  The  tumor 
simulates  more  or  less  closely  a  true  neoplasm  of  this  region,  particularly  car- 
cinoma. The  condition  is  characterized  by  gradual  constriction  of  the  lumen 
of  the  bowel,  periodic  attacks  of  severe  pain,  and  alternating  diarrhoea  and 
constipation.  The  extremely  localized  character  of  the  disease  warrants  an  ex- 
ploratory operation,  as  the  results  of  enterectomy  are  remarkably  favorable. 
Of  11  cases  reported  by  P.  M.  Caird  7  recovered.  In  a  second  form  of  this 
disease,  occurring  less  frequently  than  the  former,  there  is  no  definite  tumor- 
mass  to  be  felt,  but  a  general  induration  and  thickening  in  the  right  iliac 
fossa  similar  to  the  local  changes  produced  by  a  recurring  appendicitis.  In 
this  variety  a  fistula  discharging  fecal  matter  occasionally  results.  Both  forms 
may  be  distinguished  from  the  diseases  they  simulate  by  the  finding  of  tubercle 
bacilli  in  the  stools  or  in  the  discharge  from  the  fistula  when  such  exists. 

Tuberculosis  of  the  rectum  has  a  special  interest  in  connection  with  fistula 
in  ano,  which,  according  to  Spillman's  statistics,  occurs  in  about  3.5  per  cent 
of  cases  of  pulmonary  disease.  In  many  instances  the  lesion  has  been  shown 
to  be  tuberculous.  It  is  very  rarely  primary,  but  if  the  tissue  on  removal 
contains  bacilli  and  is  infective  the  lungs  are  almost  invariably  found  to  be 
involved.  It  is  a  common  opinion  that  the  pulmonary  symptoms  progress  rap- 
idly after  the  fistula  is  cut.  This  may  have  some  basis  if  the  operation  con- 
sists in  laying  the  tract  open,  and  not  in  a  free  excision. 

(3)  Extension  from  the  peritonaeum  may  excite  tuberculous  disease  in  the 
bowels.  The  affection  may  be  primary  in  the  peritongeum  or  extend  from  the 
tubes  in  women  or  the  mesenteric  glands  in  children.  The  coils  of  intestines 
become  matted  together,  caseous  and  suppurating  foci  develop  between  the 
folds,  and  perforation  may  take  place  between  the  coils. 

VI.  Tuberculosis  of  the  Liver. 

This  organ  is  very  constantly  involved  in  (1)  Miliary  tuberculosis.  This 
is  seen  in  acute  generalized  tuberculosis,  though  the  granules  may  be  small 
and  have  to  be  looked  for  very  carefully.  In  chronic  tuberculosis  miliary 
tubercles  are  not  at  all  uncommon  in  the  liver.  (2)  Solitary  tubercle.  Occa- 
sionally large  tuberculous  masses  are  found  in  the  organ,  sometimes  associated 


342  SPECIFIC  INFECTIOUS  DISEASES. 

with  perihepatitis,  sometimes  with  tuberculous  peritonitis,  and  in  children 
with  tuberculous  adenitis.  In  a  few  cases  the  masses  are  very  large,  though  it 
is  only  in  exceptional  cases  that  the  tumor  can  be  felt  through  the  abdominal 
wall.  Occasionally  the  solitary  tubercle  becomes  infected  with  pus  organisms, 
softens  and  forms  an  abscess.  (3)  Tuberculosis  of  the  hile  ducts;  tuber- 
culous cavities  in  the  liver.  This  is  by  far  the  most  characteristic  tubercu- 
lous change  in  the  organ,  and  is  not  uncommon.  It  was  well  described  by 
Bristowe  in  1858.  The  liver  is  enlarged,  and  section  shows  numerous  small 
cavities,  which  look  at  first  like  multiple  abscesses  in  suppurative  pylephlebitis, 
but  the  pus  is  bile-stained  and  the  whole  process  is  a  local  tuberculous  cholan- 
gitis. (4)  Tuberculous  cirrhosis.  With  the  eruption  of  miliary  tubercles 
there  may  be  slight  increase  in  the  connective  tissue,  which  is  overshadowed 
by  the  fatty  change.  In  all  the  chronic  forms  of  tubercle  in  this  organ  there 
may  be  fibrous  overgrowth.  Hanot,  who  has  described  several  varieties,  states 
that  the  condition  may  be  primary.  Practically  it  is  very  rare,  except  in 
connection  with  chronic  tuberculous  peritonitis  and  perihepatitis,  when  the 
organ  may  be  much  deformed  by  a  sclerosis  involving  the  portal  canals  and 
the  capsule,  which  may  be  greatly  involved  in  a  polyserositis. 

VII.  Tuberculosis  op  the  Brain  axd  Cord. 

Tuberculosis  of  the  brain  occurs  as  (a)  an  acute  miliary  infection  caus- 
ing meningitis  and  acute  hydrocephalus;  (b)  as  a  chronic  meningo-encepha- 
litis,  usually  localized,  and  containing  small  nodular  tubercles;  and  (c)  as 
the  so-called  solitary  tubercle.  Between  the  last  two  forms  there  are  all 
gradations,  and  it  is  rare  to  see  the  meninges  uninvolved.  The  acute  variety 
has  already  been  considered.  I  shall  here  consider  the  chronic  form,  which 
comes  on  slowly  and  has  the  clinical  characters  of  a  tumor. 

It  is  most  common  in  the  young.  Of  148  cases  collected  by  Pribram  118 
were  under  fifteen  years  of  age.  Other  organs  are  usually  involved,  partic- 
ularly the  lungs,  the  bronchial  glands,  or  the  bones.  In  rare  instances  no 
tubercles  are  found  elsewhere.  They  occur  most  frequently  in  the  cerebellum ; 
next  in  the  cerebrum  and  then  in  the  pons.  The  growths  are  often  multiple' 
in  100  out  of  183  cases  (Gowers).  They  range  in  size  from  a  pea  to  a  wal- 
nut; large  tumors  occasionally  occur,  and  sometimes  an  entire  lobe  of  the 
cerebellum  is  affected.  On  section  the  tubercle  presents  a  grayish-yellow, 
caseous  appearance,  usually  firm  and  hard,  and  encircled  by  a  translucent' 
softer  tissue.  The  centre  of  the  growth  may  be  semi-difQuent.  .  As  in  other 
localities  the  tubercle  may  calcify.  The  tumors  are  as  a  rule  attached  to  the 
menmges,  often  to  the  pia  at  the  bottom  of  a  sulcus  so  that  they  look  im- 
bedded m  the  brain-substance.  About  the  longitudinal  fissure  there  may  be 
an  aggregation  of  the  growths,  with  compression  of  the  sinus,  and  the  forma- 
tion of  a  thrombus.  The  tuberculous  tumor  not  infrequently  excites  acute 
menmgitis.  In  localized  meningo-encephalitis  the  pia  is  thickened,  tuber- 
cles are  adherent  to  the  under  surface  and  grow  about  the  arteries.  It 'is  often 
combined  with  cerebral  softening  from  interference  with  the  circulation.  Sev- 
eral of  the  most  characteristic  instances  which  I  have  seen  were  on  the 
meninges  covering  the  insula.  This  form  may  occur  in  pulmonary  tubercu- 
losis, causing  hemiplegia  or  aphasia  which  may  persist  for  months. 


TUBERCULOSIS.  343 

The  symptoms  of  tuberculous  growths  in  the  brain  are  those  of  tumor, 
and  will  be  considered  in  the  section  on  the  brain. 

In  the  spinal  cord  the  same  forms  are  found.  The  acute  tuberculous  men- 
ingitis has  been  considered  and  is  almost  always  cerebro-spinal.  The  solitary 
tubercle  of  the  cord  is  rare.  Herter  has  reported  3  cases  and  collected  24 
from  the  literature.  It  was  secondary  in  all  save  one  case.  The  symptoms 
are  those  of  spinal  tumor  or  meningitis. 

VIII.  Tuberculosis  op  the  Genito-urtnart  System. 

The  studies  of  the  past  few  years,  and  particularly  the  work  of  surgeons 
and  gynaecologists,  have  taught  us  the  great  importance  of  tuberculosis  of  this 
tract.  Any  part  of  the  genito-urinary  system  may  be  invaded.  The  suc- 
cessive involvement  of  the  organs  may  be  so  rapid  that  unless  the  case  has 
been  seen  early  it  may  be  impossible  to  state  with  any  degree  of  certainty 
which  has  been  the  primary  seat  of  infection.  There  may  be  simultaneous 
involvement  of  various  portions  of  the  tract.  In  tuberculosis  of  the  genito- 
urinary system  one  always  has  to  bear  in  mind  the  possibility  of  latent  dis- 
ease elsewhere  in  the  body.  As  Bollinger  says,  tubercle  bacilli  may  gain 
admission  at  some  part  of  the  respiratory  tract  without  producing  any  lesion 
at  the  point  of  entrance,  and  finally  reach  a  bronchial  gland,  where  they 
set  up  a  tuberculous  process  of  extremely  slow  development  without  producing 
any  symptoms.  From  this  point  bacilli  may  enter  the  blood  stream  and  lodge 
in  the  epididymis  or  testicle  proper,  and  produce  nodules  which  are  readily 
discovered,  owing  to  the  ease  with  which  these  parts  are  examined.  Such  a 
case  might  be  quite  easily  mistaken  for  one  of  primary  genital  tuberculosis, 
whereas  the  true  primary  tuberculous  focus  is  far  distant. 

Infection"  of  the  genito-urinary  tract  occurs  in  various  ways : 

1.  By  Hereditary  Transmission. — It  has  been  met  with  in  the  foetus.  The 
comparative  frequency  of  tuberculosis  of  the  testicle  in  very  young  children 
suggests  very  strongly  that  the  uro-genital  organs  may  be  involved  as  a  result 
of  direct  transmission  of  the  disease  from  the  parents. 

2.  By  infection  from  areas  of  tuberculosis  already  existing  in  the  patient. 
(a)  Infection  tJirougli  the  Blood. — In  many  cases  uro-genital  tuberculosis 

is  found  at  autopsy  associated  with  disease  of  some  distant  organ,  particu- 
larly the  lungs,  and  it  would  appear  most  probable  that  in  them  infection  has 
been  through  the  blood-vessels.  Jani's  observations,  which  were  published  by 
Weigert  after  the  author's  death,  strongly  support  this  theory.  In  studying 
sections  of  the  genital  organs  of  patients  who  died  of  pulmonary  tuberculosis, 
he  found  tubercle  bacilli  in  5  out  of  8  cases  in  the  testicle,  and  in  4  out  of  6 
cases  in  the  prostate,  without  in  any  instance  finding  microscopical  evidences 
of  tubercles  in  these  organs.  The  bacilli  lay,  in  the  testis,  partly  within  and 
partly  close  beside  the  cellular  and  granular  contents  of  the  seminal  tubules, 
while  in  the  prostate  they  were  always  situated  in  the  neighborhood  of  the 
glandular  epithelium. 

(&)  Infection  from  the  Peritonceum. — This  source  of  infection,  in  both 
men  and  women,  is  much  more  frequent  than  is  commonly  supposed.  The 
intimale  relationship  between  the  peritonaeum  and  bladder  in  both  subjects, 
and  with  the  vesiculae  seminales  and  vasa  deferentia  in  the  male,  allows  of 


344  SPECIFIC  INFECTIOUS  DISEASES. 

a  ready  way  of  invasion  of  these  organs  by  direct  extension  of  the  disease. 
The  peritona?iim  is  a  frequent  source  of  genital  tuberculosis  in  the  female. 
No  doubt  many  cases  of  tuberculosis  of  the  Fallopian  tubes  originate  from 
this  source.  The  fact  that  the  fimbriated  extremity  of  the  tube  is  often  most 
seriously  involved  points  rather  strongly  in  this  direction,  although  the  fact 
might  be  taken  as  a  point  in  favor  of  blood  infection,  favored  by  its  greater, 
vascularity.  Various  observations  go  to  show  that  the  action  of  the  cilia 
lining  the  lumina  of  the  Fallopian  tubes  tends  to  attract  particles  introduced 
into  the  peritoneal  cavity.  Jani's  observation  is  very  interesting  in  this  con- 
nection, as  showing  the  possibility  of  tubercle  bacilli  entering  the  tubes  from 
the  peritoneal  cavity  without  there  being  any  tuberculous  peritonitis.  He 
found  typical  tubercle  bacilli  in  the  lumen,  in  sections  of  a  normal  Fallopian 
tube,  in  a  woman  who  died  of  pulmonary  and  intestinal  tuberculosis.  The 
explanation  advanced  was  that  the  bacilli  made  their  way  through  the  thin 
peritoneal  coat  from  one  of  the  intestinal  ulcers,  thus  reaching  the  peritoneal 
cavity,  and  thence  were  attracted  into  the  Fallopian  tube  by  the  current  pro- 
duced by  the  action  of  the  cilia  lining  the  lumen.  The  intimate  relationship 
between  tuberculous  peritonitis  and  tuberculosis  of  the  Fallopian  tubes  is 
shown  in  the  fact  that  the  latter  are  affected  in  from  30  to  40  per  cent  of 
the  cases. 

(c)  Infection  from  otlier  Organs  liy  Direct  Extension. — The  occurrence 
of  direct  extension  from  the  peritonaeum  has  already  been  mentioned.  In 
tuberculous  ulceration  of  the  intestine  or  rectum  adhesions  to  the  bladder 
in  the  male  or  to  the  uterus  and  vagina  in  the  female  may  occur,  with  result- 
ing fistulae  and  a  direct  extension  of  the  disease.  Perirectal  tuberculous 
abscesses  may  lead  to  secondary  involvement  of  some  portion  of  the  genito- 
urinary tract.  It  must  not  be  forgotten  that  tuberculosis  of  the  vertebrae 
may  be  followed  by  tuberculosis  of  the  kidney  as  a  result  of  direct  extension 
of  the  disease. 

3.  By  Infection  from  Without. — Whether  uro-genital  tuberculosis  may 
occur  as  a  result  of  the  entrance  of  tubercle  bacilli  into  the  urethra  or  vagina 
is  still  a  disputed  question.  That  bacilli  gain  admission  to  these  passages  dur- 
ing coitus  with  a  person  the  subject  of  uro-genital  tuberculosis,  or  by  the  use 
of  foul  instruments  or  syringes,  seems  quite  probable.  The  possibility  of 
genital  tuberculosis  occurring  in  the  female  as  a  result  of  coitus  with  a  male 
the  subject  of  tuberculosis  in  some  portion  of  the  genito-urinary  system  was 
first  suggested  by  Cohnheim,  who  stated,  however,  that  it  rarely,  if  ever, 
occurred.     Gartner's  experiments  have  been  referred  to. 

In  a  patient  with  intestinal  tuberculosis  the  tubercle  bacilli  might  acci- 
dentally reach  the  urethra  or  vagina  from  the  rectum. 

Uro-genital  tuberculosis  is  commonest  between  the  ages  of  twenty  and 
forty  years — that  is,  during  the  period  of  greatest  sexual  acti^dty.  Males  are 
affected  much  more  frequently  than  females,  the  proportion  being  3  to  1. 
This  great  difference  is  no  doubt  partly  due  to  the  more  intimate  relationship 
between  the  urinary  and  genital  systems  in  the  former  than  in  the  latter.  In 
the  male  the  urethra  forms  the  common  outlet  for  the  two  systems,  while  in 
the  female  there  is  a  separate  outlet  for  each. 

Once  the  uro-genital  tract  has  been  invaded,  the  disease  is  likely  to  spread 
rapidly,  and  the  method  of  extension  is  an  important  one.     Quite  frequently 


TUBERCULOSIS.  345 

there  is  direct  extension,  as  when  the  bladder  is  involved  secondarily  to  the 
kidney  by  passage  of  the  disease  along  the  ureter,  or  where  the  tuberculous 
process  extends  along  the  vas  deferens  to  the  vesiculse  seminales.  No  doubt 
surface  inoculation  occurs  in  some  instances,  and  to  this  cause  may  be  attrib- 
uted a  certain  percentage  of  cases  of  vesical  and  prostatic  disease  following 
tuberculosis  of  the  kidney.  Although  this  probability  is  acknowledged,  there 
is  an  element  of  doubt  as  to  the  possibility  of  the  kidney  becoming  affected 
secondarily  to  the  bladder  or  prostate  by  the  direct  passage  of  the  bacilli  up 
the  lumen  of  one  ureter;  for  in  such  a  case  we  have  to  suppose  that  a  non- 
motile  bacillus,  contrary  to  the  laws  of  gravity,  ascends  against  an  almost 
constant  current  of  urine  flowing  in  the  opposite  direction.  The  lymphatics 
may  afford  a  means  for  the  spreading  of  the  disease,  but  in  a  greater  number 
of  cases  than  is  generally  supposed  it  takes  place  by  way  of  the  blood-vessels. 
Cystoscopic  examinations  of  the  bladder  not  infrequently  show  the  presence 
of  tubercles  beneath  the  mucous  membrane  before  there  is  any  evidence  of 
superficial  ulceration — a  fact  suggesting  strongly  a  blood  infection. 

The  discovery  of  tubercle  bacilli  in  the  urine  and  the  obtaining  of  tuber- 
culous lesions  in  animals  as  a  result  of  inoculation  with  the  urinary  sedi- 
ment afford  us  the  only  positive  evidence  of  genito-urinary  tuberculosis.  So 
far  there  are  no  authentic  accounts  of  tubercle  bacilli  having  been  found  in  the 
semen  of  men  with  tuberculosis  of  the  testicle  or  vesiculse  seminales.  Owing 
to  the  fact  that  the  smegma  bacillus  has  the  same  staining  reaction  as  the 
tubercle  bacillus,  and,  morphologically,  is  practically  indistinguishable  from 
it,  the  greatest  care  must  be  used  in  obtaining  the  specimen  of  urine  for 
examination,  to  eliminate,  if  possible,  all  chances  of  contamination.  Thus 
the  urine  examined  must  be  a  catheterized  specimen,  and  even  then  one  runs 
the  risk  of  carrying  back  into  the  bladder  on  the  end  of  the  catheter  a  few 
bacilli  which  may  be  washed  out  in  the  stream  of  urine  and  be  mistaken  for 
tubercle  bacilli  in  the  sediment.  By  Bunge  and  Trautenroth's  method  of 
staining  the  two  organisms  can  probably  be  definitely  differentiated,  but  the 
safer  plan  is  to  immediately  inoculate  one  or  more  guinea-pigs  with  some  of  the 
suspected  urine.  If  tubercle  bacilli  be  present  the  animals  will  manifest 
tuberculous  lesions  in  from  three  to  five  weeks. 

TuBEECULOSis  OF  THE  KiDNEYS  (PhtMsis  renum) . — In  general  tuber- 
culosis the  kidneys  frequently  present  scattered  miliary  tubercles.  In  pul- 
monary tuberculosis  it  is  common  to  find  a  few  nodules  in  the  substance  of 
the  organ,  or  there  may  be  pyelitis.  In  the  first  17,000  admissions  to  the 
medical  wards  of  the  Johns  Hopkins  Hospital  there  were  1,085  cases  of  tuber- 
culous infection.  In  17  of  these  a  clinical  diagnosis  of  renal  tuberculosis 
was  made.  Walker  analyzed  the  first  1,369  autopsies  in  the  same  hospital 
and  found  that  784  had  tuberculosis  in  some  part  of  the  body.  In  all  there 
were  61  cases  of  renal  tuberculosis.  Of  482  cases  of  pulmonary  tuberculosis 
showing  symptoms  during  life,  one  or  both  kidneys  were  involved  in  23. 
There  were  36  cases  of  acute  general  miliary  tuberculosis,  and  in  every  instance 
the  kidney  was  affected.  The  2  other  cases  of  renal  tuberculosis  occurred  in 
patients  with  latent  disease.  Primary  tuberculosis  of  the  kidneys  is  not  very 
rare,  but  in  no  instance  in  the  above  series  did  Walker  demonstrate  a  primary 
infection  in  the  kidney.  The  tuberculous  process  was  primary  in  some  other 
part  of  the  genito-urinary  tract  in  6  cases.     In  a  majority  of  the  cases  the 


346  SPECIFIC  INFECTIOUS  DISEASES. 

process  involves  the  jDclvis  and  the  ureter  as  well,  sometimes  the  bladder  and 
prostate.  It  may  be  difficult  to  say  in  advanced  cases  whether  the  disease 
has  started  in  the  bladder,  prostate,  or  vesicles,  and  crept  up  the  ureters, 
or  whether  it  started  in  the  kidneys  and  proceeded  downward.  In  a  majority 
of  cases,  I  believe,  the  latter  is  true,  and  the  infection  is  through  the  blood. 
Walker  thinks  that  a  hematogenous  infection  takes  place  in  90  per  cent  of  the 
eases,  and  that  this  is  the  channel  of  infection  in  the  majority  of  instances 
where  renal  follows  vesical  tuberculosis  rather  than  along  the  ureter.  One 
kidney  alone  may  be  involved,  and  the  disease  creeps  down  the  ureter  and 
may  only  extend  a  few  millimetres  on  the  vesical  mucosa.  A  man  with  aortic 
insufficiency,  who  had  no  lesions  in  the  lungs,  presented  a  localized  patch  in 
the  pelvis  of  the  kidney,  involving  a  pyramid,  while  the  ureter,  5  cm.  from  the 
bladder  and  at  its  orifice,  was  thickened  and  tuberculous.  The  prostate 
showed  an  area  of  caseation.  The  process  is  most  common  between  twenty 
and  thirty  years  of  age,  but  it  may  occur  at  the  extremes  of  age.  In  a  series 
of  386  cases  collected  by  Walker  in  which  the  sex  was  stated,  182  of  the 
patients  were  males  and  204  females.  The  joint  statistics  of  Guillard,  Tuffier, 
and  Albarran  include  246  cases  of  chronic  tuberculosis,  of  which  117  were 
females  and  69  males.  In  the  earliest  stage,  which  may  be  met  with  acci- 
dentally, the  disease  is  seen  to  begin  in  the  pyramids  and  calyces.  Necrosis 
and  caseation  proceed  rapidly,  and  the  colonies  of  tubercles  start  throughout 
the  pyramids  and  extend  upon  the  mucous  membrane  of  the  pelvis.  As  a 
rule,  from  the  outset  it  is  a  tuberculous  pyo-nephrosis.  The  renal  infection 
may  result  from  direct  extension  of  the  disease  from  a  tuberculous  vertebra. 
It  may  be  confined  to  one  kidney,  or  progress  more  extensively  in  one  than  in 
the  other.  Of  216  cases  in  which  the  side  affected  was  specified,  the  right 
kidney  was  involved  in  111,  the  left  in  96,  and  both  together  in  9.  At  autopsy 
both  organs  are  usually  found  enlarged.  In  only  3  of  the  61  autopsies  pre- 
viously referred  to  was  the  disease  unilateral.  One  kidney  may  be  completely 
destroj^ed  and  converted  into  a  series  of  cysts  containing  cheesy  substance — 
a  form  of  kidney  which  the  older  writers  called  scrofulous.  In  the  putty- 
like contents  of  these  cysts  lime  salts  may  be  deposited.  In  other  instances 
the  walls  of  the  pelvis  are  thickened  and  cheesy,  the  pyramids  eroded,  and 
caseous  nodules  are  scattered  through  the  organ,  even  to  the  capsule,  which 
may  be  thickened  and  adherent.  The  other  organ  is  usually  less  affected, 
and  shows  only  pyelitis  or  a  superficial  necrosis  of  one  or  two  pyramids. 
The  ureters  are  usually  thickened  and  the  mucous  membrane  ulcerated  and 
caseous.  Involvement  of  the  bladder,  vesiculse  seminales,  and  testes  is  not 
uncommon  in  males. 

The  symptoms  are  those  of  pyelitis.  The  urine  may  be  purulent  for 
years,  and  there  may  be  little  or  no  distress.  Even  before  the  bladder  be- 
comes involved  micturition  is  frequent,  and  many  instances  are  mistaken 
for  cystitis.  The  frequent  micturition  is  in  part  due  to  an  initial  polyuria, 
in  part  to  reflex  irritation,  but  chiefly  to  a  non-tuberculous  inflammation 
over  the  trigone  of  the  bladder.  It  is  usually  the  earliest  and  most  constant 
symptom.  Haematuria,  of  a  mild  grade,  occurs  at  some  time  during  the  course 
of  the  disease  in  the  majority  of  the  cases.  Dull,  aching  pain  in  the  lumbar 
region  on  one  side  is  frequently  complained  of  and  may  be  the  first  symptom. 
The  condition  is  for  many  years  compatible  with  fair  health.     The  curability 


TUBERCULOSIS.  347 

is  shown  by  the  accidental  discovery  of  the  so-called  scrofulous  kidney,  con- 
verted into  cysts  containing  a  putty-like  substance.  In  cases  in  which  the 
disease  becomes  advanced  and  both  organs  are  affected,  constitutional  symp- 
toms are  more  marked.  There  is  irregular  fever,  with  chills  and  loss  of 
weight  and  strength.  General  tuberculosis  is  common.  In  only  one  of  my 
cases  were  the  lungs  uninvolved.  In  a  case  at  the  Montreal  General  Hos- 
pital a  cyst  perforated  and  caused  fatal  peritonitis. 

Physical  examination  may  detect  special  tenderness  on  one  side,  or  the 
kidney  may  be  palpable  in  front  on  deep  pressure;  but  tuberculous  pyelo- 
nephritis seldom  causes  a  large  tumor.  Occasionally  the  pelvis  becomes 
enormously  distended;  but  this  is  rare  in  comparison  with  its  frequency  in 
calculous  pyelitis.  The  urine  presents  changes  similar  to  those  of  ordinary 
calculous  pyelitis — pus-cells,  epithelium,  and  occasionally  definite  caseous 
masses.  It  is  nearly  always  acid  in  reaction.  Albumin  is,  of  course,  pres- 
ent. Tubercle  bacilli  may  be  demonstrated  by  the  ordinary  methods.  Tube- 
casts  are  not  often  seen. 

To  distinguish  the  condition  from  calculous  pyelitis  is  often  difficult. 
Haemorrhage  may  be  present  in  both,  though  not  nearly  so  frequently  in  the 
tuberculous  disease.  Functional  hsematuria,  to  which  Senator  has  given  the 
name  essential  renal  liwmaturia,  and  Klemperer  that  of  angio-neurotic  renal 
Ticematuria  has  been  a  source  of  error  in  diagnosis  and  has  led  to  surgical 
interference.  In  this  condition  it  is  highly  probable  that  bleeding  from  the 
kidney  can  occur  in  the  absence  of  any  definite  lesion  of  the  organ,  although 
Israel  denies  the  existence  of  such  an  anomaly.  Methylene  blue  and  phlorid- 
zin,  given  subcutaneously,  are  held  to  be  of  value  in  determining  the  kidney 
affected.  The  diagnosis  rests  on  three  points:  (1)  The  detection  of  some 
focus  of  tuberculosis,  as  in  the  testes;  (2)  the  presence  of  tubercle  bacilli  in 
the  sediment;  and  (3)  the  use  of  tuberculin.  In  woman  the  kidney  involved 
is  now  easily  determined  by  catheterizing  the  ureters  after  the  plan  of  my 
colleague  Kelly. 

The  incidence  of  renal  implication  in  uro-genital  tuberculosis  may  be 
gathered  from  Orth's  Gottingen  material,  analyzed  by  Oppenheim.  Of  60 
cases  there  were  34  in  which  the  kidneys  were  involved.  Posner  in  149  eases 
found  the  bladder  involved  in  18,  and  the  testes  in  8. 

Tuberculosis  of  the  suprarenal  capsules  will  be  considered  under  Addison's 
Disease. 

Tuberculosis  of  the  Ureter  and  Bladder. — This  rarely  occurs  as 
a  primary  affection,  but  is  nearly  always  secondary  to  involvement  of  other 
parts,  particularly  the  pelvis  of  the  kidney.  In  the  case  of  uro-genital  tuber- 
culosis, above  mentioned,  in  a  patient  who  died  of  heart-disease,  the  ureter, 
just  where  it  enters  the  bladder,  showed  a  fresh  patch  of  tuberculosis. 

Protracted  cystitis,  which  has  come  on  without  apparent  cause,  is  always 
suggestive  of  tuberculosis.  The  renal  regions,  the  testes,  and  the  prostate 
should  be  examined  with  care.  It  may  follow  a  pyelo-nephritis,  or  be  asso- 
ciated with  primary  disease  of  the  prostate  or  vesiculse  seminales.  Primary 
tuberculosis  of  the  posterior  wall  of  the  bladder  may  simulate  stone. 

Tuberculosis  of  the  Prostate  and  Yesicul^  Seminales. — The 
prostate  is  frequently  involved  in  tuberculosis  of  the  uro-genital  tract.  In 
Krzyincki's  cases,  of  15  males  the  prostate  was  inyolved  in  14  and  the  vesiculse 


348  SPECIFIC  INFECTIOUS  DISEASES. 

scmiiiales  in  11.  In  Orth's  cases  the  prostate  was  involved  in  18  of  the  37 
cases  in  males.  These  parts  are  much  more  frequently  involved  than  ordinary 
post-mortem  statistics  indicate.  Per  rectum  the  prostatic  lobes  are  felt  to 
he  occupied  by  hard  nodules  varying  in  size  from  a  pea  to  a  bean.  There  is 
great  irritability  of  the  bladder,  and  agonizing  pain  in  catheterization.  An 
extremely  rare  lesion  is  primary  urethral  tuberculosis,  which  may  simulate 
stricture. 

Tuberculosis  op  the  Testes. — This  somewhat  common  affection  may 
be  primary,  or,  more  frequently,  is  secondary  to  tuberculous  disease  else- 
where. Many  cases  occur  before  the  second  year,  and  it  is  stated  to  have 
been  met  with  in  the  foetus.  In  infants  it  is  serious  and  usually  associated 
with  tuberculous  disease  in  other  parts.  In  9  cases  reported  by  Hutinel  and 
Deschamps,  in  every  one  there  was  a  general  affection.  In  20  cases  reported 
by  Jullien,  6  were  under  one  year,  and  6  between  one  and  two  years  old.  In 
5  of  the  cases  both  testicles  were  affected.  Koplik  holds  that  most  of  the 
instances  of  this 'kind  are  congenital,  in  Baumgarten's  sense.  In  the  adult 
the  tubercles  begin  within  the  substance  of  the  gland,  but  in  children  the 
tunica  albuginea  is  first  affected.  The  tubercle  does  not  always  undergo 
caseation,  but  it  may  present  a  number  of  embryonic  cells,  not  unlike  a 
sarcoma. 

Tubercle  of  the  testes  is  most  likely  to  be  confounded  with  syphilis.  In 
the  latter  the  body  of  the  organ  is  most  often  affected,  there  is  less  pain,  and 
the  outlines  of  the  growth  are  more  nodular  and  irregular.  In  obscure  peri- 
toneal disease  the  detection  of  tubercle  in  a  testis  has  not  infrequently  led 
to  a  correct  diagnosis.  The  association  of  the  two  conditions  is  not  uncom- 
mon. The  lesion  in  the  testis  may  heal  completely,  or  the  disease  may  become 
generalized.  General  infection  has  followed  operation.  Too  much  stress  can 
not  be  laid  on  the  importance  of  a  routine  examination  of  the  testes  in  hos- 
pital patients. 

Tuberculosis  of  the  Fallopian  Tubes,  Ovaries,  and  Uterus. — The 
Fallopian  iuhes  are  by  far  the  most  frequent  seat  of  genital  tuberculosis. 
The  disease  may  be  primary  and  produce  a  most  characteristic  form  of  sal- 
pingitis, in  which  the  tubes  are  enlarged,  the  walls  thickened  and  infiltrated, 
and  the  contents  cheesy.  Adhesion  takes  place  between  the  fimbrise  and  the 
ovaries,  or  the  uterus  may  be  invaded.  The  condition  is  usually  bilateral. 
It  may  occur  in  young  children.  Although,  as  a  rule,  very  evident  to  the 
naked  eye,  there  are  specimens  resembling  ordinary  salpingitis,  which  show 
on  microscopical  examination  numerous  miliary  tubercles  (Welch  and  Wil- 
liams). Tuberculous  salpingitis  may  cause  serious  local  disease  with  abscess 
formation,  and  it  may  be  the  starting-point  of  peritonitis. 

Tuberculosis  of  the  ovary  is  always  secondary.  There  may  be  an  erup- 
tion of  tubercles  over  the  surface  in  an  extensive  involvement  of  the  stroma 
with  abscess  formation. 

Tuberculosis  of  the  uterus  is  very  rare.  Only  three  examples  have  come 
under  my  observation,  all  in  connection  with  pulmonary  phthisis.  It  may 
be  primary.  The  mucosa  of  the  fundus  is  thickened  and  caseous,  and  tuber- 
cles may  be  seen  in  the  muscular  tissue.  Occasionally  the  process  extends 
to  the  vagina. 

Tuberculosis  of  the  placenta  is  more  common  than  has  been  supposed. 


TUBERCULOSIS.  349 

Of  30  placentae  from  tuberculous  women,  9  were  affected;  5  of  these  were 
from  cases  of  advanced  disease  of  the  lung.    The  lesions  are  easily  overlooked. 

IX.  Tuberculosis  op  the  Mammary  Gland. 

Mandry  (Bruns's  Beitrage,  viii)  has  collected  40  cases,  1  of  which  was 
in  a  male.  The  disease  is  most  common  between  the  fortieth  and  sixtieth 
years.  The  breast  is  frequently  fistulous,  unevenly  indurated,  and  the  nipple 
is  retracted.  The  fistulse  and  ulcers  present  a  characteristic  tuberculous 
aspect.  There  is  also  a  cold  tuberculous  abscess  of  the  breast.  The  axillary 
glands  are  affected  in  about  two-thirds  of  the  cases.  The  disease  runs  a 
chronic  course  of  months  or  years.  The  diagnosis  can  be  made  by  the  general 
appearance  of  the  fistulse  and  ulcers,  and  by  the  existence  of  tubercle  bacilli. 
The  prognosis  is  not  bad,  if  total  eradication  of  the  disease  be  possible. 

In  1836  Bedor'  described  an  hypertrophy  of  the  breast  in  the  subjects 
of  pulmonary  tuberculosis.  As  a  rule,  if  one  gland  is  involved,  usually  on 
the  side  of  the  affected  lung,  as  already  mentioned,  the  condition  is  one  of 
chronic  interstitial  mammitis,  and  is  not  tuberculous. 

X.  Tuberculosis  op  the  Circulatory  System. 

(a)  Myocardium. — -Scattered  miliary  tubercles  are  sometimes  met  with 
in  the  acute  disease.  Larger  caseous  tubercles  are  excessively  rare.  A.  Moser 
states  that  there  are  only  46  cases  on  record.  There  is  also  a  sclerotic  tuber- 
culous myocarditis.     The  infection  often  passes  from  a  mediastinal  gland. 

(&)  Endocardium. — In  216  autopsies  in  cases  of  chronic  phthisis  I  found 
endocarditis  in  12.  It  was  present  in  only  151  among  more  than  11,000 
autopsies  on  tuberculous  cases  (G.  W.  ISTorris).  As  a  rule,  it  is  a  secondary 
form,  the  result  of  a  mixed  infection,  so  common  in  pulmonary  tuberculosis. 
A  true  tuberculous  endocarditis  does,  hoAvever,  occur,  directly  dependent  upon 
infection  with  the  bacillus  of  Koch.  As  a  rule,  it  is  a  vegetative  endocardi- 
tis, not  to  be  distinguished  from  that  caused  by  Streptococcus  or  Staphylo- 
coccus.    In  rare  cases,  however,  caseous  tubercles  develop. 

(c)  Arteries. — Primary  tuberculosis  of  the  larger  blood-vessels  is  very 
rare,  and  is  usually  the  result  of  invasion  from  without.  The  disease  may, 
however,  occur  in  a  large  artery  and  not  result  from  external  invasion.  In 
a  case  of  chronic  tuberculosis  Plexner  found  a  fresh  tuberculous  growth  in 
the  aorta,  which  had  no  connection  with  cheesy  masses  outside  the  vessel. 
Simmitsky  has  collected  18  cases  of  tuberculosis  of  the  aorta. 

In  the  lungs  and  other  organs  attacked  by  tuberculosis  the  arteries  are 
involved  in  an  acute  infiltration  which  usually  leads  to  thrombosis,  or  tuber- 
cles may  develop  in  the  walls  and  proceed  to  caseation  and  softening  fre- 
quently with  a  resulting  haemorrhage.  By  extension  into  vessels,  particu- 
larly veins,  the  bacilli  are  widely  distributed  with  the  production  of  miliary 
tuberculosis. 

XL  Diagnosis  op  Tuberculosis. 

The  recognition  of  the  disease  rests  upon  the  macroscopical  and  micro- 
scopical appearances  of  the  lesions  and  the  presence  of  the  tubercle  bacilli. 


350  SPECIFIC  INFECTIOUS  DISEASES. 

Tuberculin  Beadion. —  (a)  Hypodermic. — In  obscure  internal  lesions,  in 
joint  eases,  and  in  suspected  tuberculosis  of  the  kidneys  this  gives  most  valu- 
able information.  In  adults  a  milligramme  is  injected  subcutaneously,  and 
if  this  has  no  reaction  a  larger  dose  of  two  or  three  milligrammes  is  employed 
in  two  or  three  days.  There  is  often  slight  local  irritation  following  injection, 
and  within  ten  to  twelve  hours  the  febrile  reaction  begins,  the  temperature 
rising  from  103°  to  104°.  (&)  Conjunctival  Reaction. — Calmette's  test  gives 
very  satisfactory  results — of  2,894  clinically  tuberculous  patients,  92.05  per 
cent  reacted.  A  drop  of  ^-1  per  cent  solution  of  tuberculin  is  put  into  the 
conjunctiva,  which  in  infected  individuals  reacts  with  a  hyperemia,  (c)  A 
skin  reaction  also  follows  vaccination  with  tuberculin,  but  this  is  not  so  cer- 
tain as  the  conjunctival  reaction.  Hamman's  paper  on  tuberculin  in  pul- 
monary tuberculosis  (Arch,  of  Int.  Med.,  1908),  gives  the  Johns  Hopkins 
Hospital  experience.  Influenced  by  Trudeau,  it  has  been  used  there  fifteen 
or  sixteen  years  in  obscure  medical  and  surgical  cases  with  most  satisfactory 
results. 

XII.  The  Peognosis  in  Tuberculosis, 

The  parable  of  the  sower  already  referred  to  expresses  better  than  in  any 
other  way  the  question  of  individual  predisposition.  In  a  large  propor- 
tion of  us  the  seed  falls  by  the  wayside.  The  bacilli  are  picked  up  by  the 
phagocytes  in  the  air-passages,  and  never  really  enter  the  body.  In  others 
the  seed  falling  upon  a  rock  or  on  stony  ground  withers  away  as  soon 
as  it  springs  up;  and  such  are  the  cases  in  which  the  bacilli  gain  entrance 
to  the  bronchial  glands  and  form  small  foci  which  rapidly  heal.  The  seed 
which  falls  among  thorns  represents  the  germs  which  gain  entrance  to  the 
lungs  and  which  grow  and  cause  the  characteristic  lesions,  but  the  natural 
protective  processes  limit  and  control  it,  and  the  patient  is  cured.  In  the 
last  group,  in  which  the  seed  falls  on  good  ground  and  springs  up  and  bears 
fruit  a  hundredfold,  are  the  cases  in  which  the  disease  progresses  and  the 
unfortunate  victim  dies  of  tuberculosis.  The  late  Austin  Flint,  facile  princeps 
among  American  students  of  the  disease,  called  attention  to  its  self-limitation 
and  intrinsic  tendency  to  recovery  in  tuberculosis.  Of  his  670  cases,  44  recov- 
ered, and  in  31  the  disease  was  arrested,  spontaneously  in  23  of  the  first 
group  and  in  15  of  the  second.  This  natural  tendency  to  cure  is  still  more 
strikingly  shown  in  honphatic  and  bone  tuberculosis. 

The  following  may  be  considered  favorable  circumstances  in  the  progno- 
sis of  pulmonary  tuberculosis:  An  early  diagnosis,  a  good  family  history, 
previous  good  health,  a  strong  digestion,  a  suitable  environment,  and  an  insidi- 
ous onset,  without  high  fever,  and  without  extensive  pneumonic  consolidation. 
Cases  beginning  with  pleurisy  seem  to  run  a  more  protracted  and  more  favor- 
able course.  Eepeated  attacks  of  hemoptysis  are  unfavorable.  When  well 
established  the  course  of  tuberculosis  in  any  organ  is  marked  by  intervals  of 
weeks  or  months  in  which  the  fever  lessens,  the  symptoms  subside,  and  there 
is  improvement  in  the  general  health. 

In  pulmonary  cases  the  duration  is  extremely  variable.  Laennec  placed 
the  average  duration  at  two  years,  and  for  the  majority  of  cases  this  is  perhaps 
a  correct  estimate.  Pollock's  large  statistics  of  over  3,500  cases  show  a  mean 
duration  of  the  disease  of  over  two  years  and  a  half.     Williams's  analysis  of 


TUBERCULOSIS.  351 

1,000  cases  in  private  practice  shows  a  much  more  protracted  course,  as  the 
average  duration  was  over  seven  years. 

TuBEECULOSis  AND  Maeriage. — Under  the  subject  of  prognosis  comes  the 
question  of  the  marriage  of  persons  who  have  had  tuberculosis,  or  in  whose 
family  the  disease  prevails.  The  following  brief  statements  may  be  made 
with  reference  to  it : 

(a)  Subjects  with  healed  lymphatic  or  bone  tuberculosis  marry  with  per- 
sonal impunity  and  may  beget  healthy  children.  It  is  undeniable,  however, 
that  in  such  families  scrofula,  caries  of  the  bone,  arthritis,  cerebral  and  pul- 
monary tuberculosis  are  more  common.  Which  is  it,  "  heredite  de  graine  ou 
heredite  de  terrain,"  as  the  French  have  it,  the  seed  or  the  soil,  or  both  ?  We 
can  not  yet  say.     The  risks,  however,  are  such  as  may  properly  be  taken. 

(&)  The  question  of  marriage  of  a  person  who  has  arrested  or  cured  lung 
tuberculosis  is  more  difficult  to  decide.  In  a  male,  the  personal  risk  is  not 
so  great;  and  when  the  health  and  strength  are  good,  the  external  environ- 
ment favorable,  and  the  family  history  not  extremely  bad  the  experiment — 
for  it  is  such — is  often  successful,  and  many  healthy  and  happy  families  are 
begotten  under  these  circumstances.  In  women  the  question  is  complicated 
with  that  of  child-bearing,  which  increases  the  risks  enormously.  With  a 
localized  lesion,  absence  of  hereditary  taint,  good  physique,  and  favorable 
environment,  marriage  might  be  permitted.  When  tuberculosis  has  existed, 
however,  in  a  girl  whose  family  history  is  bad,  whose  chest  expansion  is  slight, 
and  whose  physique  is  below  the  standard,  the  physician  should,  if  possible, 
place  his  veto  upon  marriage. 

(c)  With  existing  disease,  fever,  bacilli,  etc.,  marriage  should  be  prohib- 
ited. Pregnancy  usually  hastens  the  process,  though  it  may  be  held  in  abey- 
ance. After  parturition  the  disease  advances  rapidly.  There  is  much  truth, 
indeed,  in  the  remark  of  Dubois :  "If  a  woman  threatened  with  phthisis 
marries,  she  may  bear  the  first  accouchement  well;  a  second,  with  difficulty; 
a  third,  never."     Conception  may  occur  in  an  advanced  stage  of  the  disease. 

XIII.  Prophylaxis  in  Tuberculosis. 

(a)  General. — Among  the  more  important  measures  may  be  mentioned 
the  following:  First,  education  of  the  public.  Much  has  been  done  in  this 
direction  by  the  antituberculosis  crusade,  which  has  resulted  in  the  forma- 
tion of  many  active  societies,  and  has  stimulated  widespread  interest  in  the 
disease.  Secondly,  the  placing  of  pulmonary  tuberculosis  on  the  list  of  re- 
portable diseases.  This  gives  the  board  of  health  control  of  the  situation, 
and,  as  the  New  York  experience  has  demonstrated,  is  perhaps  the  most 
helpful  measure  in  the  prophylaxis.  Thirdly,  the  improved  sanitary  condition 
of  the  poor,  particularly  with  reference  to  the  housing.  Fourthly,  direct  pre- 
ventive measures,  such  as  the  enactment  of  laws  against  spitting  in  public, 
the  proper  disinfection  and  cleaning  of  the  rooms  and  houses  which  have  been 
occupied  by  tuberculous  patients,  and  the  careful  inspection  of  dairies  and 
abattoirs.  Fifthly,  in  the  large  cities,  organization  of  sanatoria  and  hospitals 
for  early  curable  and  late  incurable  cases,  and  the  establishment  of  separate 
dispensaries  with  a  system  of  visiting  of  the  patients  at  their  homes  by  specially 
assigned  nurses.    Lastly,  the  care  of  the  sputa  of  the  consumptive.    Thorough 


352  SPECIFIC  INFECTIOUS  DISEASES. 

boiling  or  putting  it  into  the  fire  is  sufficient.  In  hospitals  it  is  well  to  have 
printed  directions  as  to  the  care  of  the  sputa,  and  also  printed  cards  for  out- 
patients, giving  the  most  important  rules.  It  should  be  explained  to  the 
patient  that  the  only  risk,  practically,  is  from  this  source. 

(h)  Individual. — Individual  prophylaxis  in  the  case  of  delicate  children 
is  most  important.  An  infant  born  of  tuberculous  parents,  or  of  a  family 
in  which  consumption  prevails,  should  be  brought  up  with  the  greatest  care 
and  guarded  most  particularly  against  catarrhal  affections  of  all  kinds. 
Special  attention  should  be  given  to  the  throat  and  nose,  and  on  the  first 
indication  of  mouth-breathing,  or  any  obstruction  of  the  naso-pharynx,  a 
careful  examination  should  be  made  for  adenoid  vegetations.  The  child 
should  be  clad  in  flannel  and  live  in  the  open  air  as  much  as  possible,  avoid- 
ing close  rooms.  It  is  a  good  practice  to  sponge  the  throat  and  chest  night 
and  morning  with  cold  water.  Special  attention  should  be  paid  to  diet  and 
to  the  mode  of  feeding.  The  meals  should  be  at  regular  hours  and  the  food 
plain  and  substantial.  From  the  outset  the  child  should  be  encouraged  to 
drink  freely  of  milk.  Unfortunately,  in  these  cases  there  seems  to  be  an 
uncontrollable  aversion  to  fats  of  all  kinds.  As  the  child  grows  older,  sys- 
tematically regulated  exercise  or  a  course  of  pulmonary  gymnastics  may  be 
taken.  In  the  choice  of  an  occupation  preference  should  be  given  to  an  out-of- 
door  life.  Families  with  a  marked  predisposition  to  tuberculosis  should,  if 
possible,  reside  in  an  equable  climate. 

The  trifling  ailments  of  children  should  be  carefully  watched.  In  the 
convalescence  from  the  fevers  which  so  frequently  prove  dangerous,  the  great- 
est caution  should  be  exercised  to  prevent  catching  cold.  Cod-liver  oil,  the 
syrup  of  the  iodide  of  iron,  and  arsenic  may  be  given.  As  mentioned,  care 
of  the  throat  in  these  children  is  very  important.  Enlarged  tonsils  should 
be  removed. 

XIY.  Treatment  of  Tubeeculosis. 

I.  The  Natural  or  Spontaneous  Cure. — The  spontaneous  healing  of 
local  tuberculosis  is  an  every-day  affair.  Many  cases  of  adenitis  and  dis- 
ease of  the  bone  or  of  the  joints  terminate  favorably.  The  healing  of  pul- 
monary tuberculosis  is  shown  clinically  by  the  recovery  of  patients  in  whose 
sputa  elastic  tissue  and  bacilli  have  been  found;  anatomically,  by  the  pres- 
ence of  lesions  in  all  stages  of  repair.  In  the  granulation  products  and  asso- 
ciated pneumonia  a  scar-tissue  is  formed,  while  the  smaller  caseous  areas 
become  impregnated  with  lime  salts.  To  such  conditions  alone  should  the 
term  healing  be  applied.  When  the  fibroid  change  encapsulates  but  does 
not  involve  the  entire  tuberculous  tissue,  the  tubercle  may  be  termed  involuted 
or  quiescent,  but  is  not  destroyed.  When  cavities  of  any  size  have  formed, 
healing,  in  the  proper  sense  of  the  term,  does  not  occur.  I  have  yet  to  see 
a  specimen  which  would  indicate  that  a  vomica  had  cicatrized.  Cavities  may 
be  greatly  reduced  in  size — indeed,  an  entire  series  of  them  may  be  so  con- 
tracted by  sclerosis  of  the  tissue  about  them  that  an  upper  lobe,  in  which  this 
process  most  frequently  occurs,  may  be  reduced  to  a  third  of  its  ordinary 
dimensions.  Laennec  understood  thoroughly  this  natural  process  of  cure  in 
tuberculosis,  and  recognized  the  frequency  with  which  old  tuberculous  lesions 
occurred   in   the  lungs.      He   described   cicatrices   completes   and   cicatrices 


TUBERCULOSIS.  353 

fistuleuses,  the  latter  being  the  shrunken  cavities  communicating  with  the 
bronchi;  and  remarked  that,  as  tubercles  growing  in  the  glands,  which  are 
called  scrofula,  often  heal,  why  should  not  the  same  take  place  in  the  lungs  ? 

There  is  an  old  German  axiom,  "  Jedermann  hat  am  Ende  ein  hisclien 
Tuherculose,"  a  statement  partly  borne  out  by  the  statistics  showing  the  pro- 
portions of  cases  in  persons  dying  of  all  disease  in  whom  quiescent  or  tuber- 
culous lesions  are  found  in  the  lungs.  We  find  at  the  apices  the  following 
conditions,  which  have  been  held  to  signify  healed  tuberculous  processes: 
(1)  Thickening  of  the  pleura,  usually  at  the  posterior  surface  of  the  apex, 
with  subadjacent  induration  for  a  distance  of  a  few  millimetres.  This  has, 
perhaps,  no  greater  significance  than  the  milky  patch  on  the  pericardium. 
(3)  Puckered  cicatrices  at  the  apex,  depressing  the  pleura,  and  on  section 
showing  a  large  pigmented,  fibrous  scar.  The  bronchioles  in  the  neighborhood 
may  be  dilated,  but  there  are  neither  tubercles  nor  cheesy  masses.  This  may 
sometimes,  but  not  always,  indicate  a  healed  tuberculous  lesion.  (3)  Puck- 
ered cicatrices  with  cheesy  or  cretaceous,  nodules,  and  with  scattered  tubercles 
in  the  vicinity.  (4)  The  cicatrices  fistuleuses  of  Laennec,  in  which  the  fibroid 
puckering  has  reduced  the  size  of  one  or  more  cavities  which  communicate 
directly  with  the  bronchi. 

The  investigations  of  Naegeli  in  Ribbert's  laboratory  show  how  frequent 
tuberculous  infection  is,  and  how  common  recovery  must  be.  A  special  exami- 
nation was  made  of  every  organ  of  the  body.  In  a  series  of  cases  tuberculous 
lesions  were  found  in  97  per  cent  in  the  bodies  of  adults.  Up  to  the  fifteenth 
year  they  were  present  in  only  50  per  cent;  then  there  was  a  sudden  rise  in 
the  eighteenth  year  to  96  per  cent,  and  above  the  fortieth  year  a  tuberculous 
focus  was  found  in  every  body.  In  a  series  of  500  post  mortems  studied  with 
reference  to  this  point  by  Blumer  and  Lartigau,  healed  pulmonary  lesions  were 
found  in  30  per  cent. 

II.  General  Measures. — The  cure  of  tuberculosis  is  a  question  of  nutri- 
tion; digestion  and  assimilation  control  the  situation;  make  a  patient  grow 
fat  and  the  local  disease  may  be  left  to  take  care  of  itself.  There  are  three 
indications:  First,  to  place  the  patient  in  surroundings  most  favorable  for 
the  maintenance  of  a  maximum  degree  of  nutrition;  second,  to  take  such 
measures  as,  in  a  local  or  general  way,  influence  the  tuberculous  processes; 
third,  to  alleviate  symptoms. 

Open-air  Treatment. — The  value  of  fresh  air  and  out-of-door  life  is  well 
illustrated  by  an  experiment  of  Trudeau.  Inoculated  rabbits  confined  in  a 
dark,  damp  place  rapidly  succumbed,  while  others,  allowed  to  run  wild,  either 
recovered  or  show  slight  lesions.  It  is  the  same  in  human  tuberculosis.  A 
patient  confined  to  the  house — particularly  in  the  close,  overheated,  stuffy 
dwellings  of  the  poor,  or  treated  in  a  hospital  ward — is  in  a  position  analogous 
to  that  of  the  rabbit  confined  to  a  hutch  in  the  cellar ;  whereas  a  patient  living 
in  the  fresh  air  and  sunshine  for  the  greater  part  of  the  day  has  chances 
comparable  to  those  of  the  rabbit  running  wild. 

The  open-air  treatment  of  tuberculosis  may  be  carried  out  at  home,  by 
change  of  residence  to  a  suitable  climate,  or  in  a  sanatorium. 

(a)  At  Home. — In  a  majority  of  all  cases  the  patient  has  to  be  cared  for 
in  his  own  home,  and  if  in  the  city,  under  very  disadvantageous  circum- 
stances. Much,  however,  mav  be  done  even  in  cities  to  promote  arrest  by 
24 


354  SPECIFIC  INFECTIOUS  DISEASES. 

insisting  upon  systematic  treatment.  How  much  may  be  done  by  care  and 
instruction  is  shown  by  the  success  of  J.  H.  Pratt's  tuherculosis  classes.  As 
not  five  per  cent  of  the  patients  can  be  dealt  with  in  sanatoria^,  it  is  surpris- 
ing and  gratifying  to  see  how  successful  the  home  treatment  may  be.  Even 
in  cities  the  patients  may  be  trained  to  sleep  out  of  doors,  and  the  results 
obtained  by  Pratt,  Millett,  and  others  are  as  good  as  any  that  have  been  pub- 
lished. While  there  is  fever  the  patient  should  he  at  rest  in  bed,  and  for  the 
greater  part  of  each  day,  unless  the  weather  is  blustering  and  rainy,  the 
windows  should  be  open,  so  that  he  may  be  exposed  freely  to  the  fresh  air. 
Low  temperature  is  not  a  contraindication.  If  there  is  a  balcony  or  a  suit- 
able yard,  on  the  brighter  days  the  patient  may  be  wrapped  up  and  put  in  a 
reclining  chair  or  on  a  sofa.  The  important  thing  is  for  the  physician  to 
emphasize  the  fact  that  neither  the  cough,  fever,  night  sweats,  and  not  even 
haemoptysis  contraindicate  a  full  exposure  to  the  fresh  air.  In  country  places 
this  can  be  carried  out  much  more  effectively.  In  the  summer  the  patient 
should  be  out  of  doors  for  at  least  eleven  or  twelve  hours,  and  in  winter  six  or 
eight  hours.  At  night  the  room  should  be  cool  and  thoroughly  well  ventilated. 
It  may  require  several  months  of  this  rest  treatment  in  the  open  air  before  the 
temperature  falls  to  normal. 

(6)  Treatment  in  Sanatoria. — Perhaps  the  most  important  advance  in 
the  treatment  of  tuberculosis  has  been  in  the  establishment  in  favorable  locali- 
ties of  institutions  in  which  patients  are  made  to  live  according  to  strict 
rules.  To  Brehmer,  of  Gobersdorf,  we  owe  the  successful  execution  of'  this 
plan,  which  has  been  followed  in  Germany  with  most  gratifying  results.  In 
the  United  States  the  zeal,  energy,  and  scientific  devotion  of  Edward  L. 
Trudeau  have  demonstrated  its  feasibility,  and  the  Saranac  institution  has 
become  a  model  of  its  kind.  The  results  at  Gobersdorf,  Palkenstein,  and 
Saranac  demonstrate  the  great  importance  of  system  and  rigid  discipline  in 
carrying  out  a  successful  treatment  of  tuberculosis.  Much  has  been  done 
both  in  the  United  States  and  Great  Britain  to  promote  the  sanatorium  treat- 
ment of  tuberculosis.  The  past  three  years  have  been  rich  in  experience.  The 
good  results  have  quite  justified  the  heavy  expenditure  of  money.  In  many 
places  it  has  been  demonstrated  that  with  an  inexpensive  plant  excellent 
results  may  be  obtained.  A  reaction  has  naturally  followed  the  "  stuffing  " 
plan  of  feeding,  and  more  reasonable  methods  are  now  employed.  The  "  abso- 
lute rest "  plan  has  been  modified  to  meet  individual  cases.  The  system  of 
graduated  work  introduced  by  Patersin  at  Erimley  has  shown  how  beneficial 
hard  work  is  for  the  physical  and  moral  condition  of  the  consumptive.  The 
all-important  matter  is  the  establishment  near  to  the  large  cities  of  public 
sanatoria  for  the  treatment  of  cases  in  the  early  stages.  There  should  be 
opened  in  the  large  general  hospitals  special  out-patient  departments  for 
tuberculous  patients,  from  which  suitable  cases  could  be  sent  to  the  civic  sana- 
toria. They  could  be  partly  self-supporting,  as  many  patients  would  pay  a 
reasonable  sum  per  month.  A  useful  Directory  of  Institutions  for  Tubercu- 
losis in  the  United  States  and  Canada  has  been  compiled  by  Lilian  Brandt, 
and  published  by  the  charity  organization  of  New  York  and  the  N'ational 
Association  for  the  Study  of  Tuberculosis.  Bulstr ode's  Eeport  (Local  Govern- 
ment Board,  1908)  gives  full  details  as  to  institutions  in  England. 

(c)   Climatic  Treatment.— This,  after  all,  is  only  a  modification  of  the 


TUBERCULOSIS.  355 

open-air  method.  The  first  question  to  be  decided  is  whether  the  patient  is 
fit  to  be  sent  from  home.  In  many  instances  it  is  a  positive  liardship.  A 
patient  with  well-marked  cavities,  hectic  fever,  night  sweats,  and  emacia- 
tion is  much  better  at  home,  and  the  physician  should  not  be  too  much  influ- 
enced by  the  importunities  of  the  sick  man  or  his  friends.  The  requirements 
of  a  suitable  climate  are  a  pure  atmosphere,  an  equable  temperature  not  sub- 
ject to  rapid  variations,  and  a  maximum  amount  of  sunshine.  Given  these 
three  factors,  it  makes  little  difference  where  a  patient  goes,  so  long,  as  he 
lives  an  outdoor  life.  Major  Woodruff  believes  that  sunshine  may  be  hurtful, 
and  he  has  collected  statistics  to  show  that  tuberculosis  is  more  prevalent  and 
more  fatal  among  the  dark  races,  who  live  where  the  sun  shines  the  brightest. 
The  point  is  one  of  interest,  but  I  do  not  think  the  case  against  the  sun  is 
made  out.  The  different  climates  may  be  grouped  into  the  high  altitudes, 
the  dry,  warm  climates,  and  the  moist,  warm  climates.  Among  high  alti- 
tudes in  the  United  States,  the  Colorado  resorts  are  the  most  important.  Of 
others,  those  in  Arizona  and  New  Mexico  have  been  growing  rapidly.  The 
rarefaction  of  the  air  in  high  altitudes  is  of  benefit  in  increasing  the  respira- 
tory movements  in  pulmonary  disease,  but  brings  about  in  time  a  condition  of 
dilatation  of  the  air-vesicles  and  a  permanent  increase  in  the  size  of  the  chest 
which  is  a  marked  disadvantage  when  such  persons  attempt  subsequently  to 
reside  at  the  sea-level.  The  great  advantage  of  these  western  resorts  is  that 
they  are  in  progressive,  prosperous  countries,  in  which  a  man  may  find  means 
of  livelihood  and  live  in  comfort.  In  Europe  the  chief  resorts  at  high  alti- 
tudes are  Davos,  Les  Avants,  and  St.  Moritz.  Of  resorts  at  a  moderate 
altitude,  Asheville  and  the  Adirondacks  are  the  best  known  in  America.  The 
Adirondack  cure  has  become  of  late  years  quite  famous.  One  very  decided 
advantage  is  that  after  arrest  of  the  disease  the  patient  can  return  to  the  sea- 
level  without  any  special  risk.  The  cases  most  suitable  for  high  altitudes  are 
those  in  which  the  disease  is  limited,  without  much  cavity  formation,  and  with- 
out much  emaciation.  The  thin,  irritable  patients  with  chronic  tuberculosis 
and  a  good  deal  of  emphysema  are  better  at  the  sea-level.  The  cold  winter 
climate  seems  to  be  of  decided  advantage  in  tuberculosis,  and  in  the  Adiron- 
dacks, where  the  temperature  falls  sometimes  to  30°  or  even  more  below  zero, 
the  patients  are  able  to  lead  an  out-of-door  life  throughout  the  entire  winter. 

Of  the  moist,  warm  climates,  in  America  Florida  and  the  Bermudas, 
in  Europe  the  Madeira  Islands,  and  in  Great  Britain  Eastbourne,  Bourne- 
mouth, Torquay,  and  Falmouth  are  the  best  known.  Of  the  dry,  warm  cli- 
mates, Southern  California  in  the  United  States  is  the  most  satisfactory. 
Many  of  the  health  resorts  in  the  Southern  States,  such  as  Aiken,  Thomas- 
ville,  and  Summerville,  are  delightful  winter  climates  for  tuberculous  cases. 
Egypt,  Algiers,  and  the  Eiviera  are  the  most  satisfactory  resorts  for  patients 
from  Europe.  For  additional  information  on  the  subject  of  climate,  particu- 
larly in  America,  the  reader  is  referred  to  Solly's  work  on  the  subject. 

Other  considerations  which  should  influence  the  choice  of  a  locality  are 
good  accommodations  and  good  food.  Very  much  is  said  concerning  the 
choice  of  locality  in  the  different  stages  of  pulmonary  tuberculosis,  but  when 
the  disease  is  limited  to  an  apex,  in  a  man  of  fairly  good  personal  and  family 
history,  the  chances  are  that  he  may  fight  a  winning  battle  if  he  lives  out  of 
doors  in  any  climate,  whether  high,  dry  and  cold,  or  low,  moist  and  warm. 


356  SPECIFIC  INFECTIOUS  DISEASES. 

With  bilateral  disease  and  cavity  formation  there  is  but  little  hope  of  perma- 
nent cure,  and  the  mild  or  warm  climates  are  preferable. 

III.  Measures  which,  by  their  Local  or  General  Action,  influence 
THE  Tuberculous  Process. — Under  this  heading  we  may  consider  the 
specific,  the  dietetic,  and  the  general  medicinal  treatment  of  tuberculosis. 

(a)  Specific  Treatment. — The  use  of  tuberciilin  has  again  become  popu- 
lar, and  the  publications  of  Koch,  von  Behring,  Maragliano,  and  Wright  have 
shown  that  in  certain  cases  it  had  a  definite  value.  This  has  been  the  posi- 
tion taken  by  Trudeau  even  after  the  fiasco  attending  its  introduction,  and  at 
the  Saranac  Sanatorium  a  certain  number  of  cases  were  given  tuberculin  in 
addition  to  the  regular  treatment.  L.  Brown  has  reported  on  159  of  these 
cases,  43  of  which  were  in  the  incipient  stage.  In  104  advanced  cases,  30  were 
discharged  apparently  cured  and  56  with  the  disease  arrested.  Of  the  43 
early  cases,  30  were  discharged  apparently  well  and  9  with  the  disease  arrested. 
The  method  of  Wright  and  Douglas  has  been  extensively  tested  during  the  past 
three  years,  and  it  is  difficult  yet  to  arrive  at  positive  conclusions.  The  inde- 
pendent work  in  England  and  in  America  appears  to  be  against  the  opsonic 
index  as  a  trustworthy  guide;  on  the  other  hand,  in  suitable  cases,  particu- 
larly of  local  tuberculosis,  the  vaccine  treatment  has  proved  of  great  value. 

(&)  Dietetic  Treatment. — The  outlook  in  tuberculosis  depends  much 
upon  the  digestion.  It  is  rare  to  see  recovery  in  a  case  in  which  there  is 
persistent  gastric  trouble,  and  the  physician  should  ever  bear  in  mind  the 
fact  that  in  this  disease  the  primcB  vice  control  the  position.  The  early  nausea 
and  loss  of  appetite  in  many  cases  are  serious  obstacles.  Many  patients  loathe 
food  of  all  kinds.  A  change  of  air  or  a  sea  voyage  may  promptly  restore  the 
appetite.  When  either  of  these  is  impossible,  and  if,  as  is  almost  always  the 
case,  fever  is  present,  the  patient  should  be  placed  at  rest,  kept  in  the  open 
air  nearly  all  day,  and  fed  at  stated  intervals  with  small  quantities  either  of 
milk,  buttermilk,  or  koumyss,  alternating  if  necessary  with  meat  juice  and 
egg  albumin.  Some  cases  which  are  disturbed  by  eggs  and  milk  do  well  on 
koumyss.  It  may  be  necessary  to  resort  to  Debove's  method  of  over-alimenta- 
tion or  forced  feeding.  The  stomach  is  first  washed  out  with  cold  water,  and 
then,  through  the  tube,  a  mixture  is  given  containing  a  litre  of  milk,  an  egg, 
and  100  grammes  of  very  finely  powdered  meat.  This  is  given  three  times  a 
day.  Sometimes  the  patients  will  take  this  mixture  without  the  unpleasant 
necessity  of  the  stomach-tube,  in  which  case  a  smaller  amount  may  be  given. 
Eaw  eggs  are  very  suitable  for  the  purpose  of  over-feeding,  and  may  be  taken 
in  the  intervals  between  the  meals.  Beginning  with  one  three  times  a  day  the 
number  may  be  increased  to  two,  three,  or  even  four  at  a  time.  In  the  Ger- 
man sanatoria  a  very  special  feature  is  this  over-feeding,  even  when  fever  is 
present.  E.  W.  Philip  advises  a  raw  meat  diet — zomotherapy — ^lialf  a  pound 
three  times  a  day,  either  minced  or  as  a  soup. 

In  many  cases  the  digestion  is  not  at  all  disturbed  and  the  patient  can 
take  an  ordinary  diet.  It  is  remarkable  how  rapidly  the  appetite  and  diges- 
tion improve  on  the  fresh-air  treatment,  even  in  cases  which  have  to  remain 
in  the  city.  Care  should  be  taken  that  the  medicines  do  not  disturb  the  stom- 
ach. Not  infrequently  the  sweet  syrups  used  in  the  cough  mixtures,  cod-liver 
oil,  creasote,  and  the  hypophosphites  produce  irritation,  and  by  interfering 
with  digestion  do  more  harm  than  good.    On  the  other  hand,  the  bitter  tonics. 


TUBERCULOSIS.  357 

with  acids,  and  the  various  malt  preparations  are  often  in  these  cases  most 
satisfactory.  The  indications  for  alcohol  in  tuberculosis  are  enfeebled  diges- 
tion with  fever,  a  weak  heart,  and  rapid  pulse.  A  routine  administration  is 
not  advisable,  and  there  is  no  evidence  that  its  persistent  use  promotes  fibroid 
processes  in  the  tuberculous  areas.  In  the  advanced,  stages,  particularly  when 
the  temperature  is  low  between  eight  and  ten  in  the  morning,  whisky  and 
milk,  or  whisky,  egg,  and  milk  may  be  given  with  great  advantage.  The  red 
wines  are  also  beneficial  in  moderate  quantities. 

(c)  General  Medical  Treatment. — Ko  medicinal  agents  have  any  special 
or  peculiar  action  upon  tuberculous  processes.  The  influence  which  they 
exert  is  upon  the  general  nutrition,  increasing  the  physiological  resistance, 
and  rendering  the  tissues  less  susceptible  to  invasion.  The  following  are 
the  most  important  remedies  which  seem  to  act  in  this  manner : 

Creasote,  which  may  be  administered  in  capsules,  in  increasing  doses, 
beginning  with  1  minim  three  times  a  day  and,  if  well  borne,  increasing  the 
dose  to  8  or  10  minims.  It  may  also  be  given  in  solution,  with  tincture  of 
cardamoms  and  alcohol.  It  is  an  old  remedy,  strongly  recommended  by 
Addison,  and  the  reports  of  Jaccoud,  Fraentzel,  and  many  others  show  that 
it  has  a  positive  value  in  the  disease.  Guaiacol  may  be  given  as  a  substitute, 
either  internally  or  hypodermieally. 

Cod-liver  Oil. — In  glandular  and  bone  tuberculosis,  this  remedy  is  un- 
doubtedly beneficial  in  improving  the  nutrition.  In  pulmonary  tuberculosis 
its  aj3tion  is  less  certain,  and  it  is  scarcely  worthy  of  the  unbounded  confidence 
which  it  enjoyed  for  so  many  years.  It  should  be  given  in  small  doses,  not 
more  than  a  teaspoonf ul  three  times  a  day  after  meals.  It  seems  to  act  better 
in  children  than  in  adults.  Fever  and  gastric  irritation  are  contraindica- 
tions to  its  use.  When  it  is  not  well  borne,  a  dessertspoonful  of  rich  cream 
three  times  a  day  is  an  excellent  substitute.  The  clotted  or  Devonshire  cream 
is  preferable. 

The  HypopJiospJiites. — These  in  various  forms  are  useful  tonics,  but  it  is 
doubtful  if  they  have  any  other  action.  They  certainly  exercise  no  specific 
influence  upon  tubercle.  They  may  be  given  in  the  form  of  the  syrup  of  the 
hypophosphites  of  calcium,  sodium,  and  potassium  of  the  U.  S.  P. 

Arsenic. — There  is  no  general  tonic  more  satisfactory  in  cases  of  tuber- 
culosis of  all  kinds  than  Fowler's  solution.  It  may  be  given  in  5-minim  doses 
three  times  a  day  and  gradual^  increased;  stopping  its  use  whenever  unpleas- 
ant symptoms  arise,  and  in  any  case  intermitting  it  every  third  or  fourth  week. 

Treatment  by  compressed  air  is  in  many  cases  beneflcial,  and  under  its 
use  the  appetite  improves,  there  is  gain  in  weight,  and  reduction  of  the  fever. 
The  air  may  be  saturated  with  creasote. 

IV.  Teeatment  of  Special  Symptoms  in  Pulmonary  Tubeeculosis. — 
(a)  The  Fever. — There  is  no  more  difficult  problem  in  practical  therapeutics 
than  the  treatment  of  the  pyrexia  of  tuberculosis.  The  patient  should  be 
at  rest,  and  in  the  open  air  night  and  day  for  some  weeTcs.  Fever  does  not 
contraindicate  an  out-of-door  life,  but  it  is  well  for  patients  with  a  tem- 
perature above  100.5°  to  be  at  rest.  For  the  continuous  pyrexia  or  the  remit- 
tent type  of  the  early  stages,  quinine,  small  doses  of  digitalis,  and  the  salicyl- 
ates may  be  tried;  but  they  are  uncertain  and  rarely  reliable.  Under  no 
circumstances  is  that  priceless  remedy,  quinine,  so  much  abused  as  in  the 


358  SPECIFIC  INFECTIOUS  DISEASES. 

fever  of  tuberculosis.  In  large  doses  it  has  a  moderate  antipyretic  ac- 
tion, but  it  is  just  in  these  efficient  doses  that  it  is  so  apt  to  disturb  the 
stomach. 

Antip}Tin  and  antifebrin  may  be  used  cautiously;  but  it  is  better,  vhen 
the  fever  rises  above  103°,  to  rely  upon  cold  sponging  or  the  tepid  bath,  grad- 
ually cooled.  When  softening  has  taken  place  and  the  fever  assumes  the  char- 
acteristic septic  type,  the  problem  becomes  still  more  difficult.  As  shown  by 
Chart  XII  (which  is  not  by  any  means  an  exceptional  one),  the  p^Texia,  at 
this  stage,  lasts  only  for  twelve  or  fifteen  hours.  As  a  rule  there  are  not  more 
than  from  eight  to  ten  hours  in  which  the  fever  is  high  enough  to  demand  anti- 
pjTetic  treatment.  Sometimes  antifebrin,  given  in  2-grain  doses  every  hour 
for  three  or  four  hours  before  the  rise  in  temperature  takes  place,  either  pre- 
vents entirely  or  limits  the  paroxysm.  If  the  temperature  begins  to  rise 
between  two  and  three  in  the  afternoon,  the  antifebrin  may  be  given  at  eleven, 
twelve,  one,  and,  if  necessary,  at  two.  It  answers  better  in  this  way  than  given 
in  the  single  doses.  Careful  sponging  of  the  extremities  for  from  half  an 
hour  to  an  hour  during  the  height  of  the  fever  is  useful.  Quinine  is  of  little 
benefit  in  this  t}-pe  of  fever ;  the  salicylates  are  of  still  less  use. 

(h)  Sweating. — Atropine,  in  doses  of  gr.  jy^-^,  and  the  aromatic  sid- 
phuric  acid  in  large  doses,  are  the  best  remedies.  "When  there  are  cough  and 
nocturnal  restlessness,  an  eighth  of  a  grain  of  morphia  may  be  given  with  the 
atropine.  Muscarin  (Tii  v  of  a  1-per-cent  solution),  tincture  of  nux  vomica 
(TTl  xxx),  picrotoxin  (gr.  -gV)  may  be  tried.  The  patient  shoidd  use  light  flan- 
nel night-dresses,  as  the  cotton  night-shirts,  when  soaked  with  perspiration, 
have  a  very  unpleasant  cold,  clammy  feeling. 

(c)  The  cough  is  a  troublesome,  though  necessary,  feature  in  pulmonary 
tuberculosis.  Unless  very  worrying  and  disturbing  sleep  at  night,  or  so  severe 
as  to  produce  vomiting,  it  is  not  well  to  attempt  to  restrict  it.  When  irrita- 
tive and  bronchial  in  character,  inhalations  are  useful,  particidarly  the  tinc- 
ture of  benzoin  or  preparations  of  tar,  creasote,  or  turpentine.  The  throat 
should  be  carefully  examined,  as  some  of  the  most  irritable  and  distressing 
forms  of  cough  in  phthisis  result  from  larjTigeal  erosions.  The  distressing 
nocturnal  cough,  which  begins  just  as  the  patient  gets  into  bed  and  is  prepar- 
ing to  fall  asleep,  requires,  as  a  rule,  preparations  of  opium.  Codeia,  in 
quarter-  or  half -grain  doses,  or  the  s}Tupus  codeise  (3  j)  may  be  given.  An 
excellent  combination  for  the  nocturnal  cough  of  phthisis  is  morphia  (gr.  J-i), 
dilute  hydrocyanic  acid  (lU  ij-iij),  and  s3Tup  of  wild  cherry  (5  j).  The  spirits 
of  chloroform,  B.  P.,  or  the  mistura  chloroformi,  U.  S.  P.,'  or  Hoffman's  ano- 
d5'ne,  given  in  whisky  before  going  to  sleep,  are  efficacious.  Mild  counter- 
irritation,  or  the  application  of  a  hot  poultice,  will  sometimes  promptly  relieve 
the  cough.  The  morning  cough  is  often  much  relieved  by  taking  Immedi- 
ately after  getting  up  a  glass  of  hot  milk  or  a  cup  of  hot  water,  to  which  15 
grains  of  bicarbonate  of  soda  have  been  added.  In  the  later  stages  of  the  dis- 
ease, when  cavities  have  formed,  the  accumulated  secretion  must  be  expec- 
torated and  the  paroxysms  of  coughing  are  now  most  exhausting.  The  seda- 
tives, such  as  morphia  and  hydrocyanic  acid,  should  be  given  cautiously.  The 
aromatic  spirit  of  ammonia  in  full  doses  helps  to  allay  the  paroxysm."^  When 
the  expectoration  is  profuse,  creasote  internally,  or  inhalations  of  turpentine 
and  iodine,  or  oil  of  eucahT)tus,  are  useful.     For  the  troublesome  dysphagia 


LEPROSY,  359 

a  strong  solution  of  cocaine  (gr.  x)  with  boric  acid  (gr.  v)  in  glycerine  and 
water  (§  j)  may  be  used  locally. 

(d)  For  the  diarrTioRa  large  doses  of  bismuth,  combined  with  Dover's  pow- 
der, and  small  starch  enemata^,  with  or  without  opium,  may  be  given.  The 
acetate  of  lead  and  opium  pill  often  acts  promptly,  and  the  acid  diarrhoea 
mixture,  dilute  acetic  acid  (TIXx-xv),  morphia  (gr.  ^),  and  acetate  of  lead 
(gr,  j-ij),  may  be  tried. 

(e)  The  treatment  of  the  hemoptysis  will  be  considered  in  the  section 
on  haemorrhage  from  the  lungs.  Dyspnoea  is  rarely  a  prominent  symptom 
except  in  the  advanced  stages,  when  it  may  be  very  troublesome  and  distress- 
ing.    Ammonia  and  morphia,  cautiously  administered,  may  be  used. 

If  the  pleuritic  pains  are  severe,  the  side  may  be  strapped,  or  painted  with 
tincture  of  iodine.  The  dyspeptic  symptoms  require  careful  treatment,  as 
the  outlook  in  individual  cases  depends  much  upon  the  condition  of  the  stom- 
ach. Small  doses  of  calomel  and  soda  often  allay  the  distressing  nausea  of 
the  early  stage. 

A  last  word  on  this  siibject  to  the  general  practitioner.  The  battle  against 
this  scourge  is  in  your  hands.  Much  has  been  done,  much  remains  to  do.  By 
early  diagnosis  and  prompt,  systematic  treatment  of  individual  cases,  by  striv- 
ing in  every  possible  way  to  improve  the  social  condition  of  the  poor,  by  join- 
ing actively  in  the  ivorh  of  the  local  and  national  antituberculosis  societies  you 
can  help  in  the  most  important  and  the  most  hopeful  campaign  ever  under- 
taken by  the  profession. 

XXXIV.    LEPROSY. 

Definition. — A  chronic  infectious  disease  caused  by  Bacillus  leprcB,  charac- 
terized by  the  presence  of  tubercular  nodules  in  the  skin  and  mucous  mem- 
branes (tubercular  leprosy)  or  by  changes  in  the  nerves  (anaesthetic  leprosy). 
At  first  these  forms  may  be  separate,  but  ultimately  both  are  combined,  and 
in  the  characteristic  tubercular  form  there  are  disturbances  of  sensation. 

History. — The  disease  appears  to  have  prevailed  in  Egypt  even  so  far  back 
as  three  or  four  thousand  years  before  Christ.  The  Hebrew  writers  make 
many  references  to  it,  but,  as  is  evident  from  the  description  in  Leviticus, 
many  different  forms  of  skin  diseases  were  embraced  under  the  term  leprosy. 
Both  in  India  and  in  China  the  affection  was  also  known  many  centuries  be- 
fore the  Christian  era.  The  old  Greek  and  Eoman  physicians  were  perfectly 
familiar  with  its  manifestations.  Evidence  of  a  pre-Columbian  existence  of 
leprosy  in  America  has  been  sought  in  the  old  pieces  of  Peruvian  pottery 
representing  deformities  suggestive  of  this  disease,  but  Ashmead  denies  their 
significance.  Throughout  the  middle  ages  leprosy  prevailed  extensively  in 
Europe,  and  the  number  of  leper  asylums  has  been  estimated  as  at  least 
20,000.     During  the  sixteenth  century  it  gradually  declined. 

Geographical  Distribution. — In  Europe  leprosy  prevails  in  Iceland,  Nor- 
way and  Sweden,  parts  of  Russia,  particularly  about  Dorpat,  Eiga,  and  the 
Caucasus,  and  in  certain  provinces  of  Spain  and  Portugal.  In  Great  Britain 
the  cases  are  now  all  imported. 

In  the  United  States  there  are  three  important  foci :  Louisiana,  in  which 
the  disease  has  been  known  since  1785,  and  has  of  late  increased.    The  state- 


360  SPECIFIC  INFECTIOUS  DISEASES. 

ment  that  it  was  introduced  by  the  Acadians  does  not  seem  to  me  very  likely, 
since  the  records  of  its  existence  in  Nova  Scotia  and  New  Brunswick  do  not 
date  back  to  that  period.  Dyer  estimates  that  there  are  at  least  524  cases 
in  the  United  States,  a  majority  of  them  in  Louisiana  and  Florida.  In 
Minnesota  with  the  Norwegian  colonists  about  170  lepers  are  known  to  have 
settled.  The  disease  has  steadily  decreased.  Bracken  writes  (November  2, 
1904)  that  there  are  only  10  known  cases  of  leprosy  in  Minnesota  at  present, 
a  gradual  reduction  since  1897,  when  there  were  21;  4  of  these  10  cases  are 
from  Sweden.  One  of  the  cases  is  a  native,  born  of  Norwegian  parents. 
Bracken  says  there  are  at  least  two  native-born  lepers  in  the  State  of  Miime- 
sota.  The  Leprosy  Commission  (1902)  of  the  United  States  collected  records 
of  278  cases,  145  born  in  the  United  States,  120  in  foreign  countries;  186 
probably  contracted  the  disease  in  the  United  States. 

The  few  cases  seen  in  the  large  cities  of  the  Atlantic  coast  are  imported. 

In  the  Dominion  of  Canada  there  are  foci  of  leprosy  in  two  or  three 
coimties  of  New  Brunswick,  settled  by  French  Canadians,  and  in  Cape  Breton, 
Nova  Scotia.  The  disease  appears  to  have  been  imported  from  Norinandy 
about  the  end  of  the  18th  century.  The  number  of  cases  has  gradually  les- 
sened. Dr.  A.  C.  Smith,  the  physician  in  charge  of  the  lazaretto  at  Tracadie, 
New  Brunswick,  reports  under  date  of  October  11,  1904,  that  there  are  14 
lepers  at  present  under  his  care — 9  males  and  5  females,  with  2  outside  soon 
to  be  admitted.  Of  these,  3  are  immigrant  Icelanders  from  Manitoba;  1  is 
a  negro  from  the  West  India  Islands.  Dr.  Smith  states  that  segregation  is 
gradually  stamping  out  the  disease  in  New  Brunswick.  The  cases  have  dwin- 
dled from  about  40  to  half  that  number.  In  Cape  Breton  it  has  almost  dis- 
appeared. A  few  cases  are  met  with  among  the  Icelandic  settlers  in  Mani- 
toba, and  with  the  Chinese  the  affection  has  been  introduced  into  British 
Columbia.  In  the  various  provinces  of  the  Philippine  Islands  there  were 
reported  in  October,  1904,  3,803  lepers. 

Leprosy  is  endemic  in  the  West  India  Islands.  It  also  occurs  in  Mexico 
and  throughout  the  Southern  States.  In  the  Sandwich  Islands  it  spread  rap- 
idly after  1860,  and  strenuous  attempts  have  been  made  to  stamp  it  out  by 
segregating  all  lepers  on  the  island  of  Molokai.  In  1904  there  were  856  lepers 
in  the  settlement. 

In  British  India,  according  to  the  Leprosy  Commission,  there  are  100,000 
lepers.  This  is  probably  a  low  estimate.  In  China  leprosy  prevails  exten- 
sively. In  South  Africa,  it  has  increased  rapidly.  In  Australia,  New 
Zealand,  and  the  Australasian  islands  it  also  prevails,  chiefly  among  the  Chi- 
nese. The  essays  of  Ashburton  Thompson  and  James  Cantlie  deal  fully  with 
leprosy  in  China,  Australia,  and  the  Pacific  islands. 

Etiology. — Bacillus  lepra,  discovered  by  Hansen,  of  Bergen,  in  1871,  is 
universally  recognized  as  the  cause  of  the  disease.  It  has  many  points  of  re- 
semblance to  the  tubercle  bacillus,  but  can  be  readily  differentiated.  It  is  cul- 
tivated with  extreme  difficulty,  and,  in  fact,  there  is  some  doubt  as  to  whether 
it  is  capable  of  growth  on  artificial  media. 

Modes  of  Infection.— (a)  hiocnl  at  ion. —While  it  is  highly  probable  that 
leprosy  may  be  contracted  by  accidental  inoculation,  the  experimental  evi- 
dence is  as  yet  inconclusive.  With  one  possible  exception  negative  results 
have  followed  the  attempts  to  reproduce  the  disease  in  man.     The  Hawaiian 


LEPROSY.  361 

convict  under  sentence  of  death,  who  was  inoculated  on  September  30,  1884, 
by  Arning,  four  weeks  later  had  rheumatoid  pains  and  gradual  painful  swell- 
ing of  the  ulnar  and  median  nerves.  The  neuritis  gradually  subsided,  but 
there  developed  a  small  lepra  tubercle  at  the  site  of  the  inoculation.  In  1887 
the  disease  was  quite  manifest,  and  the  man  died  of  it  six  years  after  inocula- 
tion. The  case  is  not  regarded  as  conclusive,  as  he  had  leprous  relatives  and 
lived  in  a  leprous  country. 

(&)  Heredity. — For  years  it  was  thought  that  the  disease  was  transmitted 
from  parent  to  child,  but  the  general  opinion,  as  expressed  in  the  recent 
Leprosy  Congress  in  Berlin,  was  decidedly  against  this  view.  Of  course,  the 
possibility  of  its  transmission  can  not  be  denied,  and  in  this  respect  leprosy 
and  tuberculosis  occupy  very  much  the  same  position,  though  men  with  very 
wide  experience  have  never  seen  a  new-born  leper.  The  youngest  cases  are 
rarely  under  three  or  four  years  of  age. 

(c)  By  Contagion. — The  bacilli  are  given  off  from  the  open  sores;  they 
are  found  in  the  saliva  and  expectoration  in  the  cases  with  leprous  lesions 
in  the  mouth  and  throat,  and  occur  in  very  large  numbers  in  the  nasal  secre- 
tion. Sticker  found  in  153  lepers,  subjects  of  both  forms  of  the  disease, 
bacilli  in  the  nasal  secretion  in  128,  and  herein,  he  thinks,  lies  the  chief 
source  of  danger.  Schaffer  was  able  to  collect  lepra  bacilli  on  clean  slides 
placed  on  tables  and  floors  near  to  lepers  whom  he  had  caused  to  read  aloud. 
The  bacilli  have  also  been  isolated  from  the  urine  and  the  milk  of  patients. 
It  seems  probable  that  they  may  enter  the  body  in  many  ways  through  the 
mucous  membranes  and  through  the  skin.  Sticker  believes  that  the  initial 
lesion  is  in  an  ulcer  above  the  cartilaginous  part  of  the  nasal  septum.  One 
of  the  most  striking  examples  of  the  contagiousness  of  leprosy  is  the  follow- 
ing: "In  1860,  a  girl  who  had  hitherto  lived  at  Holstfershof,  where  no 
leprosy  existed,  married  and  went  to  live  at  Tarwast  with  her  mother-in-law, 
who  was  a  leper.  She  remained  healthy,  but  her  three  children  (1,  2,  3) 
became  leprous,  as  also  her  younger  sister  (4),  who  came  on  a  visit  to  Tar- 
wast and  slept  with  the  children.  The  younger  sister  developed  leprosy  after 
returning  to  Holstfershof.  At  the  latter  place  a  man  (5),  fifty- two  years  old, 
who  married  one  of  the  '  younger  sister's '  children,  acquired  leprosy ;  also  a 
relative  (6),  thirty-six  years  old,  a  tailor  by  occupation,  who  frequented  the 
house,  and  his  wife  (7),  who  came  from  a  place  where  no  leprosy  existed. 
The  two  men  last  mentioned  are  at  present  (1897)  inmates  of  the  leper 
asylum  at  Dorpat."  There  is  certain  evidence  to  show  that  the  disease  may 
be  spread  through  infected  clothing,  and  the  high  percentage  of  washerwomen 
among  lepers  is  also  suggestive. 

Conditions  influencing  Infection. — The  disease  attacks  persons  of  all 
ages.  We  do  not  yet  understand  all  the  conditions  necessary.  Evidently 
the  closest  and  most  intimate  contact  is  essential.  The  doctors,  nurses,  and 
Sisters  of  Charity  who  care  for  the  patients  are  very  rarely  attacked.  In  the 
lazaretto  at  Tracadie  not  one  of  the  Sisters  who  for  -more  than  forty  years 
have  so  faithfully  nursed  the  lepers  has  contracted  the  disease.  Father 
Damian,  in  the  Sandwich  Islands,  and  Father  Boglioli,  in  Few  Orleans, 
both  fell  victims  in  the  discharge  of  their  priestly  duties.  There  has  long 
been  an  idea  that  possibly  the  disease  may  be  associated  with  some  special 
kind  of  food,  and  Jonathan  Hutchinson  believes  that  a  fish  diet  is  the  tertium 
25 


362  SPECIFIC  INFECTIOUS  DISEASES. 

quid,  which  either  renders  the  patient  susceptible  or  with  which  the  poison 
may  be  taken. 

Morbid  Anatomy. — The  leprosy  tubercles  consist  of  granulomatous  tissue 
made  up  of  cells  of  various  sizes  in  a  connective-tissue  matrix.  The  bacilli 
in  extraordinary  numbers  lie  partly  between  and  partly  in  the  cells.  The 
process  gradually  involves  the  skin,  giving  rise  to  tuberous  outgrowths  with 
intervening  areas  of  ulceration  or  cicatrization,  which  in  the  face  may  grad- 
ually produce  the  so-called  fades  leontina.  The  mucous  membranes,  particu- 
larly the  conjunctiva,  the  cornea,  and  the  larynx  may  gradually  be  involved. 
In  many  cases  deep  ulcers  form  which  result  in  extensive  loss  of  substance 
or  loss  of  fingers  or  toes,  the  so-called  lepra  mutilans.  In  anesthetic  leprosy 
there  is  a  peripheral  neuritis  due  to  the  development  of  the  bacilli  in  the  nerve- 
fibres.  Indeed,  this  involvement  of  the  nerves  plays  a  primary  part  in  the 
etiology  of  many  of  the  important  features,  particularly  the  trophic  changes 
in  the  skin  and  the  disturbances  of  sensation. 

Clinical  Forms. — (a)  Tubercular  Leprosy. — Prior  to  the  appearance 
of  the  nodules  there  are  areas  of  cutaneous  erythema  which  may  be  sharply 
defined  and  often  hypergesthetic.  This  is  sometimes  known  as  macular 
leprosy.  The  affected  spots  in  time  become  pigmented.  In  some  instances 
this  superficial  change  continues  without  the  development  of  nodules,  the  areas 
become  angesthetic,  the  pigment  gradually  disappears,  and  the  skin  gets  per- 
fectly white — the  lepra  alia.  Among  the  patients  at  Tracadie  it  was  particu- 
larly interesting  to  see  three  or  four  in  this  early  stage  presenting  on  the  face 
and  forearms  a  patchy  erythema  with  slight  swelling  of  the  skin.  The  diag- 
nosis of  the  condition  is  perfectly  clear,  though  it  may  be  a  long  time  before 
any  other  than  sensory  changes  develop.  The  eyelashes  and  eyebrows  and  the 
hairs  on  the  face  fall  out.  The  mucous  membranes  finally  become  involved, 
particular!}^  of  the  mouth,  throat,  and  larynx;  the  voice  becomes  harsh  and 
finally  aphonic.  Death  results  not  infrequently  from  the  laryngeal  compli- 
cations and  aspiration  pneumonia.  The  conjunctivae  are  frequently  attacked, 
and  the  sight  is  lost  by  a  leprous  keratitis. 

(&)  Anesthetic  Leprosy. — This  remarkable  form  has,  in  characteristic 
cases,  no  external  resemblance  whatever  to  the  other  variety.  It  usually 
begins  with  pains  in  the  limbs  and  areas  of  hypersesthesia  or  of  numbness. 
Very  early  there  may  be  trophic  changes,  seen  in  the  formation  of  small  bullae 
(Hillis).  Maculge  appear  upon  the  trunk  and  extremities,  and  after  persist- 
ing for  a  variable  time  gradually  disappear,  leaving  areas  of  anaesthesia,  but 
the  loss  of  sensation  may  come  on  independently  of  the  outbreak  of  maculae. 
The  nerve-trunks,  where  superficial,  may  be  felt  to  be  large  and  nodular.  The 
trophic  disturbances  are  usually  marked.  Pemphigus-like  bullae  develop  in 
the  affected  areas,  which  break  and  leave  ulcers  which  may  be  very  destructive. 
The  fingers  and  toes  are  liable  to  contractures  and  to  necrosis,  so  that  in 
chronic  cases  the  phalanges  are  lost.  The  course  of  angesthetic  leprosy  is 
extraordinarily  chronic  and  may  persist  for  years  without  leading  to  much 
deformity.  One  of  the  most  prominent  clergymen  on  this  continent  had  anaes- 
thetic leprosy  for  more  than  thirty  years,  which  did  not  seriously  interfere 
with  his  usefulness,  and  not  in  the  slightest  with  his  career. 

Diagnosis. — Even  in  the  early  stage  the  duslcy  erythematous  maculae  with 
hypersesthesia  or  areas  of  anaesthesia  are  very  characteristic.     In  an  advanced 


INFECTIOUS  DISEASES  OF  DOUBTFUL  NATURE.  363 

grade  neither  the  tubercular  nor  anaesthetic  forms  could  possibly  be  mistaken 
for  any  other  afEection.  In  a  doubtful  case  the  microscopical  examination  of 
an  excised  nodule  is  decisive. 

Treatment. — There  are  no  specific  remedies  in  the  disease.  The  gurjun 
and  chaulmoogra  oils  have  been  recommended,  the  former  in  doses  of  from 
5  to  10  minims,  the  latter  in  2-drachm  doses.  Calmette's  antivenene,  20  to 
30  c.  c,  subcutaneously,  has  been  followed  by  remarkable  results  in  a  few  cases. 
Segregation  should  be  compulsory  in  all  cases  except  where  the  friends  can 
show  that  they  have  ample  provision  in  their  own  home  for  the  complete  isola- 
tion and  proper  care  of  the  patient. 

XXXV.     INFECTIOUS    DISEASES    OF    DOUBTFUL 

NATURE. 

(1)  Febricula — Ephemeral  Fever, 

Definition. — Fever  of  slight  duration,  probably  depending  upon  a  variety 
of  causes. 

A  febrile  paroxysm  lasting  for  twenty-four  hours  and  disappearing  com- 
pletely is  spoken  of  as  ephemeral  fever.  If  it  persists  for  three,  four,  or 
more  days  without  local  afEection  it  is  referred  to  as  febricula. 

The  cases  may  be  divided  into  several  groups: 

(a)  Those  which  represent  mild  or  abortive  types  of  the  infectious  dis- 
eases. It  is  not  very  unusual,  during  an  epidemic  of  typhoid,  scarlet  fever, 
or  measles,  to  see  cases  with  some  of  the  prodromal  symptoms  and  slight  fever, 
which  persist  for  two  or  three  days  without  any  distinctive  features.  I  have 
already  spoken  of  these  in  connection  with  the  abortive  type  of  typhoid  fever. 
Possibly,  as  Kahler  suggests,  some  of  the  cases  of  transient  fever  are  due  to 
the  rheumatic  poison. 

(&)  In  a  larger  and  perhaps  more  important  group  of  cases  the  symp- 
toms develop  with  dyspepsia.  In  children  indigestion  and  gastro-intestinal 
catarrh  are  often  accompanied  by  fever.  Possibly  some  instances  of  longer 
duration  may  be  due  to  the  absorption  of  certain  toxic  substances.  Slight 
fever  has  been  known  to  follow  the  eating  of  decomposing  substances  or  the 
drinking  of  stale  beer;  but  the  gastric  juice  has  remarkable  antiseptic  prop- 
erties, and  the  frequency  with  which  persons  take  from  choice  articles  which 
are  "  high,"  shows  that  poisoning  is  not  likely  to  occur  imless  there  is  existing 
gastro-intestinal  disturbance. 

(c)  Cases  which  follow  exposure  to  foul  odors  or  sewer-gas.  That  a 
febrile  paroxysm  may  follow  a  prolonged  exposure  to  noxious  odors  has  long 
been  recognized.  The  cases  which  have  been  described  under  this  heading 
are  of  two  kinds:  an  acute  severe  form  with  nausea,  vomiting,  colic,  and 
fever,  followed  perhaps  by  a  condition  of  collapse  or  coma;  secondly,  a  form 
of  low  fever  with  or  without  chills.  A  good  deal  of  doubt  still  exists  in 
the  minds  of  the  profession  about  these  cases  of  so-called  sewer-gas  poison- 
ing. It  is  a  notorious  fact  that  workers  in  sewers  are  remarkably  free  from 
disease,  and  in  many  of  the  cases  which  have  been  reported  the  illness  may 
have  been  only  a  coincidence.  There  are  instances  in  which  persons  have 
been  taken  ill  with  vomiting  and  slight  fever  after  exposure  to  the  odor  of  a 


364  SPECIFIC  INFECTIOUS  DISEASES. 

very  offensive  post  mortem.  Whether  true  or  not,  the  idea  is  firmly  implanted 
in  the  minds  of  the  laity  that  very  powerful  odors  from  decomposing  matters 
may  produce  sickness. 

(d)  Many  cases  doubtless  depend  upon  slight  unrecognized  lesions,  such  as 
tonsillitis  or  occasionally  an  abortive  or  larval  pneumonia.  Children  are 
much  more  frequently  affected  than  adults. 

The  symptoms  set  in,  as  a  rule,  abruptlj'-,  though  in  some  instances  there 
may  have  been  preliminary  tnalaise  and  indisposition.  Headache,  loss  of 
appetite,  and  furred  tongue  are  present.  The  urine  is  scanty  and  high-colored, 
the  fever  ranges  from  101°  to  103°,  sometimes  in  children  it  rises  higher. 
The  cheeks  may  be  flushed  and  the  patient  has  the  outward  manifestations  of 
fever.  In  children  there  may  be  bronchial  catarrh  with  slight  cough. 
Herpes  on  the  lips  is  a  common  symptom.  Occasionally  in  children  the  cere- 
bral symptoms  are  marked  at  the  outset,  and  there  may  be  irritation,  restless- 
ness, and  nocturnal  delirium.  The  fever  terminates  abruptly  by  crisis  from 
the  second  to  the  fourth  day;  in  some  instances  it  may  continue  for  a  week. 

The  diagnosis  generally  rests  upon  the  absence  of  local  manifestations, 
particularly  the  characteristic  skin  rashes  of  the  eruptive  fevers,  and  most 
important  of  all  the  rapid  disappearance  of  the  pyrexia.  The  cases  most 
readily  recognized  are  those  with  acute  gastro-intestinal  disturbance. 

The  treatment  is  that  of  mild  pyrexia — rest  in  bed,  a  laxative,  and  a  fever 
mixture  containing  nitrate  of  potassium  and  sweet  spirits  of  nitre. 

(2)  IisTFECTious  Jaundice. 
Epidemic  Catarrhal  Jaundice  {WeiVs  Disease). 

Local  and  wide-spread  outbreaks  of  jaundice  have  been  known  for  years. 
Three  or  four  cases  may  occur  in  one  house,  or  many  persons  in  an  institu- 
tion are  attacked,  or  the  disease  becomes  wide-spread  in  a  community.  In 
Great  Britain  this  epidemic  form  is  rare.  In  the  United  States  many  out- 
breaks have  occurred.  It  prevailed  extensively  in  North  Carolina  in  1899- 
1900,  and  a  fatal  case  of  that  epidemic  came  under  my  observation.  In  Syria, 
in  Greece,  in  Egypt  (Sandwith),  in  India  (S.  Anderson),  and  in  South  Africa 
during  the  Boer  war  (H.  B.  Matheas),  epidemics  have  been  described.  It 
has  prevailed  most  frequently  in  the  summer  months.  The  symptoms  are  at 
first  gastric,  then  fever  follows  (with  the  usual  concomitants)  and  jaundice, 
which  may  be  slight  or  very  intense,  and  as  a  rule  albuminuria.  The  liver 
and  spleen  enlarge,  and  in  severe  forms  there  are  nervous  symptoms  and 
haemorrhages.  There  is  often  a  secondary  fever.  The  attack  lasts  from  ten 
days  to  three  weeks.  The  course  is  nsually  favorable ;  fatal  cases  are  rare  in 
the  United  States  and  in  India  and  South  Africa,  but  in  the  Greek  Hospital 
at  Alexandria  the  death-rate  was  32  among  300  cases  (Sandwith). 

In  1886  Weil  described  a  disease  characterized  by  the  features  just  men- 
tioned, but  the  cases  occurred  in  groups,  and  a  very  large  proportion  in 
butchers.  It  is  probable  there  are  several  types  of  acute  infectious  jaundice. 
The  etiology  is  unknown.  The  proteus  has  been  described  in  connection  with 
Weil's  disease.  In  the  fatal  case  from  North  Carolina  the  autopsy  threw  no 
light  on  the  nature  of  the  disease.  The  proteus  was  isolated  from  the  liver 
and  kidney,  and  four  other  organisms  from  various  parts.     It  is  possible  that 


INFECTIOUS   DISEASES   OF   DOUBTFUL  NATURE.  365 

acute  catarrhal  jaimdice  is  a  mild  infection,  representing  the  sporadic  form 
of  the  disease. 

(3)   Milk-Sickness. 

This  remarkable  disease  prevails  in  certain  districts  of  the  United  States, 
west  of  the  Alleghany  Mountains,  and  is  connected  with  the  affection  in  cat- 
tle known  as  the  trembles.  It  prevailed  extensively  in  the  early  settlements 
in  certain  of  the  Western  States  and  proved  very  fatal.  The  general  opinion 
is  that  it  is  communicated  to  man  only  by  eating  the  flesh  or  drinking  the 
milk  of  diseased  animals.  The  butter  and  cheese  are  also  poisonous.  In  ani- 
mals, cattle  and  the  young  of  horses  and  slieep  are  most  susceptible.  It  is 
stated  that  cows  giving  milk  do  not  themselves  show  marked  symptoms  unless 
driven  rapidly,  and,  according  to  Graff,  the  secretion  may  be  infective  when 
the  disease  is  latent.  When  a  cow  is  very  ill,  food  is  refused,  the  eyes  are 
injected,  the  animal  staggers,  the  entire  muscular  system  trembles,  and  death 
occurs  in  convulsions,  sometimes  with  great  suddenness.  The  disease  is  most 
frequent  in  new  settlements. 

In  man  the  symptoms  are  those  of  a  more  or  less  acute  intoxication.  After 
a  few  days  of  uneasiness  and  distress  the  patient  is  seized  with  pains  in  the 
stomach,  nausea  and  vomiting,  fever  and  intense  thirst.  There  is  usually 
obstinate  constipation.  The  tongue  is  swollen  and  tremulous,  the  breath  is 
extremely  foul  and,  according  to  Graff,  is  as  characteristic  of  the  disease  as 
is  the  odor  in  small-pox.  Cerebral  symptoms — restlessness,  irritability,  coma, 
and  convulsions — are  sometimes  marked,  and  there  may  gradually  be  produced 
a  typhoid  state  in  which  the  patient  dies. 

The  duration  of  the  disease  is  variable.  In  the  most  acute  form  death 
occurs  within  two  or  three  days.  It  may  last  for  ten  days,  or  even  for  three 
or  four  weeks.  Graff  states  that  insanity  occurred  in  one  case.  The  poisonous 
nature  of  the  flesh  and  of  the  milk  has  been  demonstrated  experimentally. 
An  ounce  of  butter  or  cheese,  or  four  ounces  of  the  beef,  raw  or  boiled,  given 
three  times  a  day,  will  kill  a  dog  within  six  days.  Fortunately,  the  disease 
has  become  rare.  No  definite  pathological  lesions  are  known.  Jordan  and 
Harris  have  studied  a  Kew-Mexico  epidemic  (1908)  and  have  found  a  bacillus 
{B.  lactimorhi)  with  cultures  of  which  the  disease  may  be  reproduced  in  other 
animals. 

(4)   Glandular  Fever. 

Definition. — An  infectious  disease  of  children,  developing,  as  a  rule,  with- 
out premonitory  signs,  and  characterized  by  slight  redness  of  the  throat,  high 
fever,  swelling  and  tenderness  of  the  lymph-glands  of  the  neck,  particularly 
those  behind  the  sterno-cleido-mastoid  muscles.  The  fever  is  of  short  dura- 
tion, but  the  enlargement  of  the  glands  persists  for  from  ten  days  to  three 
weeks. 

In  children  acute  adenitis  of  the  cervical  and  other  glands  with  fever  has 
been  noted  by  many  observers,  but  Pfeiffer  in  1889  called  special  attention 
to  it  under  the  name  of  Druesenfieher.  He  described  it  as  an  infectious  dis- 
ease of  young  children  between  the  ages  of  five  and  eight  years,  characterized 
by  the  above-mentioned  symptoms.  Since  Pfeiffer's  paper  a  good  deal  of  work 
has  been  done  in  connection  with  the  subject,  and  in  the  United  States  West 


366  SPECIFIC  INFECTIOUS  DISEASES. 

and  Hamill,  and  in  England  Dawson  Williams^,  have  more  particularly  empha- 
sized the  condition. 

Etiology. — It  may  occur  in  epidemic  form.  West,  of  Bellaire,  Ohio, 
describes  an  ejjideniic  of  96  cases  in  children  between  the  ages  of  seven  months 
and  thirteen  years.  Bilateral  swelling  of  the  carotid  lymph-glands  was  a  most 
marked  feature.  In  three-fourths  of  the  cases  the  post-cervical,  inguinal,  and 
axillary  glands  were  involved.  The  mesenteric  glands  were  felt  in  37  cases, 
the  spleen  was  enlarged  in  57,  and  the  liver  in  87  cases.  Coryza  was  not  pres- 
ent, and  there  were  no  bronchial  or  pulmonary  symptoms.  Cases  occurred 
between  the  months  of  October  and  June.  The  nature  of  the  infection  has 
not  been  determined. 

Symptoms. — The  onset  is  sudden  and  the  first  complaint  is  of  pain  on 
moving  the  head  and  neck.  There  may  be  nausea  and  vomiting  and  abdomi- 
nal pain.  The  temperature  ranges  from  101°  to  103°.  .  The  tonsils  may  be 
a  little  red  and  the  lymphatic  tissues  swollen,  but  the  throat  symptoms  are 
quite  transient  and  unimportant.  On  the  second  or  third  day  the  enlarged 
glands  appear,  and  during  the  course  they  vary  in  size  from  a  pea  to  a  goose- 
egg.  They  are  painful  to  the  touch,  but  there  is  rarely  any  redness  or  swell- 
ing of  the  skin,  though  at  times  there  is  some  puffiness  of  the  subcutaneous 
tissues  of  the  neck,  and  there  may  be  a  little  difficulty  in  swallowing.  In 
some  instances  there  has  been  discomfort  in  the  chest  and  a  paroxysmal  cough, 
indicating  involvement  of  the  tracheal  and  bronchial  glands.  The  swelling 
of  the  glands  persists  for  from  two  to  three  weeks.  Among  the  serious  fea- 
tures of  the  disease  are  the  termination  of  the  adenitis  in  suppuration,  which 
seems  rare  (though  Neumann  has  met  with  it  in  13  cases),  and  hemorrhagic 
nephritis.  Acute  otitis  media  and  retro-pharyngeal  abscess  have  also  been 
reported. 

The  outlook  is  favorable.  West  suggests  the  use  of  small  doses  of  calomel 
during  the  height  of  the  trouble. 

(5)  Mountain  Fever — Mountain  Sickness. 

Several  distinct  diseases  have  been  described  as  mountain  fever.  An  im- 
portant group,  the  mountain  anaemia,  is  associated  with  the  anJcylostoma.  A 
second  group  of  cases  belongs  to  typhoid  fever;  and  instances  of  this  disease 
occurring  in  mountainous  regions  in  the  Western  States  are  referred  to  as 
mountain  fever.  The  observations  of  Hoff  and  Smart,  and  more  recently  of 
Woodruff  and  of  Eajnuond,  show  that  the  disease  is  typhoid  fever. 

C.  E.  AVoodrufP,  of  the  United  States  Army,  has  reported  a  group  of  35 
cases  at  Fort  Custer,  which,  as  he  says,  would  certainly  have  been  described 
as  mountain  fever,  but  in  which  the  clinical  features  and  the  Widal  reaction 
showed  there  was  no  question  that  they  were  typhoid.  It  would  be  well,  I 
thmk,  for  the  use  of  the  term  mountain  fever  to  be  discontinued. 

Mountain  sichiess  comprises  the  remarkable  group  of  phenomena  which 
develop  m  very  high  altitudes.  The  condition  has  been  very  accurately  de- 
scribed by  Mr.  WhAonper.  In  the  ascent  of  Chimborazo  they  were  first 
affected  at  a  height  of  16,664  feet.  The  symptoms  were  severe  headache, 
gaspmg  for  breath,  parched  throat,  intense  thirst,  loss  of  appetite,  and  an 
mtense  malaise.    Mr.  Whymper's  temperature  was  100.4°.    The  symptoms  in 


INFECTIOUS  DISEASES  OF  DOUBTFUL  NATURE.  367 

his  case  lasted  nearly  three  days.  In  a  less  aggravated  form  such  symptoms 
may  present  themselves  at  much  lower  levels.  A  very  full  description  is  given 
by  Allbutt  in  vol.  iii  of  his  System. 

(6)   Miliary  Fever — Sweating  Sickness, 

The  disease  is  characterized  by  fever,  profuse  sweats,  and  an  eruption  of 
miliary  vesicles.  It  prevailed  and  was  very  fatal  in  England  in  the  fifteenth 
and  sixteenth  centuries,  and  was  made  the  subject  of  an  important  memoir 
by  Johannes  Caius,  1552.  Of  late  years  it  has  been  confined  entirely  to  cer- 
tain districts  in  France  (Picardy)  and  Italy.  An  epidemic  of  some  extent 
occurred  in  France  in  1887.  Hirsch  gives  a  chronological  account  of  194 
epidemics  between  1718  and  1879,  many  of  which  were  limited  to  a  single 
village  or  to  a  few  localities.  Occasionally  the  disease  has  become  widely 
spread.  Slight  epidemics  have  occurred  in  Germany  and  Switzerland.  Within 
the  past  few  years  there  have  been  several  small  outbreaks  in  Austria.  They 
are  usually  of  short  duration,  lasting  only  for  three  or  four  weeks — sometimes 
not  more  than  seven  or  eight  days.  As  in  infiuenza,  a  very  large  number  of 
persons  are  attacked  in  rapid  succession.  In  the  mild  cases  there  is  only  slight 
fever,  with  loss  of  appetite,  and  erythematous  eruption,  profuse  perspiration, 
and  an  outbreak  of  miliary  vesicles.  The  severe  cases  present  the  symptoms 
of  intense  infection — delirium,  high  fever,  profound  prostration,  and  haemor- 
rhage. The  death-rate  at  the  outset  of  the  disease  is  usually  high,  and,  as 
is  so  graphically  described  in  the  account  of  some  of  the  epidemics  of  the 
middle  ages,  death  may  occur  in  a  few  hours.  The  most  recent  and  the  full- 
est account  of  the  disease  is  given  in  Nothnagel's  Ilandbuch  by  Immermann, 

(7)   foot-and-mouth  disease — epidemic   stomatitis — aphthous 

Fever. 

Foot-and-mouth  disease  is  an  acute  infectious  disorder  met  with  chiefly 
in  cattle,  sheep,  and  pigs,  but  attacking  other  domestic  animals.  It  is  of 
extraordinary  activity,  and  spreads  with  "  lightning  rapidity  "  over  vast  terri- 
tories, causing  very  serious  losses.  In  cattle,  after  a  period  of  incubation  of 
three  or  five  days,  the  animal  gets  feverish,  the  mucous  membrane  of  the 
mouth  swells,  and  little  grayish  vesicles  the  size  of  a  hemp  seed  begin  to  de- 
velop on  the  edges  and  lower  portion  of  the  tongue,  on  the  gums,  and  on  the 
mucous  membrane  of  the  lips.  They  contain  at  first  a  clear  fluid,  which 
becomes  turbid,  and  then  they  enlarge  and  gradually  become  converted  into 
superficial  ulcers.  There  is  ptyalism,  and  the  animals  lose  flesh  rapidly.  In 
the  cow  the  disease  is  also  frequently  seen  about  the  udder  and  teats,  and  the 
milk  becomes  yellowish-white  in  color  and  of  a  mucoid  consistency. 

The  transmission  to  man  is  by  no  means  uncommon,  and  several  impor- 
tant epidemics  have  been  studied  in  the  neighborhood  of  Berlin.  In  Zuill's 
translation  of  Friedberger  and  Frohner's  Pathology  and  Therapeutics  of 
Domestic  Animals  (Philadelphia,  1895)  the  disease  is  thus  described:  "In 
man  the  symptoms  are:  fever,  digestive  troubles,  and  vesicular  eruption  upon 
the  lips,  the  buccal  and  pharyngeal  mucous  membranes  (angina).  The  dis- 
ease does  not  seem  to  be  transmissible  through  the  meat  of  diseased  animals." 

In  wide-spread  epidemics  there  has  been  sometimes  a  marked  tendency 


368  SPECIFIC  INFECTIOUS  DISEASES. 

to  hsemorrhages.     The   disease  nins,   as   a  rule,  a  favorable  course,  but  in 
Siegel's  report  of  an  epidemic  the  mortality  was  8  per  cent. 

Wlien  epidemics  are  prevailing  in  cattle  the  milk  should  be  boiled,  and 
the  proper  prophylactic  measures  taken  to  isolate  both  the  cattle  and  the 
individuals  who  come  in  contact  with  them. 

(8)   Psittacosis. 

A  disease  in  birds,  characterized  by  loss  of  appetite,  weakness,  diarrhoea, 
convulsions,  and  death.  In  Germany,  France,  and  Italy  a  disease  in  man 
characterized  by  an  atj^Dical  pneumonia,  great  weakness  and  depression,  and 
signs  of  a  profound  infection  has  been  ascribed  to  contagion  from  birds,  par- 
ticularly parrots.  There  have  usually  been  house  epidemics  with  a  very  high 
rate  of  mortality.  A  few  cases  have  been  reported  in  England,  and  Vickery,  of 
Boston,  has  reported  three  probable  cases.     The  bacteriolog}'  is  still  doubtful. 

(9)  EocKT  Mountain  Spotted  Fever.    Tick  Fever. 

In  the  Bitter-root  A'alley  of  Montana  and  in  the  mountains  of  Idaho, 
jSTevada,  and  Wyoming  there  is  an  acute  infection  characterized  by  chill,  fever, 
pains  in  back  and  bones,  and  a  macular  rash,  becoming  liEemorrhagic.  It  was 
reported  upon  occasionally  by  army  surgeons — e.  g.,  Wood,  but  nothing  defi- 
nite was  known  until  the  careful  studies  of  Wilson  and  Chowning  (1902),  who 
described  a  piroplasma  in  the  blood,  and  believed  the  disease  to  be  transmitted 
by  ticks.  This  latter  point  has  been  confirmed,  but  the  existence  of  the  piro- 
plasma is  doubtful.  The  studies  of  King  and  Eicketts  have  demonstrated 
beyond  doubt  the  transmission  of  the  disease  by  the  tick,  Dermacentor  occi- 
dentalis,  but  the  true  parasite  has  not  been  determined.  The  disease  is  readily 
given  to  the  guinea-pig  and  monkey,  and  is  transmissible  from  one  animal  to 
another  by  the  bite  of  the  tick.  Immunity  is  given  by  an  attack,  and  in  ani- 
mals this  is  transmitted  to  the  young.  After  an  incubation  of  from  three  to 
ten  days  the  disease  begins  with  a  chill,  fever,  and  severe  pains  in  the  limbs. 
The  rash  appears  from  the  second  to  the  seventh  day,  is  macular,  dark,  and 
becomes  hfemorrhagic.  Illustrations  of  it  show  a  rash  not  unlike  that  of 
tj^jhus.  The  skin  is  often  swollen.  Haemorrhages  from  the  mucous  mem- 
branes are  not  uncommon.  The  temperature  range  is  from  103°  to  105°,  and 
at  the  height  of  the  disease  there  is  delirium  and  stupor.  Convalescence  begins 
in  the  fourth  week.  The  death-rate  is  high  for  an  eruptive  fever,  reaching  70 
per  cent  in  Montana,  but  in  Idaho  it  is  not  more  than  3  or  3  per  cent.  The 
treatment  is  that  of  an  acute  infection. 

(10)    SwiXE  Fever. 

A  few  cases  have  been  described  from  accidental  inoculation  in  the  prepara- 
tion of  cultures  and  in  making  post  mortems  upon  pigs.  In  the  course  of  from 
twelve  hours  to  three  days  there  is  swelling  of  the  fingers  of  the  affected  hand, 
which  have  a  blue-red  color,  and  small  nodules  form.  In  some  of  the  instances 
the  course  has  been  like  that  of  a  painful  erythema  migrans,  with  swelling  of 
the  l}Tnph-glands.  A  specific  serum  has  been  used  with  success  in  several 
cases. 


SECTION    III. 
THE    INTOXIOATIOI^S 

AND   SUN-STROKE. 


I.    ALCOHOLISM. 

(1)  Acute  Alcoholism. — When  a  large  quantity  of  alcohol  is  taken,  the 
influence  is  chiefly  on  the  nervous  system,  and  is  manifested  in  muscular  inco- 
ordination, mental  disturbance,  and,  finally,  narcosis.  The  individual  pre- 
sents a  flushed,  sometimes  slightly  cyanosed  face,  the  pulse  is  full,  respira- 
tions deep  but  rarely  stertorous.  The  pupils  are  dilated.  The  temperature 
is  frequently  below  normal,  particularly  if  the  patient  has  been  exposed  to 
cold.  Perhaps  the  lowest  reported  temperatures  have  been  in  cases  of  this 
sort.  An  instance  is  on  record  in  which  the  patient  on  admission  to  hospital 
had  a  temperature  of  34°  C.  (ca.  75°  F.),  and  ten  hours  later  the  temperature 
had  not  risen  to  91°.  The  unconsciousness  is  rarely  so  deep  that  the  patient 
can  not  be  roused  to  some  extent,  and  in  reply  to  questions  he  mutters  inco- 
herently. Muscular  twitchings  may  occur,  but  rarely  convulsions.  The 
breath  has  a  heavy  alcoholic  odor.  The  respirations  may  be  very  slow;  in 
a  recent  case  they  were  only  six  in  the  minute. 

The  diagnosis  is  not  difficult,  yet  mistakes  are  frequently  made.  Per- 
sons are  sometimes  brought  to  hospital  by  the  police  supposed  to  be  drunk 
when  in  reality  they  are  dying  from  apoplexy.  Too  great  care  can  not  be  exer- 
cised, and  the  patient  should  receive  the  benefit  of  the  doubt.  In  some  in- 
stances the  mistake  has  arisen  from  the  fact  that  a  person  who  has  been  drink- 
ing heavily  has  been  stricken  with  apoplexy.  In  this  condition  the  coma  is 
usually  deeper,  stertor  is  present,  and  there  may  be  evidence  of  hemiplegia  in 
the  greater  flaccidity  of  the  limbs  on  one  side.  The  subject  will  be  considered 
in  the  section  upon  ursemic  coma. 

Dipsomania  is  a  form  of  acute  alcoholism  seen  in  persons  with  a  strong 
hereditary  tendency  to  drink.  Periodically  the  victims  go  "  on  a  spree,"  but 
in  the  intervals  they  are  entirely  free  from  any  craving  for  alcohol. 

(2)  Chronic  Alcoholism. — In  moderation,  wine,  beer,  and  spirits  may  be 
taken  throughout  a  long  life  without  impairing  the  general  health. 

According  to  Fajne,  the  poisonous  efi^ects  of  alcohol  are  manifested  (1) 
as  a  functional  poison,  as  in  acute  narcosis;  (2)  as  a  tissue  poison,  in  which 
its  effects  are  seen  on  the  parenchymatous  elements,  particularly  epithelium 
and  nerve,  producing  a  slow  degeneration,  and  on  the  blood-vessels,  causing 
thickening  and  ultimately  fibroid  changes;  and   (3)   as  a  checker  of  tissue 

369 


370  THE  INTOXICATIONS  AND  SUN-STROKE. 

oxidation,  since  the  alcohol  is  consumed  in  place  of  the  fat.  This  leads  to 
fatty  changes  and  sometimes  to  a  condition  of  general  steatosis. 

The  chief  effects  of  chronic  alcohol  poisoning  may  be  thus  summarized. 

Nervous  System. — Functional  disturbance  is  common.  Unsteadiness  of 
the  muscles  in  performing  any  action  is  a  constant  feature.  The  tremor  is 
best  seen  in  the  hands  and  in  the  tongue.  The  mental  processes  may  be  dull, 
particularly  in  the  early  morning  hours,  and  the  patient  is  unable  to  transact 
any  business  until  he  has  had  his  accustomed  stimulant.  Irritability  of  tem- 
per, forgetfulness,  and  a  change  in  the  moral  character  of  the  individual 
gradually  come  on.  The  judgment  is  seriously  impaired,  the  will  enfeebled, 
and  in  the  final  stages  dementia  may  supervene.  An  interesting  combina- 
tion of  symptoms  in  chronic  alcoholics  is  characterized  by  peripheral  neuritis, 
loss  of  memory,  and  pseudo-reminiscences — that  is,  false  notions  as  to  the 
patient's  position  in  time  and  space,  and  fabulous  explanations  of  real  occur- 
rences. The  peripheral  neuritis  is  not  always  present;  there  may  be  only 
tremor  and  jactitation  of  the  lips,  and  thickness  of  the  speech,  with  visual  hal- 
lucinations. The  mental  condition  was  described  by  Jackson  and  by  Wilks. 
Korsakoff  speaks  of  it  as  a  psychosis  polyneuritica,  and  the  symptom-complex 
is  sometimes  called  by  his  name.  The  relation  of  chronic  alcoholism  to  insan- 
ity has  been  much  discussed.  According  to  Savage,  of  4,000  patients  admitted 
to  the  Bethlehem  Hospital,  133  gave  drink  as  the  cause  of  their  insanity. 
Chronic  alcoholism  is  certainly  one  of  the  important  elements  in  the  strain 
which  leads  to  mental  breakdown.  Epilepsy  may  result  directly  from  chronic 
drinking.  It  is  a  hopeful  form,  and  may  disappear  entirely  with  a  return  to 
habits  of  temperance. 

There  is  a  remarkable  condition  in  chronic  alcoholics  of  which  I  have  seen 
at  least  half  a  dozen  cases.  A  heavy  drinker,  who  may  perhaps  have  had 
attacks  of  delirium  tremens,  begins  to  get  drowsy  or  a  little  more  befuddled 
than  usual ;  gradually  the  stupor  deepens  until  he  becomes  comatose,  in  which 
state  he  may  remain  for  weeks.  There  may  be  slight  fever,  but  there  are 
no  signs  of  paralysis,  and  no  optic  neuritis.  The  urine  may  be  normal.  The 
lumbar  puncture  yields  a  clear  fluid,  but  under  high  pressure.  In  one  case, 
which  died  at  the  end  of  six  weeks,  there  were  the  anatomical  features  of  a 
serous  meningitis. 

No  characteristic  changes  are  found  in  the  nervous  system.  Hsemorrhagic 
pach}Tneningitis  is  not  very  rmcommon.  Opacity  and  thickening  of  the  pia- 
arachnoid  membranes,  with  more  or  less  wasting  of  the  convolutions,  gen- 
erally occur.  These  are  in  no  way  peculiar  to  chronic  alcoholism,  but  are 
found  in  old  persons  and  in  chronic  wasting  diseases.  In  the  very  protracted 
cases  there  may  be  chronic  encephalo-meningitis  with  adhesions  of  the  mem- 
branes. Finer  changes  in  the  nerve-cells,  their  processes,  and  the  neuroglia 
have  been  described  by  Berkley,  Hoch,  and  others.  By  far  the  most  striking 
effect  of  alcohol  on  the  nervous  system  is  the  production  of  the  alcoholic 
neuritis,  which  will  be  considered  later. 

Digestive  System. — Catarrh  of  the  stomach  is  the  most  common  symptom. 
The  toper  has  a  furred  tongue,  heavy  breath,  and  in  the  morning  a  sensation 
of  sinking  at  the  stomach  until  he  has  had  his  dram.  The  appetite  is  usu- 
ally impaired  and  the  bowels  are  constipated.  In  beer-drinkers  dilatation  of 
the  stomach  is  common. 


ALCOHOLISM.  371 

Alcohol  produces  definite  changes  in  the  liver,  leading  ultimately  to  the 
various  forms  of  cirrhosis,  to  be  described.  In  Welch's  laboratory  J.  Frieden- 
wald  has  caused  typical  cirrhosis  in  rabbits  by  the  administration  of  alcohol. 
The  effect  is  probably  a  primary  degenerative  change  in  the  liver-cells, 
although  many  good  observers  still  hold  that  the  poison  acts  first  upon  the 
connective-tissue  elements.  It  is  probable  that  a  special  vulnerability  of  the 
liver-cells  is  necessary  in  the  etiology  of  alcoholic  cirrhosis.  There  are  cases 
in  which  comparatively  moderate  drinking  for  a  few  years  has  been  followed 
by  cirrhosis;  on  the  other  hand,  the  livers  of  persons  who  have  been  steady 
drinkers  for  thirty  or  forty  years  may  show  only  a  moderate  grade  of  sclero- 
sis. For  years  before  cirrhosis  develops  heavy  drinkers  may  present  an  en- 
larged and  tender  liver,  with  at  times  swelling  of  the  spleen.  With  the  gas- 
tric and  hepatic  disorders  the  facies  often  becomes  very  characteristic.  The 
venules  of  the  cheeks  and  nose  are  dilated;  the  latter  becomes  enlarged,  red, 
and  may  present  the  condition  known  as  acne  rosacea.  The  eyes  are  watery, 
the  conjunctiva  hyperaemic  and  sometimes  bile-tinged. 

The  heart  and  arteries  in  chronic  topers  show  important  degenerative 
changes.  Alcoholism  is  one  of  the  special  factors  in  causing  arterio-sclerosis. 
Steell  has  pointed  out  the  frequency  of  cardiac  dilatation  in  these  cases. 

Kidneys. — The  influence  of  chronic  alcoholism  upon  these  organs  is  by  no 
means  so  marked.  According  to  Dickinson  the  total  of  renal  disease  is  not 
greater  in  the  drinking  class,  and  he  holds  that  the  effect  of  alcohol  on  the 
kidneys  has  been  much .  overrated.  Formad  has  directed  attention  to  the  fact 
that  in  a  large  proportion  of  chronic  alcoholics  the  kidneys  are  increased  in 
size.  The  Guy's  Hospital  statistics  support  this  statement,  and  Pitt  notes  that 
in  43  per  cent  of  the  bodies  of  hard  drinkers  the  kidneys  were  hypertrophied 
without  showing  morbid  change.  The  typical  granular  kidney  seems  to  result 
indirectly  from  alcohol  through  the  arterial  changes. 

It  was  formerly  thought  that  alcohol  was  in  some  way  antagonistic  to 
tuberculous  disease,  but  the  observations  of  late  years  indicate  clearly  that 
the  reverse  is  the  case  and  that  chronic  drinkers  are  much  more  liable  to 
both  acute  and  pulmonary  tuberculosis.  It  is  probably  altogether  a  ques- 
tion of  altered  tissue-soil,  the  alcohol  lowering  the  vitality  and  enabling  the 
bacilli  more  readily  to  develop  and  grow. 

(3)  Delirium  tremens  {mania  a  potu)  is  really  only  an  incident  in  the 
history  of  chronic  alcoholism,  and  results  from  the  long-continued  action 
of  the  poison  on  the  brain.  The  condition  was  first  accurately  described  early 
in  the  19th  century  by  Sutton,  of  Greenwich,  who  had  numerous  opportunities 
for  studying  the  different  forms  among  the  sailors.  One  of  the  most  thor- 
ough and  careful  studies  of  the  disease  was  made  by  Ware,  of  Boston.  A 
spree  in  a  temperate  person,  no  matter  how  prolonged,  is  rarely  if  ever  fol- 
lowed by  delirium  tremens;  but  in  the  case  of  an  habitual  drinker  a  tem- 
porary excess  is  apt  to  bring  on  an  attack.  It  sometimes  follows  in  conse- 
quence of  the  sudden  withdrawal  of  the  alcohol.  There  are  circumstances 
which  in  a  heavy  drinker  determine,  sometimes  with  abruptness,  the  onset  of 
delirium.  Such  are  an  accident,  a  sudden  fright  or  shock,  and  an  acute  in- 
flammation, particularly  pneumonia.  It  is  especially  apt  to  occur  in  drinkers 
admitted  to  hospitals  for  injuries,  especially  fractures,  and  as  this  seems 
most  likely  to  occur  when  the  alcohol  is  withdrawn,  it  is  well  to  give  such 


372  THE  INTOXICATIONS   AND  SUN-STROKE. 

patients  a  moderate  amount  of  alcohol.  At  the  outset  of  the  attack  the  patient 
is  restless  and  depressed  and  sleeps  badly,  symptoms  which  cause  him  to  take 
alcohol  more  freely.  After  a  day  or  two  the  characteristic  delirium  sets  in. 
The  patient  talks  constantly  and  incoherently;  he  is  incessantly  in  motion, 
and  desires  to  go  out  and  attend  to  some  imaginary  business.  Hallucinations 
of  sight  and  hearing  develop.  He  sees  objects  in  the  room,  such  as  rats, 
mice,  or  snakes,  and  fancies  that  they  are  crawling  over  his  body.  The  terror 
inspired  by  these  imaginary  objects  is  great,  and  has  given  the  popular  name 
"  horrors  ''  to  the  disease.  The  patients  need  to  be  watched  constantly,  for 
in  their  delusions  they  may  jump  out  of  the  window  or  escape.  Auditory 
hallucinations  are  not  so  common,  but  the  patient  may  complain  of  hearing 
the  roar  of  animals  or  the  threats  of  imaginary  enemies.  There  is  much  mus- 
cular tremor;  the  tongue  is  covered  with  a  thick  white  fur,  and  when  pro- 
truded is  tremulous.  The  pulse  is  soft,  rapid,  and  readily  compressed.  There 
is  usually  fever,  but  the  temperature  rarely  registers  above  102°  or  103°.  In 
fatal  cases  it  may  be  higher.  Insomnia  is  a  constant  feature.  On  the  third 
or  fourth  day  in  favorable  cases  the  restlessness  abates,  the  patient  sleeps, 
and  improvement  gradually  sets  in.  The  tremor  persists  for  some  days,  the 
hallucinations  gradually  disappear,  and  the  appetite  returns.  In  more  serious 
cases  the  insomnia  persists,  the  delirium  is  incessant,  the  pulse  becomes  more 
frequent  and  feeble,  the  tongue  dry,  the  prostration  extreme,  and  death  takes 
place  from  gradual  heart-failure. 

Diagnosis. — The  clinical  picture  of  the  disease  can  scarcely  be  confounded 
with  any  other.  Cases  with  fever,  however,  may  be  mistaken  for  meningitis. 
By  far  the  most  common  error  is  to  overlook  some  local  disease,  such  as  pneu- 
monia or  erysipelas,  or  an  accident,  as  a  fractured  rib,  which  in  a  chronic 
drinker  may  precipitate  an  attack  of  delirium  tremens.  In  every  instance  a 
careful  examination  should  be  made,  particularly  of  the  lungs.  It  is  to  be 
remembered  that  in  the  severer  forms,  particularly  the  febrile  cases,  conges- 
tion of  the  bases  of  the  lungs  is  by  no  means  uncommon.  Another  point  to 
be  borne  in  mind  is  the  fact  that  pneumonia  of  the  apex  is  apt  to  be  accom- 
panied by  delirium  similar  to  mania  a  potu. 

Prognosis. — ^Eecovery  takes  place  in  a  large  proportion  of  the  cases  in  pri- 
vate practice.  In  hospital  practice,  particularly  in  the  large  city  hospitals 
to  which  the  debilitated  patients  are  taken,  the  death-rate  is  higher.  Gerhard 
states  that  of  1,341  cases  admitted  to  the  Philadelphia  Hospital  121  proved 
fatal.  Eecurrence  is  frequent,  almost  indeed  the  rule,  if  the  drinking  is 
kept  up. 

Treatment. — Acute  alcoholism  rarely  requires  any  special  measures,  as  the 
patient  sleeps  off  the  effects  of  the  debauch.  In  the  case  of  profound  alco- 
holic coma  it  may  be  advisable  to  wash  out  the  stomach,  and  if  collapse  symp- 
toms occur  the  limbs  should  be  rubbed  and  hot  applications  made  to  the  body. 
Should  convulsions  supervene,  chloroform  may  be  carefully  administered.  In 
the  acute,  violent  alcoholic  mania  the  hypodermic  injection  of  apomorphia, 
one-eighth  or  one-sixth  of  a  grain,  is  usually  very  effectual,  causing  nausea 
and  vomiting,  and  rapid  disappearance  of  the  maniacal  symptoms. 

Chronic  alcoholism  is  a  condition  very  difficult  to  treat,  and  once  fully 
established  the  habit  is  rarely  abandoned.  The  most  obstinate  cases  are  those 
with  marked  hereditary  tendency.     Withdrawal  of  the  alcohol  is  the  first 


MORPHIA  HABIT.  373 

essential.  This  is  most  effectually  accomplished  by  placing  the  patient  in 
an  institution,  in  which  he  can  be  carefully  watched  during  the  trying  period 
of  the  first  week  or  ten  days  of  abstention.  The  absence  of  temptation  in 
institution  life  is  of  special  advantage.  For  the  sleeplessness  the  bromides 
or  hyoscine  may  be  employed.  Quinine  and  strychnine  in  tonic  doses  may 
be  given.  Cocaine  or  the  fluid  extract  of  coca  has  been  recommended  as  a  sub- 
stitute for  alcohol,  but  it  is  not  of  much  service.  Prolonged  seclusion  in  a 
suitable  institution  is  in  reality  the  only  efliectual  means  of  cure.  When  an 
hereditary  tendency  exists  a  lapse  into  the  drinking  habit  is  almost  inevitable. 

In  delirium  tremens  the  patient  should  be  confined  to  bed  and  carefully 
watched  night  and  day.  The  danger  of  escape  in  these  cases  is  very  great,  as 
the  patient  imagines  himself  pursued  by  enemies  or  demons.  Flint  mentions 
the  case  of  a  man  who  escaped  in  his  night-clothes  and  ran  barefooted  for 
fifteen  miles  on  the  frozen  ground  before  he  was  overtaken.  The  patient 
should  not  be  strapped  in  bed,  as  this  aggravates  the  delirium;  sometimes, 
however,  it  may  be  necessary,  in  which  case  a  sheet  tied  across  the  bed  may 
be  sufficient,  and  this  is  certainly  better  than  violent  restraint  by  three  or  four 
men.     Alcohol  should  be  withdrawn  at  once  unless  the  pulse  is  feeble. 

Delirium  tremens  is  a  disease  which,  in  a  large  majority  of  cases,  runs  a 
course  very  slightly  influenced  by  medicine.  The  indications  for  treatment 
are  to  procure  sleep  and  to  support  the  strength.  In  mild  cases  half  a  drachm 
of  bromide  of  potassium  combined  with  tincture  of  capsicum  may  be  given 
every  three  hours.  Chloral  is  often  of  great  service,  and  may  be  given  with- 
out hesitation  unless  the  heart's  action  is  feeble.  Good  results  sometimes 
follow  the  hypodermic  use  of  hyoscine,  one  one-hundredth  of  a  grain.  Opium 
must  be  used  cautiously,  A  special  merit  of  Ware's  work  was  the  demon- 
stration that  on  a  rational  or  expectant  plan  of  treatment  the  percentage  of 
recoveries  was  greater  than  with  the  indiscriminate  use  of  sedatives,  which 
had  been  in  vogue  for  many  years.  When  opium  is  indicated  it  should  be 
given  as  morphia,  hypodermically.  The  effect  should  be  carefully  watched, 
and  if  after  three  or  four  quarter-grain  doses  have  been  given  the  patient  is 
still  restless  and  excited,  it  is  best  not  to  push  it  farther.  Eepeated  doses  of 
trional  (grs.  xv-xx)  every  four  hours  may  be  tried.  Lamber  advises  ergotin 
hypodermically  in  both  the  acute  and  chronic  alcoholism.  When  fever  is 
present  the  tranquilizing  effects  of  a  cold  douche  or  cold  bath  may  be  tried,  or 
the  cold  or  warm  packs.  The  large  doses  of  digitalis  formerly  employed  are 
not  advisable. 

Careful  feeding  is  the  most  important  element  in  the  treatment  of  these 
cases.  Milk  and  concentrated  broths  should  be  given  at  stated  intervals.  If 
the  pulse  becomes  rapid  and  shows  signs  of  flagging  alcohol  may  be  given  in 
combination  with  the  aromatic  spirits  of  ammonia. 

II.    MORPHIA  HABIT  (Morphinomania ;  Morphinism). 

Taken  at  first  to  allay  pain,  a  craving  for  the  drug  is  gradually  engendered, 
and  the  habit  in  this  way  acquired.  The  effects  of  the  constant  use  of  opium 
vary  very  much.  In  the  East,  where  opium-smoking  is  as  common  as  tobacco- 
smoking  with  us,  the  ill  effects  are,  according  to  good  observers,  not  very 
striking.     Taken  as  morphia,  and  hypodermically,  as  is  the  rule,  it  is  very 


374  THE  INTOXICATIONS  AND  SUN-STROKE. 

injurious,  but  a  moderate  amount  may  be  taken  for  years  without  serious 
damage. 

The  habit  is  particularly  prevalent  among  women  and  physicians  who  use 
the  hypodermic  syringe  for  the  alleviation  of  pain,  as  in  neuralgia  or  sciatica. 
The  acquisition  of  the  habit  as  a  pure  luxury  is  rare  in  this  country. 

Symptoms. — The  symptoms  at  first  are  slight,  and  for  months  there  may  be 
no  disturbance  of  health.  There  are  exceptional  instances  in  which  for  a  period 
of  years  excessive  amounts  have  been  taken  without  deterioration  of  the  mental 
or  bodily  functions.  As  a  rule,  the  dose  necessary  to  obtain  the  desired  sensa- 
tion has  gradually  to  be  increased.  As  the  effects  wear  off  the  victim  expe- 
riences sensations  of  lassitude  and  mental  depression,  accompanied  often  with 
slight  nausea  and  epigastric  distress,  or  even  recurring  colic,  which  may  be  mis- 
taken for  appendicitis.  The  confirmed  opium-eater  usually  has  a  sallow,  pasty 
complexion,  is  emaciated,  and  becomes  prematurely  gray.  He  is  restless,  irrita- 
ble, and  unable  to  remain  quiet  for  any  time.  Itching  is  a  common  symptom. 
The  sleep  is  disturbed,  the  appetite  and  digestion  are  deranged,  and  except 
when  directly  under  the  influence  of  the  drug  the  mental  condition  is  one  of 
depression.  Occasionally  there  are  profuse  sweats,  which  may  be  preceded  by 
chills.  The  pupils,  except  when  under  the  direct  influence  of  the  drug,  are 
dilated,  sometimes  unequal.  In  one  case  there  was  a  persistent  oedema  of  the 
legs  without  sufficient  renal  changes  or  anasmia  to  account  for  it.  Persons 
addicted  to  morphia  are  inveterate  liars,  and  no  reliance  whatever  can  be 
placed  upon  their  statements.  In  many  instances  this  is  not  confined  to  mat- 
ters relating  to  the  vice.  In  women  the  symptoms  may  be  associated  with 
those  of  pronounced  hysteria  or  neurasthenia.  The  practice  may  be  contin- 
ued for  an  indefinite  time,  usually  requiring  increase  in  the  dose  until  ulti- 
mately enormous  quantities  may  be  needed  to  obtain  the  desired  effect. 
Finally  a  condition  of  asthenia  is  induced,  in  which  the  victim  takes  little  or 
no  food  and  dies  from  the  extreme  bodily  debility.  An  increase  in  the  dose 
is  not  always  necessary,  and  there  are  habitues  who  reach  the  point  of  satis- 
faction with  a  daily  amount  of  2  or  3  grains  of  morphia,  and  who  are  able 
to  carry  on  successfully  for  many  years  the  ordinary  business  of  life.  They 
may  remain  in  good  physical  condition,  and  indeed  often  look  ruddy. 

Treatment.— The  treatment  of  the  morphia  habit  is  extremely  difficult,  and 
can  rarely  be  successfully  carried  out  by  the  general  practitioner.  Isolation, 
systematic  feeding,  and  gradual  withdrawal  of  the  drug  are  the  essential  ele- 
ments. As  a  rule,  the  patients  must  be  under  control  in  an  institution  and 
should  be  in  bed  for  the  first  ten  days.  It  is  best  in  a  majority  of  cases  to 
reduce  the  morphia  gradually.  The  diet  should  consist  of  beef-juice,  milk,  and 
egg-white,  which  should  be  given  at  short  intervals.  The  sufferings  of  the  pa- 
tients are  usually  very  great,  more  particularly  the  abdominal  pains,  sometimes 
nausea  and  vomiting,  and  the  distressing  restlessness.  Usually  within  a  week  or 
ten  days  the  opium  may  be  entirely  withdrawn.  In  all  eases  the  pulse  should  be 
carefully  watched  and,  if  feeble,  stimulants  should  be  given,  with  the  aromatic 
spirits  of  ammonia  and  digitalis.  For  the  extreme  restlessness  a  hot  bath  is 
serviceable.  The  sleeplessness  is  the  most  distressing  symptom,  and  various 
drugs  may  have  to  be  resorted  to,  particularly  hyoscine  and  sulphonal  and 
sometimes,  if  the  insomnia  persist,  morphia  itself. 

It  is  essential  in  the  treatment  of  a  case  to  be  certain  that  the  patient  has 


LEAD-POISONING.  375 

no  means  of  obtaining  morphia.  Even  under  the  favorable  circumstances  of 
seclusion  in  an  institution,  and  constant  watching  by  a  night  and  a  day  nurse, 
I  have  known  a  patient  to  practice  deception  for  a  period  of  three  months. 
After  an  apparent  cure  the  patients  are  only  too  apt  to  lapse  into  the  habit. 
The  condition  is  one  which  has  become  so  common,  and  is  so  much  on 
the  increase,  that  physicians  should  exercise  the  utmost  caution  in  prescrib- 
ing morphia,  particularly  to  female  patients.  Under  no  circumstances  should 
a  patient  with  neuralgia  or  sciatica  be  allowed  to  use  the  hypodermic  syringe, 
and  it  is  even  safer  not  to  intrust  this  dangerous  instrument  to  the  hands  of 
the  nurse. 

III.    LEAD-POISONING  (Plumbism;  Saturnism). 

Etiology. — The  disease  is  wide-spread,  particularly  in  lead-workers  and 
among  plumbers,  painters,  and  glaziers.  The  metal  is  introduced  into  the 
system  in  many  forms.  Miners  usually  escape,  but  those  engaged  in  the  smelt- 
ing of  lead-ores  are  often  attacked.  Animals  in  the  neighborhood  of  smelt- 
ing furnaces  have  suffered  with  the  disease,  and  even  the  birds  that  feed  on 
the  berries  in  the  neighborhood  may  be  affected.  Men  engaged  in  the  white- 
lead  factories  are  particularly  prone  to  plumbism.  Accidental  poisoning  may 
come  in  many  ways;  most  commonly  by  drinking  water  which  has  passed 
through  lead  pipes  or  been  stored  in  lead-lined  cisterns.  Wines  and  cider 
which  contain  acids  quickly  become  contaminated  in  contact  with  lead.  It 
was  the  frequency  of  colic  in  certain  of  the  cider  districts  of  Devonshire  which 
gave  the  name  of  Devonshire  colic,  as  the  frequency  of  it  in  Poitou  gave  the 
name  colica  Pictonum.  Among  the  innumerable  sources  of  accidental  poi- 
soning may  be  mentioned  milk,  various  sorts  of  beverages,  hair  dyes,  false 
teeth,  and  thread.  We  have  had  in  the  Johns  Hopkins  Hospital  four  cases 
following  the  use  of  lead  and  opium  pills  for  dysentery,  of  which  cause  Miller 
(Therapeutic  Gazette,  1904)  has  collected  many  cases  from  the  literature.  It 
has  also  followed  the  use  of  Emplastrum  Diachylon  to  produee  abortion,  and 
there  is  a  case  reported  in  an  infant  from  the  application  of  lead-water  on 
the  mother's  nipples.  One  grain  every  three  hours  for  three  days,  and  two 
grains  every  three  hours  for  one  day,  have  caused  signs  of  poisoning.  A  seri- 
ous outbreak  of  lead-poisoning,  which  was  investigated  by  David  D.  Stewart, 
occurred  in  Philadelphia,  owing  to  the  disgraceful  adulteration  of  a  baking- 
powder  with  chromate  of  lead,  which  was  used  to  give  a  yellow  tint  to  the 
cakes.     Lead  given  medicinally  rarely  produces  poisoning. 

All  ages  are  attacked,  but  J.  J.  Putnam  states  that  children  are  relatively 
less  liable.  The  largest  number  of  cases  occur  between  thirty  and  forty.  Ac- 
cording to  Oliver,  females  are  more  susceptible  than  males.  He  states  that 
they  are  much  more  quickly  brought  under  its  influence,  and  in  a  recent  epi- 
demic in  which  a  thousand  cases  were  involved  the  proportion  of  females  to 
males  was  four  to  one. 

The  lead  gains  entrance  to  the  system  through  the  lungs,  the  digestive 
organs,  or  the  skin.  Poisoning  may  follow  the  use  of  cosmetics  containing 
lead.  Through  the  lungs  it  is  freely  absorbed.  The  chief  channel,  according 
to  Oliver,  is  the  digestive  system.  It  is  rapidly  eliminated  by  the  kidneys  and 
skin,  and  is  present  in  the  urine  of  lead-workers.     The  susceptibility  is  re- 


376  THE  INTOXICATIONS  AND  SUN-STROKE. 

markably  varied.  The  s}Tnptoms  may  be  manifest  within  a  month  of  expo- 
sure. On  the  other  hand,  Tanquerel  (des  Planches)  met  with  a  case  in  a 
man  who  had  been  a  lead-worker  for  fifty-two  years. 

Morbid  Anatomy. — Small  quantities  of  lead  occur  in  the  body  in  health. 
J.  J.  Putnam's  reports  show  that  of  150  persons  not  presenting  symptoms  of 
lead-poisoning  traces  of  lead  occurred  in  the  urine  of  35  per  cent. 

In  chronic  poisoning  lead  is  found  in  the  various  organs.  The  affected 
muscles  are  yellow,  fatt}^,  and  fibroid.  The  nerves  present  the  features  of 
a  peripheral  degenerative  neuritis.  The  cord  and  the  nerve-roots  are,  as  a 
rule,  uninvolved.  In  the  primary  atrophic  form  the  ganglion  cells  of  the 
anterior  horns  are  probably  implicated.  In  the  acute  fatal  cases  there  may 
be  the  most  intense  entero-colitis. 

Clinical  Forms. — iVcuTE  Poisoning. — We  do  not  refer  here  to  the  acci- 
dental or  suicidal  cases,  which  present  vomiting,  pain  in  the  abdomen,  and 
collapse  symptoms.  In  workers  in  lead  there  are  several  manifestations  which 
follow  a  short  time  after  exposure  and  set  in  acutely.  There  may  be,  in  the 
first  place,  a  rapidly  developing  anaemia.  Acute  neuritis  has  been  described, 
and  convulsions,  epilepsy,  and  a  delirium,  which  may  be,  as  Stephen  Mac- 
kenzie has  noted,  not  unlike  that  produced  by  alcohol.  There  are  also  cases 
in  which  the  gastro-intestinal  symptoms  are  most  intense  and  rapidly  prove 
fatal.  There  was  admitted  under  my  care  in  the  Philadelphia  Hospital  a 
painter,  aged  fifty,  suffering  with  anaemia  and  severe  abdominal  pain,  which 
had  lasted  about  a  week.  He  had  vomiting,  constipation  at  first,  afterward 
severe  diarrhcea  and  melasna,  with  distention  and  tenderness  of  the  abdo- 
men. There  were  albumin  and  tube-casts  in  the  urine.  The  temperature  was 
usually  subnormal.  Death  occurred  at  the  end  of  the  second  week.  There 
was  found  the  most  intense  entero-colitis  with  hemorrhages  and  exudation. 
These  acute  forms  occur  more  frequently  in  persons  recently  exposed,  and, 
according  to  Mackenzie,  are  more  frequent  in  winter  than  in  summer.  Da 
Costa  has  reported  the  onset  of  hemiplegia  after  three  days'  exposure  to  the 
poison. 

Chronic  Poisoning. 

(a)  Blood  Changes. — A  moderate  grade  of  ancemia,  the  so-called  saturnine 
cachexia,  is  usually  present.  The  corpuscles  do  not  often  fall  below  50  per 
cent.  Many  of  the  red  cells  show  a  remarkable  granular,  basophilic  degenera- 
tion when  stained  with  Jenner's  stain,  or  with  polychrome  methylene  blue. 
Grawitz  first  demonstrated  their  presence  in  cases  of  pernicious  ansemia,  and 
Pepper  (tertius)  and  White  showed  that  they  were  constantly  present  in  lead- 
poisoning.  Further  observations  by  Vaughan  and  others  have  shown  that 
such  granulations  are  found  in  the  blood  in  a  great  variety  of  conditions,  even 
in  normal  blood,  but  that  they  are  most  numerous  in  lead-poisoning,  in  which 
their  occurrence  in  very  large  numbers  is  of  considerable  value  in  diagnosis. 
Cadwalader  has  shown  the  constant  presence  of  nucleated  red  Mood-corpuscles 
even  when  the  anaemia  is  of  very  slight  grade. 

(h)  Blue  line  on  the  gums,  which  is  a  valuable  indication,  but  not  in- 
variably present.  Two  lines  must  be  distinguished:  one,  at' the  margin 
between  the  gums  and  teeth,  is  on,  not  in  the  gums,  and  is  readily  removed 
by  rinsing  the  mouth  and  cleansing  the  teeth.  The  other  is  the  well-known 
characteristic  blue-black  line  at  the  margin  of  the  gum.     The  color  is  not 


LEAD-POISONING.  377 

uniform,  but  being  in  the  papillae  of  the  gums  the  line  is,  as  seen  with  a 
magnifying-glass,  interrupted.  The  lead  is  absorbed  and  converted  in  the 
tissues  into  a  black  sulphide  by  the  action  of  sulphuretted  hydrogen  from  the 
tartar  of  the  teeth.  The  line  may  form  in  a  few  days  after  exposure  (Oliver) 
and  disappear  within  a  few  weeks,  or  may  persist  for  many  months.  Philip- 
son  has  noted  the  occurrence  of  a  black  line  in  miners,  due  to  the  deposition 
of   carbon. 

The  most  important  symptoms  of  chronic  lead-poisoning  are  colic,  lead- 
palsy,  and  the  encephalopathy.  Of  these,  the  colic  is  the  most  frequent.  Of 
Tanquerel's  cases,  there  were  1,217  of  colic,  101  of  paralysis,  and  72  of  enceph- 
alopathy. 

(c)  Colic  is  the  most  common  symptom  of  chronic  lead-poisoning.  It 
is  often  preceded  by  gastric  or  intestinal  symptoms,  particularly  constipation. 
The  pain  is  over  the  whole  abdomen.  The  colic  is  usually  paroxysmal,  like 
true  colic,  and  is  relieved  by  pressoire.  There  is  often,  in  addition,  between 
the  paroxysms  a  dull,  heavy  pain.  There  may  be  vomiting.  During  the 
attack,  as  Riegel  noted,  the  pulse  is  increased  in  tension  and  the  heart's  action 
is  retarded.  Attacks  of  pain  with  acute  diarrhoea  may  recur  for  weeks  or 
even  for  three  or  four  years. 

Certain  of  the  cases  with  acute  colic  may  present  the  features  of  an  acute 
intra-abdominal  inflammatory  condition.  A  case  was  lately  admitted  to  the 
surgical  wards  with  a  diagnosis  of  appendicitis.  Localized  pain,  slight  fever, 
and  moderate  leucocytosis  may  be  present.  The  cases  may  simulate  intestinal 
obstruction.  The  history,  the  presence  of  a  blue  line  on  the  gums,  and  the 
blood  changes  are  of  importance  in  differential  diagnosis. 

(d)  Lead-palsy. — This  is  rarely  a  primary  manifestation.  Among  54 
cases  of  lead-poisoning  treated  in  the  J.  H.  H.  and  dispensary,  there  were 
30  cases  of  lead-paralysis  (H.  M.  Thomas).  The  upper  limbs  are  most  fre- 
quently affected.  In  26  cases  the  arms  alone  were  affected,  and  18  of  these 
showed  the  typical  double  wrist-drop.  In  7  the  right  arm  alone  was  involved, 
and  in  one  the  left.  In  4  cases  both  arms  and  legs  were  attacked.  The  onset 
may  be  acute,  subacute,  or  chronic.  It  usually  occurs  without  fever.  In  its 
distribution  it  may  be  partial,  limited  to  a  muscle  or  to  certain  muscle  groups, 
or  generalized,  involving  in  a  short  time  the  muscles  of  the  extremities  and 
the  trunk.  Madame  Dejerine-Klumpke  recognizes  the  following  localized 
forms : 

(1)  Antebrachial  type,  paralysis  of  the  extensors  of  the  fingers  and  of 
the  wrist.  In  this  the  musculo-spiral  nerve  is  involved,  causing  the  char- 
acteristic wrist-drop.  The  supinator  longus  usually  escapes.  In  the  long- 
continued  flexion  of  the  carpus  there  may  be  slight  displacement  backward 
of  the  bones,  with  distention  of  the  synovial  sheaths,  so  that  there  is  a  promi- 
nent swelling  over  the  wrist.  This,  which  is  sometimes  known  as  Gruebler's 
tumor,  though  not  of  any  moment,  is  often  very  annoying  to  the  patient. 

(2)  Brachial  type,  which  involves  the  deltoid,  the  biceps,  the  brachialis 
anticus,  and  the  supinator  longus,  rarely  the  pectorals.  The  atrophy  is  of  the 
scapulo-humeral  form.  It  is  bilateral,  and  sometimes  follows  the  first  form, 
but  it  may  be  primary. 

(3)  The  Aran-Duchenne  type,  in  which  the  small  muscles  of  the  hand 
and  of  the  thenar  and  hypothenar  eminences  are  involved;  so  that  we  have  a 


378  THE  INTOXICATIONS  AND  SUN-STROKE. 

paralysis  closely  resembling  that  of  the  early  stage  of  polio-myelitis  anterior 
chronica.  The  atrophy  is  marked,  and  may  be  the  first  manifestation  of  the 
lead-palsy.    Mobius  has  shown  that  this  form  is  particularly  marked  in  tailors. 

(4)  The  peroneal  type.  According  to  Tanquerel,  the  lower  limbs  are 
involved  in  the  proportion  of  13  to  100  of  the  upper  limbs.  The  lateral 
peroneal  muscles,  the  extensor  communis  of  the  toes,  and  the  extensor  proprius 
of  the  big  toe  are  involved,  producing  the  steppage  gait. 

(5)  Laryngeal  form.  Adductor  paralysis  has  been  noted  by  Morell  Mac- 
kenzie and  others  in  lead-palsy. 

Generalized  Palsies. — There  may  be  a  slow,  chronic  paralysis,  gradually 
involving  the  extremities,  beginning  with  the  classical  picture  of  wrist-drop. 
More  frequently  there  is  a  rapid  generalization,  producing  complete  paralysis 
in  all  the  muscles  of  the  parts  in  a  few  days.  It  may  pursue  a  course  like 
an  ascending  paralysis,  associated  with  rapid  wasting  of  all  four  limbs.  Such 
cases,  however,  are  very  rare.  Death  has  occurred  by  involvement  of  the  dia- 
phragm. Oliver  reports  a  case  of  Philipson's  in  which  complete  paralysis 
supervened.  A  case  of  generalized  paralysis  was  admitted  last  winter  (1904) 
in  which  the  paralysis  began  in  the  legs  after  but  two  weeks'  work  as  an 
enameler.  It  spread  rapidly,  so  that  in  a  little  over  a  week  he  was  bed- 
ridden, and  on  admission  to  the  hospital  nearly  every  muscle  below  the  neck 
was  involved.  The  diaphragm  was  completely  paralyzed.  He  was  walking 
about  when  he  left  the  hospital,  though  there  was  still  some  weakness  remain- 
ing. Dejerine-Klumpke  also  recognizes  a  febrile  form  of  general  paralysis 
in  lead-poisoning,  which  may  closely  resemble  the  subacute  spinal  paralysis 
of  Duchenne. 

There  is  also  a  primary  saturnine  muscular  atrophy  in  which  the  weak- 
ness and  wasting  come  on  together.  It  is  this  form,  according  to  Gowers, 
which  most  frequently  assumes  the  Aran-Duchenne  type. 

The  electrical  reactions  are  those  of  lesions  of  the  lower  motor  segment, 
and  will  be  described  under  diseases  of  the  nerves."  The  degenerative  reac- 
tion in  its  different  grades  may  be  present,  depending  upon  the  severity  of 
the  disease. 

Usually  with  the  onset  of  the  paralysis  there  are  pains  in  the  legs  and 
joints,  the  so-called  saturnine  arthralgias.  Sensation  may,  however,  be 
unaffected. 

(e)  The  cerebral  symptoms  are  numerous..  Seven  of  our  cases  showed 
marked  cerebral  involvement.  One  of  the  cases  had  delusions  and  maniacal 
excitement  and  had  to  be  removed  to  an  insane  hospital.  In  other  cases  there 
occurred  transient  delirium,  attacks  of  unconsciousness,  and  in  one  case  con- 
vulsions. Optic  neuritis  or  neuro-retinitis  may  occur.  Hysterical  symptoms 
occasionally  occur  in  girls.  Convulsions  are  not  uncommon,  and  in  an  adult 
the  possibility  of  lead-poisoning  should  always  be  considered.  True  epilepsy 
may  follow  the  convulsions.  An  acute  delirium  may  occur  with  hallucina- 
tions. The  patients  may  have  trance-like  attacks,  which  follow  or  alternate 
with  convulsions.  A  few  cases  of  lead  encephalopathy  finally  drift  into 
lunatic  asylums.  Tremor  is  one  of  the  commonest  manifestations  of  lead- 
poisoning. 

(/)  Arteriosclerosis. — Lead-workers  are  notoriously  subject  to  arterio- 
sclerosis with  contracted  kidneys  and  hypertrophy  of  the  heart.     The  cases 


ARSENICAL  POISONING.  379 

usually  show  distinct  gouty  deposits,  particularly  in  the  big-toe  joint;  but 
in  this  country  acute  gout  in  lead-workers  is  rare.  According  to  Sir  Wil- 
liam Eoberts,  the  lead  favors  the  precipitation  of  the  crystalline  urates  of 
the  tissues.  Ealfe  has  shown  that  lead  diminishes  the  alkalinity  of  the 
blood,  and  so  lessens  the  solubility  of  the  uric  acid. 

Prognosis. — In  the  minor  manifestations  this  is  good.  According  to  Gow- 
ers,  the  outlook  is  bad  in  the  primary  atrophic  form  of  paralysis.  Convulsions 
are,  as  a  rule,  serious,  and  the  mental  symptoms  which  succeed  may  be  perma- 
nent.    Occasionally  the  wrist-drop  persists. 

Treatment. — Prophylactic  measures  should  be  taken  at  all  lead-works,  but, 
unless  employes  are  careful,  poisoning  is  apt  to  occur  even  under  the  most 
favorable  conditions.  Cleanliness  of  the  hands  and  of  the  finger-nails,  fre- 
quent bathing,  and  the  use  of  respirators  when  necessary,  should  be  insisted 
upon.  When  the  lead  is  in  the  system,  the  iodide  of  potassium  should  be 
given  in  from  5-  to  10-grain  doses  three  times  a  day.  For  the  colic,  local 
applications  and,  if  severe,  morphia  may  be  used.  An  occasional  morning 
purge  of  magnesium  sulphate  may  be  given.  For  the  ansemia  iron  should 
be  used.  In  the  very  acute  cases  it  is  well  not  to  give  the  iodide,  as,  accord- 
ing to  some  writers^  the  liberation  of  the  lead  which  has  been  deposited  in  the 
tissues  may  increase  the  severity  of  the  symptoms.  For  the  local  palsies  mas- 
sage and  the  constant  current  should  be  used. 

IV.    ARSENICAL  POISONING. 

Acute  poisoning  by  arsenic  is  common,  particularly  by  Paris  green  and 
such  mixtures  as  "  Eough  on  Eats,"  which  are  used  to  destroy  vermin  and 
insects.  The  chief  symptoms  are  intense  pain  in  the  stomach,  vomiting,  and, 
later,  colic,  with  diarrhoea  and  tenesmus ;  occasionally  the  symptoms  are  those 
of  collapse.  If  recovery  takes  place,  paralysis  may  follow.  The  treatment 
should  be  similar  to  that  of  other  irritant  poisons — rapid  removal  with  the 
stomach  pump,  the  promotion  of  vomiting,  and  the  use  of  milk  and  eggs. 
If  the  poison  has  been  taken  in  solution,  dialyzed  iron  may  be  used  in  doses 
of  from  6  to  8  drachms. 

Chronic  Arsenical  Poisoning. — Arsenic  is  used  extensively  in  the  arts, 
particularly  in  the  manufacture  of  colored  papers,  artificial  fiowers,  and  in 
many  of  the  fabrics  employed  as  clothing.  The  glazed  green  and  red  papers 
used  in  kindergartens  also  contain  arsenic.  It  is  present,  too,  in  many  wall- 
papers and  carpets.  Much  attention  has  been  paid  to  this  question  of  late 
years,  as  instances  of  poisoning  have  been  thought  to  depend  upon  wall-papers 
and  other  household  fabrics.  The  arsenic  compounds  may  be  either  in  the 
form  of  solid  particles  detached  from  the  paper  or  as  gaseous  volatile  bodies 
formed  from  arsenical  organic  matter  by  the  action  of  several  moulds,  notably 
Penicilium  trevicaule,  Mucor  niucedo^  etc.  (Gosio).  In  moisture,  and  at  a 
temperature  of  from  60°  to  95°  F.,  a  volatile  compound  is  set  free,  probably 
"an  organic  derivative  of  arsenic  pentoxide "  (Sanger).  The  chronic  poi- 
soning from  fabrics  and  wall-papers  may  be  due,  according  to  this  author, 
to  the  ingestion  of  minute  continued  doses  of  this  derivative.  Contaminated 
glucose,  used  in  manufacturing  beer,  caused  the  recent  epidemic  of  poison- 
ing at  Manchester.     The  associated  presence' of  selenium  compounds  may  have 


380  THE  INTOXICATIONS  AND  SUN-STROKE. 

plaj'ed  a  part  in  the  production  of  the  poisoning  (TunnielifEe  and  Rosenheim). 
Arsenic  is  eliminated  in  all  the  secretions,  and  has  been  found  in  the  milk. 
J.  J.  Putnam,  it  should  be  remembered,  has  shown  that  it  is  not  uncommon 
to  find  traces  of  arsenic  in  the  urine  of  many  persons  in  apparent  health  (30 
per  cent).  The  effects  of  moderate  quantities  of  arsenic  are  not  infrequently 
seen  in  medical  practice.  In  chorea  and  in  pernicious  anaemia,  steadily  in- 
creasing doses  are  often  given  until  the  patient  takes  from  15  to  20  drops  of 
FoTvler  s  solution  three  times  a  day.  Flushing  and  In-perEemia  of  the  skin, 
puffiness  of  the  eyelids  or  above  the  eyebrows,  nausea,  vomiting,  and  diarrhoea 
are  the  most  common  symptoms.  Eedness  and  sometimes  bleeding  of  the 
gums  and  salivation  occur.  In  the  protracted  administration  of  arsenic 
patients  may  complain  of  numbness  and  tingling  in  the  fingers.  Cutaneous 
pigmentation  and  keratosis  are  very  characteristic,  and  as  a  late  rare  sequence 
of  the  latter,  epithelioma.  In  chorea  neuritis  has  occurred,  and  a  patient  of 
mine  with  Hodgkin's  disease  had  multiple  neuritis  after  taking  ^iv  oj  of  Fow- 
ler's solution  in  seventy-five  days,  during  which  time  there  were  fourteen  days 
on  which  the  drug  was  omitted. 

In  the  Manchester  epidemic  nearly  all  cases  presented  signs  of  neuritis 
and  lesions  of  the  skin.  In  some  the  sensory  disturbances  predominated, 
in  others  the  motor,  the  individuals  being  unable  to  walk  or  to  use  their 
hands.  In  a  certain  number  there  was  muscular  inco-ordination,  resembling 
that  of  locomotor  ataxia.  Eapid  muscular  atrophy  characterized  some  cases. 
In  not  a  few  patients  a  condition  of  erythromelalgia  was  present.  Occasion- 
ally a  catarrh  of  the  respiratory  and  alimentary  tracts  was  the  chief  feature. 
Pigmentation,  keratosis,  and  herpes  were  the  most  characteristic  cutaneous 
manifestations  (Kehmack  and  Kirkby,  Arsenical  Poisoning  in  Beer  Drink- 
ers). How  far  similar  symptoms  are  to  be  attributed  to  the  small  quantities 
of  arsenic  absorbed  from  wall-papers  and  fabrics  is  by  some  considered  doubt- 
ful. That  children  and  adults  may  take  with  impunity  large  doses  for  months 
without  unpleasant  effects,  and  the  fact  of  the  gradual  establishment  of  a 
toleration  which  enables  Styrian  peasants  to  take  as  much  as  8  grains  of  arse- 
nious  acid  in  a  day,  speak  strongly  against  it.  On  the  other  hand,  as  Sanger 
states,  we  do  not  know  accurately  the  effects  of  many  of  the  compounds  in 
minute  and  long-continued  doses,  notably  the  arsenates. 

Arsenical  paralysis  has  the  same  characteristics  as  lead-palsy,  but  the  legs 
are  more  affected  than  the  arms,  particularly  the  extensors  and  peroneal 
group,  so  that  the  patient  has  the  characteristic  steppage  gait  of  peripheral 
neuritis. 

The  electrical  reaction  in  the  muscles  may  be  disturbed  before  there  is 
any  loss  of  power,  and  when  the  patient  is  asked  to  extend  the  wrist  fully  and 
to  spread  the  fingers  slight  weakness  may  be  detected  early. 

V.     FOOD  POISONING. 

There  may  be  "  death  in  the  pot "'  from  many  causes.  Food  poisons  may 
be  endogenous  or  exogenous.  Those  articles  in  which  the  poison  is  of  endoge- 
nous origin  can  scarcely  be  designated  as  foods.  The  poisonous  mushroom, 
for  example,  is  often  mistaken  for  the  edible  form.  The  former  is  injurious 
because  it  normally  produces  a  highly  poisonous  alkaloid,  muscarine.     Cer- 


FOOD  POISONING.  381 

tain  fish  also  produce  normal  physiological  but  toxic  products.  When  eaten 
by  mistake,  as  frequently  occurs  in  the  West  Indies  and  Japan,  these  fish  may 
cause  poisonous  symptoms.  The  exogenous  origin  of  food  poisons  is  by  far 
the  commonest.  Under  this  head  come  those  foods  which  are  rendered  poison- 
ous by  accidental  contamination  from  outside  sources.  Food  may  contain 
the  specific  organisms  of  disease,  as  of  tuberculosis  or  trichinosis;  milk  and 
other  foods  may  become  infected  with  typhoid  bacilli,  and  so  convey  the  disease. 

Animals  (or  insects,  as  bees)  may  feed  on  substances  which  cause  their 
flesh  or  products  to  be  poisonous  to  man. 

The  grains  used  as  food  may  be  infected  with  fungi  and  cause  the  epi- 
demics of  ergotism,  etc. 

Foods  of  all  sorts  may  become  contaminated  with  the  bacteria  of  putre- 
faction, the  products  of  which  may  be  highly  poisonous. 

The  term  "  ptomaine  poisoning  "  has  been  popularized  to  such  an  extent 
that  it  is  used  synonymously  with  food  poisoning.  The  term  ptomaine  was 
introduced  twenty-five  years  ago  by  the  Italian  chemist,  Selmi,  to  designate 
basic  alkaloidal  products  formed  in  putrefaction.  It  is  largely  through  the 
labors  of  Brieger  that  our  knowledge  of  ptomaines  was  gained.  Mytilotoxin, 
found  in  poisonous  mussels,  is  of  this  class,  and  is  by  far  the  most  poisonous 
of  the  known  ptomaines. 

Among  the  more  common  forms  are  the  following: 

(1)  Meat  Poisoning. — Cases  have  usually  followed  the  eating  of  sausages 
or  pork-pie  or  head-cheese,  and  also  occasionally  beef,  veal,  never  mutton. 
Sausage  poisoning,  which  is  known  by  the  name  of  botulism  or  allantiasis,  has 
long  been  recognized,  and  there  have  been  numerous  outbreaks,  particularly 
in  parts  of  Germany.  Similar  attacks  have  been  produced  by  ham  and  by 
head-cheese.  The  precise  nature  of  the  kreotoxicons  has  not  yet  been  deter- 
mined. Other  outbreaks  have  followed  the  eating  of  beef  and  veal.  In  the 
majority  of  these  cases  the  meat  has  undergone  decomposition,  though  the 
change  may  not  have  been  evident  to  the  taste.  The  organisms  which  pro- 
duce the  toxins  causing  the  poisonous  symptoms  are  nearly  always  anaerobes. 
Van  Ermengena  isolated  an  organism,  to  which  he  gave  the  name  B.  botu- 
linus,  from  a  diseased  ham,  which  poisoned  thirty-four  persons,  all  members 
of  a  musical  society,  at  Ellezelles,  in  Germany.  An  organism  frequently 
found  in  infected  meat  is  B.  enteritidis,  first  isolated  by  Gartner  in  1888  from 
meat  which  had  poisoned  a  large  number  of  persons.  In  recent  years  a  num- 
ber of  epidemics  of  food  poisoning  have  been  shown  to  be  in  all  probability 
caused  by  the  Proteus  vulgaris  or  its  related  species.  Such  epidemics  have 
been  reported  by  Levy  and  Vesenberg.  The  symptoms  of  meat  poisoning  are 
those  of  acute  gastro-intestinal  irritation.  Ballard's  description  of  the  Well- 
beck  cases,  quoted  by  Vaughan,  holds  good  for  a  majority  of  them: 

"  A  period  of  incubation  preceded  the  illness.  In  51  cases  where  this 
could  be  accurately  determined,  it  was  twelve  hours  or  less  in  5  cases ;  between 
twelve  and  thirty-six  hours  in  34  cases;  between  thirty-six  and  forty-eight 
hours  in  8  cases;  and  later  than  this  in  only  4  cases.  In  many  cases  the 
first  definite  symptoms  occurred  suddenly,  and  evidently  unexpectedly,  but 
in  some  cases  there  were  observed  during  the  incubation  more  or  less  feeling 
of  languor  and  ill-health,  loss  of  appetite,  nausea,  or  fugitive,  griping  pains  in 
the  belly.     In  about  a  third  of  the  cases  the  first  definite  symptom  was  a  sense 


382  THE  INTOXICATIONS  AND  SUN-STROKE. 

of  chilliness,  usually  with  rigors,  or  trembling,  in  one  case  accompanied  by 
dj^spnoea;  in  a  few  cases  it  was  giddiness  with  faintness,  sometimes  accom- 
panied by  a  cold  sweat  and  tottering;  in  others  the  first  symptom  was  head- 
ache or  pain  somewhere  in  the  trunk  of  the  body — e.  g.,  in  the  chest,  back, 
between  the  shoulders,  or  in  the  abdomen,  to  which  part  the  pain,  wherever 
it  might  have  commenced,  subsequently  extended.  In  one  case  the  first  symp- 
tom noticed  was  a  difficulty  in  swallowing.  In  tAvo  cases  it  was  intense  thirst. 
But  however  the  attack  may  have  commenced,  it  was  usually  not  long  before 
pain  in  the  abdomen,  diarrhoea,  and  vomiting  came  on,  diarrhoea  being  of 
more  certain  occurrence  than  vomiting.  The  pain  in  several  cases  commenced 
in  the  chest  or  between  the  shoulders,  and  extended  first  to  the  upper  and 
then  to  the  lower  part  of  the  abdomen.  It  was  usually  very  severe  indeed, 
quickly  producing  prostration  or  faintness,  with  cold  sweats.  It  was  variously 
described  as  crampy,  burning,  tearing,  etc.  The  diarrhoeal  discharges  were 
in  some  cases  quite  unrestrainable,  and  (where  a  description  of  them  could 
be  obtained)  were  said  to  have  been  exceedingly  offensive  and  usually  of  a 
dark  color.  Muscular  weakness  was  an  early  and  very  remarkable  symptom 
in  nearly  all  the  cases,  and  in  many  it  was  so  great  that  the  patient  could  only 
stand  by  holding  on  to  something.  Headache,  sometimes  severe,  was  a  com- 
mon and  early  symptom;  and  in  most  cases  there  was  thirst,  often  intense 
and  most  distressing.  The  tongue, -when  observed,  was  described  usually  as 
thickly  coated  with  a  brown,  velvety  fur,  but  red  at  the  tip  and  edges.  In 
the  early  stage  the  skin  was  often  cold  to  the  touch,  but  afterward  fever  set 
in,  the  temperature  rising  in  some  cases  to  101°,  103°,  and  104°  F.  In  a 
few  severe  cases,  where  the  skin  was  actually  cold,  the  patient  complained  of 
heat,  insisted  on  throwing  off  the  bedclothes,  and  was  very  restless.  The 
pulse  in  the  height  of  the  illness  became  quick,  counting  in  some  cases 
100  to  128." 

Many  instances  are  on  record  of  poisoning  by  canned  goods,  particu- 
larly meat.  Some  of  these,  according  to  John  G.  Johnson,  have  been  cases 
of  corrosive  poisoning  from  muriate  of  zinc  and  muriate  of  tin  used  as  an 
amalgam,  but  poisonous  effects  identical  with  those  just  described  have  fol- 
lowed the  use  of  canned  meats. 

Certain  game  birds,  particularly  the  grouse,  are  stated  to  be  poisonous, 
in  special  districts  and  at  certain  seasons  of  the  year.  It  is  a  noteworthy  fact 
that  mutton  and  lamb  have  thus  far  not  been  implicated  as  a  cause  of  food 
poisoning. 

(3)  Poisoning  by  Milk  Products. — (a)  The  poisonous  effects  which  fol- 
low the  drinking  of  milk  infected  with  saprophytic  bacteria,  is  considered  in 
the  section  on  the  diarrhoea  of  infants. 

(b)  Cheese  Poisoning. — Various  milk  products,  ice  cream,  custard,  and 
cheese  may  prove  highly  poisonous.  Among  the  poisons  Vaughan  now  states 
that  the  tyrotoxicon  "  is  not  the  one  most  frequently  present,  nor  is  it  the 
most  active  one."  In  one  epidemic  he  and  ISTovy  have  isolated  from  cheese  a 
substance  belonging  to  the  poisonous  albumins,  and  in  an  extensive  ice-cream 
epidemic  Vaughan  and  Perkins  found  in  the  ice  cream  a  highly  pathogenic 
bacillus,  but  its  toxin  has  not  been  separated. 

The  symptoms  are  those  of  acute  gastro-intestinal  irritation,  and  are 
similar  to  those  already  detailed  by  Ballard. 


FOOD  POISONING.  383 

(3)  Poisoning  by  Shell-fish  and  Fish. —  (a)  Mussel  Poisoning. — Brieger 
has  separated  a  ptomaine — mytilotoxin — which  exists  chiefly  in  the  liver  of 
the  mussel.  The  observations  of  Schmidtmann  and  Cameron  have  shown 
that  the  mussel  from  the  open  sea  only  becomes  poisonous  when  placed  in  filthy 
waters,  as  at  Wilhelmshafen. 

Dangerous,  even  fatal,  effects  may  follow  the  eating  of  either  raw  or  cooked 
mussels.  The  symptoms  are  those  of  an  acute  poisoning  with  profound  action 
on  the  nervous  system,  and  without  gastro-intestinal  manifestations.  There 
are  numbness  and  coldness,  no  fever,  dilated  pupils,  and  rapid  pulse;  death 
occurs  sometimes  within  two  hours  with  collapse  symptoms.  In  an  epidemic 
at  Wilhelmshafen,  Germany,  in  1885,  nineteen  persons  were  attacked,  four 
of  whom  died.  Salkowski  and  Brieger  isolated  the  mytilotoxin  from 
specimens  of  the  mussels.  Poisoning  occasionally  follows  the  eating  of 
oysters  which  are  stale  or  decomposed.  The  symptoms  are  usually  gastro- 
intestinal. 

(b)  Fish  Poisoning. — There  are  two  distinct  varieties;  in  one  the  poison 
is  a  physiological  product  of  certain  glands  of  the  fish,  in  the  other  it  is  a 
product  of  bacterial  growth.  The  salted  sturgeon  used  in  parts  of  Russia 
has  sometimes  proved  fatal  to  large  numbers  of  persons.  In  the  middle  parts 
of  Europe  the  barb  is  stated  to  be  sometimes  poisonous,  producing  the  so- 
called  "  harben  cholera."  In  China  and  Japan  various  species  of  the  tetrodon 
are  also  toxic,  sometimes  causing  death  within  an  hour,  with,  symptoms  of 
intense  disturbance  of  the  nervous  system.  Beri-beri  is  thought  by  some  to 
be  due  to  the  consumption  of  certain  kinds  of  fish. 

(4)  Grain  and  Vegetable  Food  Poisoning. 

(1)  Ergotis7n. — The  prolonged  use  of  meal  made  from  grains  contami- 
nated with  the  ergot  fungus  (claviceps  purpurea)  causes  a  series  of  symp- 
toms know  as  ergotism,  epidemics  of  which  have  prevailed  in  different  parts 
of  Europe.  Two  forms  of  this  chronic  ergotism  are  described — tbe  one, 
gangrenous,  is  believed  to  be  due  to  the  sphacelinic  acid,  the  other,  convulsive, 
or  spasmodic,  is  due  to  the  cornutin.  In  the  former,  mortification  affects 
the  extremities — usually  the  toes  and  fingers,  less  commonly  the  ears  and 
nose.  Preceding  the  onset  of  the  gangrene  there  are  usually  anesthesia, 
tingling,  pains,  spasmodic  movements  of  the  muscles,  and  gradual  blood  stasis 
in  certain  vascular  territories. 

The  nervous  manifestations  are  very  remarkable.  After  a  prodromal  stage 
of  ten  to  fourteen  days,  in  which  the  patient  complains  of  weakness,  headache, 
and  tingling  sensations  in  different  parts  of  the  body,  perhaps  accompanied 
with  slight  fever,  symptoms  of  spasm  develop,  producing  cramps  in  the  mus- 
cles and  contractures.  The  arms  are  flexed  and  the  legs  and  toes  extended. 
These  spasms  may  last  from  a  few  hours  to  many  days  and  relapses  are  fre- 
quent. In  severer  cases  epilepsy  develops  and  the  patient  may  die  in  convul- 
sions. Mental  symptoms  are  common,  manifested  sometimes  in  a  prelimi- 
nary delirium,  but  more  commonly,  in  the  chronic  poisoning,  as  melancholia 
or  dementia.  Posterior  spinal  sclerosis  occurs  in  chronic  ergotism.  In  the 
interesting  group  of  29  cases  studied  by  Tuczek  and  Siemens,  9  died  at  various 
periods  after  the  infection,  and  four  post  mortems  showed  degeneration  of  the 
posterior  columns.  A  condition  similar  to  tabes  dorsalis  is  gradually  pro- 
duced by  this  slow  degeneration  in  the  spinal  cord. 


384  THE  INTOXICATIONS  AND  SUN-STROKE. 

(2)  Lathyrism  (Lupinosis). — An  affection  produced  by  the  use  of  meal 
from  varieties  of  vetches,  chiefly  the  Lathyrus  sativus  and  L.  cicera.  The 
grain  is  popularly  known  as  the  chick-pea.  The  grains  are  usually  powdered 
and  mixed  with  the  meal  from  other  cereals  in  the  preparation  of  bread.  As 
early  as  the  seventeenth  century  it  was  noticed  that  the  use  of  flour  with  which 
the  seeds  of  the  Lathyrus  were  mixed  caused  stiffness  of  the  legs.  The  subject 
did  not,  however,  attract  much  attention  before  the  studies  of  James  Irving, 
in  India,  who  between  1859  and  1868  jiublished  several  important  communi- 
cations, describing  a  form  of  spastic  parajjlegia  affecting  large  numbers  of 
the  inhabitants  in  certain  regions  of  India  and  due  to  the  use  of  meal  made 
from  the  Lathyrus  seeds.  It  also  produces  a  spastic  paraplegia  in  animals. 
The  Italian  observers  describe  a  similar  form  of  paraplegia,  and  it  has  been 
observed  in  Algiers  by  the  French  physicians.  The  condition  is  that  of  a 
spastic  paralysis,  involving  chiefly  the  legs,  which  may  proceed  to  complete 
paraplegia.  The  arms  are  rarely,  if  ever,  affected.  It  is  evidently  a  slow 
sclerosis  induced  under  the  influence  of  this  toxic  agent.  The  precise  ana- 
tomical condition,  so  far  as  I  can  ascertain,  has  not  yet  been  determined. 

(3)  Pellagra. — Maidismus,  a  disease  due  to  the  use  of  altered  maize,  occurs 
extensively  in  parts  of  Italy,  in  the  south  of  France,  and  in  Spain.  Searcy, 
Babcock,  Wood,  and  Bellamy  have  shown  (1907-1908)  that  it  is  not  an  un- 
common disease  in  the  southern  parts  of  the  United  States;  many  of  the 
cases  are  acute.  A  case  has  been  described  in  England  (1906).  In  the 
early  stage  the  symptoms  are  indefinite,  characterized  by  debility,  pains  in 
the  sj^ine,  insomnia,  digestive  disturbances,  more  rarely  diarrhoea.  The  first 
clear  manifestation  of  the  disease  is  the  pellagral  erythema,  which  almost 
invariably  appears  in  the  spring.  This  is  followed  by  desiccation  and  exfolia- 
tion of  the  epidermis,  which  becomes  very  rough  and  dry,  and  occasionally 
crusts  form,  beneath  which  there  is  suppuration.  With  these  cutaneous  mani- 
festations there  are  digestive  troubles — salivation,  dyspepsia,  and  diarrhoea — 
which  may  be  of  a  dysenteric  nature.  After  lasting  for  a  few  months  improve- 
ment occurs  in  the  milder  cases  and  convalescence  is  gradvially  established. 
In  the  more  severe  and  chronic  forms  there  are  pronounced  nervous  symptoms 
— headache,  backache,  spasms,  and  finally  paralysis  and  mental  disturbance. 
The  paralytic  condition  affects  the  legs  and  leads  gradually  to  paraplegia.  The 
mental  manifestations,  which  are  rarely  met  with  until  the  third  or  fourth 
attack,  are  melancholia  or  suicidal  mania.  Finally,  there  may  be  a  condition 
of  the  most  pronounced  cachexia.     Symmetrical  gangrene  sometimes  occurs. 

The  anatomical  findings  are  indefinite.  Chronic  degenerative  changes 
have  been  found,  particularly  fatty  degeneration  and  a  peculiar  pigmentation 
in  the  viscera.  The  measures  to  be  employed  are  change  in  diet,  removal  from 
the  infected  district,  and,  as  a  prophylaxis,  proper  ripening  and  preservation 
of  the  corn,  the  toxic  changes  in  which  are  apparently  due  to  the  action  of  a 
special  organism. 

(4)  Potato-poisoning. — It  has  long  been  known  that  potatoes  contain 
normally  a  very  small  amoimt  (about  0.06  per  cent)  of  the  poisonous  prin- 
ciple, solanin,  but  it  is  only  quite  recently  that  it  has  been  discovered  that, 
under  certain  circumstances,  they  may  contain  the  poison  in  amounts  sufficient 
to  cause  grave  disturbance  of  the  system.  The  increase  is  due  to  the  action 
of  at  least  two  species  of  bacteria,  Bacterium  solaniferum  non-colorabile  and 


SUN-STROKE.  385 

Bacterium  solaniferum  colorahile,  and  occurs  in  those  tubers  which,  during 
growth,  have  lain  partially  exposed  above  ground,  and  in  those  which,  during 
storage,  have  become  well  sprouted.  '  The  most  extensive  outbreak  of  potato- 
poisoning  recorded  occurred  in  1899  in  a  German  regiment,  fifty-six  members 
of  which,  after  eating  sprouted  potatoes,  were  seized  with  chills,  fever,  head- 
ache, vomiting,  diarrhoea,  colic,  and  great  prostration.  Many  were  jaundiced 
and  several  collapsed,  but  all  recovered.  Samples  of  the  remaining  potatoes 
yielded  0.38  per  cent  of  solanin,  and  this  would  indicate  that  a  full  portion 
must  have  contained  about  5  grains. 

Treatment. — The  source  of  the  infection  must  be  ascertained  and  the 
ofi^ending  food  destroyed.  The  stomach  should  be  washed  out  and  the  bowels 
evacuated  by  a  brisk  saline  purge.  Little  can  be  done  for  the  symptoms  of 
poisoning  of  the  nervous  system.  Saline  infusions,  hypodermically,  may  be 
of  service  in  promoting  the  elimination  of  the  toxins. 


VI.     SUN-STROKE   (Siriasis). 

{Heat  Exhaustion ;  Insolation;  Thermic  Fever;  Heat-stroke;  Coup  de  Soleil.) 

Definition. — A  condition  produced  by  exposure  to  excessive  heat. 

It  is  one  of  the  oldest  of  recognized  diseases ;  two  instances  are  mentioned 
in  the  Bible.  It  was  long  confounded  with  apoplexy.  The  Anglo-Indian 
surgeons  gave  admirable  descriptions  of  it.  In  the  United  States  the  most 
important  contributions  have  come  from  the  New  York  Hospital  and  the 
Pennsylvania  Hospital;  from  the  former,  the  studies  of  Swift  and  Darrach, 
from  the  latter,  the  papers  of  Gerhard,  George  B.  Wood,  the  elder  Pepper,  and 
Levick.  In  Kew  Orleans,  Bennett  Dowler  studied  the  disease  and  recognized 
the  difference  between  heat  exhaustion  and  sun-stroke.  Two  forms  are  recog- 
nized, heat  exhaustion  and  heat-stroke. 

Heat  Exhaustion. — Prolonged  exposure  to  high  temperatures,  particu- 
larly when  combined  with  physical  exertion,  is  liable  to  be  followed  by  extreme 
prostration,  collapse,  restlessness,  and  in  severe  cases  by  delirium.  The  sur- 
face is  usually  cool,  the  pulse  small  and  rapid,  and  the  temperature  may  be 
subnormal — as  low  as  95°  or  96°.  The  individual  need  not  necessarily  be 
exposed  to  the  direct  rays  of  the  sun,  but  the  condition  may  come  on  at  night 
or  when  working  in  close,  confined  rooms.  It  may  also  follow  exposure  to 
great  artificial  heat,  as  in  the  engine  rooms  of  the  Atlantic  steamships. 

Sun-stroke  or  Thermic  Fever, — The  cases  are  chiefly  found  in  persons  who, 
while  working  very  hard,  are  exposed  to  the  sun.  Soldiers  on  the  march 
with  their  heavy  accoutrements  are  particularly  liable  to  attack.  In  the 
larger  cities  of  this  country  the  cases  are  almost  exclusively  confined  to  work- 
men who  are  much  exposed  and,  at  the  same  time,  have  been  drinking  beer 
and  whisky. 

Morbid  Anatomy  and  Pathology. — Bigor  mortis  occurs  early.  Putrefac- 
tive changes  may  come  on  with  great  rapidity.  The  venous  engorgement  is 
extreme,  particularly  in  the  cerebrum.  The  left  ventricle  is  contracted 
(Wood),  and  the  right  chamber  dilated.  The  blood  is  usually  fluid;  the 
lungs  are  intensely  congested.  Parenchymatous  changes  occur  in  the  liver 
and  kidneys.  '  • 

26 


386  THE  INTOXICATIONS  AND  SUN-STROKE. 

According  to  Wood,  "  lieat  exhaustion  with  lowered  temiDerature  repre- 
sents a  sudden  vaso-motor  palsy,  i.  e.,  a  condition  in  which  the  existing  effect 
of  the  heat  j)aral3'zes  the  centre  in  the  medulla."'  On  the  other  hand,  thermic 
fever  is  held  to  be  due  to  paralysis  under  the  influence  of  the  extreme  external 
heat  of  the  centre  in  the  medulla  which  regulates  the  disposition  of  the  bodily 
heat.  Owing  to  this  disturbance,  more  heat  is  produced  and  less  given  ofE 
than  normally. 

Sambron  has  (B.  M.  J.,  1898,  i)  advanced  the  view  that  siriasis  is  an 
infectious  disease.  He  argues  that  heat  alone  can  not  cause  it,  that  it  occurs 
in  certain  localities  and  in  epidemic  outbursts,  and  persons  acclimatized  have 
a  relative  immunity,  etc. 

Symptoms. — The  patient  may  be  struck  down  and  die  within  an  hour 
with  sjTiiptoms  of  heart-failure,  dyspncea,  and  coma.  This  form,  sometimes 
known  as  the  asphyxial,  occurs  chiefly  in  soldiers  and  is  graphically  described 
by  Parkes.  Death  indeed  may  be  almost  instantaneous,  the  victims  falling 
as  if  struck  upon  the  head.  The  more  usual  form  comes  on  during  exposure, 
with  pain  in  the  head,  dizziness,  a  feeling  of  oppression,  and  sometimes  nausea 
and  vomiting.  Visual  disturbances  are  common,  and  a  patient  may  have  col- 
ored vision.  Diarrhoea  or  frequent  micturition  may  supervene.  Insensi- 
bility follows,  which  may  be  transient  or  which  deepens  into  a  profound  coma. 
The  patients  are  usually  admitted  to  hospital  in  an  unconscious  state,  with 
the  face  flushed,  the  skin  pungent,  the  pulse  rapid  and  full,  and  the  tempera- 
ture ranging  from  107°  to  110°,  or  even  higher,  as  shown  in  the  accompany- 
ing chart.  F.  A.  Packard  states  that  of  the  31  cases  admitted  to  the  Penn- 
sylvania Hospital  in  the  summer  of  1887,  in  a  majority  of  them  the  tempera- 
ture was  between  110°  and  111°.  In  one  case  the  temperature  was  112°.  The 
breathing  is  labored  and  deep,  sometimes  stertorous.  Usually  there  is  com- 
plete relaxation  of  the  muscles,  but  twitchings,  jactitation,  or  very  rarely  con- 
vulsions may  occur.  The  pupils  may  at  first  be  dilated,  but  by  the  time  the 
cases  are  admitted  to  hospital  they  are  (in  a  majorit}')  extremely  contracted. 
Petechise  may  be  present  upon  the  skin.  In  the  fatal  cases  the  coma  deepens, 
the  cardiac  pulsations  become  more  rapid  and  feeble,  the  breathing  becomes 
hurried  and  shallow  and  of  the  Che}Tie-Stokes  type.  The  fatal  termination 
may  occur  within  twent3-four  or  thirty-six  hours.  Favorable  indications  are 
the  return  of  consciousness  and  a  fall  in  the  fever.  The  recovery  in  these 
cases  may  be  complete.  In  other  instances  there  are  remarkable  after-effects, 
the  most  constant  of  which  is  a  permanent  inability  to  bear  high  temperatures. 
Such  patients  become  very  uneasy  when  the  thermometer  reaches  80°  F.  in 
the  shade.  Loss  of  the  power  of  mental  concentration  and  failure  of  memory 
are  more  constant  and  very  troublesome  sequelae.  Such  patients  are  always 
worse  in  the  hot  weather.  Occasionally  there  are  convulsions,  followed  by 
marked  mental  disturbance.  Dercum  has  described  peripheral  neuritis  as 
a  sequence,  and  the  patient  whose  chart  is  here  given  had  an  acute  neu- 
ritis in  the  legs.  This  is  a  point  in  favor  of  the  infectious  nature  of  the 
disease. 

Guiteras  has  called  attention  to  a  form  of  fever  occurring  in  the  South, 
known  in  Florida  as  "  Florida  fever,"  in  the  Carolinas  as  "  country  fever," 
and  in  tropical  countries  as  fievre  inflammatoire.  The  cases  last  for  a  vari- 
able time,  and  are  mistaken  for  malaria  or  t^'phoid;  but  he  believes  them 


SUN-STROKE. 


387 


to  be  entirely  distinct  and  due  to  a  prolonged  action  of  the  high  tempera- 
tures.    He  has  called  the  condition  a  "  continued  thermic  fever." 

The  diagnosis  of  heat  exhaustion  from  thermic  fever  is  readily  made,  as 
the  difference  between  the  two  conditions  is  striking.  "  In  solar  exhaustion 
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Chart  XIII. — Case  of  Sun-stroke  Treated  with  the  Ice-bath;  Recovery. 
.  (Rectal  Temperatures.) 


pulse  is  small  and  soft;  the  vital  forces  fall  into  a  temporary  collapse;  the 
senses  remain  entire"  (Dowler)  ;  whereas  in  sun-stroke  or  heat  apoplexy 
there  is  usually  unconsciousness  and  pyrexia. 

The  mode  of  onset,  together  with  the  circumstances  under  which  it  occurs 
and  the  high  temperature,  permits  thermic  fever  to  be  readily  differentiated 
from  apoplexy  and  coma  from  other  conditions. 

Treatment. — In  heat  exhaustion  stimulants  should  be  given  freely,  and 
if  the  temperature  is  below  normal  the  hot  bath  should  be  used.  Ammonia 
may  be  given  if  necessary.  In  thermic  fever  the  indications  are  to  reduce 
the  temperature  as  rapidly  as  possible.  This  may  be  done  by  packing  the 
patient  in  a  bath  with  ice.  Rubbing  the  body  with  ice  was  practised  at  the 
New  York  Hospital  by  Darrach  in  1857,  and  is  an  excellent  procedure  to 
lower  the  temperature  rapidly.  Ice-water  enemata  may  also  be  employed. 
At  the  Pennsylvania  Hospital  in  the  summer  of  1887  the  ice-pack  was  used 
with  great  advantage.  Of  31  cases  only  13  died,  results  probably  as  satis- 
factory as  can  be  obtained,  considering  that  many  of  the  patients  are  almost 


388  THE  INTOXICATIONS  AND  SUN-STROKE. 

moribund  when  brought  to  hospital.  They  should  be  compared  with  Swift's 
statistics,  in  which  of  150  cases  78  died.  In  the  cases  in  which  the  symptoms 
are  those  of  intense  asphyxia,  and  in  which  death  may  take  place,  in  a  few 
minutes,  free  bleeding  should  be  practised,  a  procedure  which  saved  Weir 
Mitchell  when  a  young  man.  For  the  convulsions  chloroform  should  be  given 
at  once.  Of  other  remedies,  the  antipyretics  have  been  employed,  and  may  be 
given  when  there  is  any  special  objection  to  hydrotherapy,  for  which,  however, 
they  can  not  be  substituted. 


SECTION    IV. 
OOI^STITUTIO^AL  DISEASES. 


I.    ARTHRITIS    DEFORMANS. 

Definition. — A  chronic  disease  of  the  joints  of  doubtful  etiology,  charac- 
terized by  changes  in  the  synovial  membranes  and  peri-articular  structures, 
and  in  some  cases  by  atrophic  and  hypertrophic  changes  in  the  bones. 

Long  believed  to  be  intimately  associated  with  gout  and  rheumatism 
(whence  the  names  rheumatic  gout  and  rheumatoid  arthritis),  this  close  rela- 
tionship seems  now  very  doubtful,  since  in  a  majority  of  the  cases  no  history 
of  either  affection  can  be  determined.  By  the  studies  of  the  Boston  orthopedic 
surgeons  (Bradford,  Goldthwaite,  and  Lovett)  and  of  Strangeways  and  his 
pupils  at  Cambridge  (England)  we  are  gradually  getting  a  very  accurate 
knowledge  of  the  anatomical  and  clinical  forms  of  this  common  disease. 

Etiology. — Age. — A  majority  of  the  cases  are  between  the  ages  of  thirty 
and  fifty.  In  A.  E.  Garrod's  analysis  of  500  cases  there  were  only  25  under 
twenty  years  of  age.  In  my  series  of  170  cases  studied  by  T.  McCrae,  in 
one  half  the  onset  was  before  the  age  of  thirty  years. 

Sex. — Among  Garrod's  500  cases  there  were  411  in  women.  More  than 
half  in  my  series  were  in  males.  In  James  Stewart's  report  of  40  cases  from 
the  Eoyal  Victoria  Hospital  only  20  were  in  females.  In  women  its  close  asso- 
ciation with  the  menopause  has  been  noted.  It  seems  to  be  more  frequent,  too, 
in  those  who  have  had  ovarian  or  uterine  trouble  or  who  are  sterile. 

Predisposition. — In  216  cases  in  Garrod's  series  there  was  a  family  history 
of  joint  troubles.  About  one-third  of  my  series  gave  a  family  history  of 
arthritis.  Two  or  three  children  in  a  family  may  be  affected.  In  America 
the  incidence  in  the  negro  is  much  less  than  in  the  white. 

BJieumatism  and  Gout. — In  nearly  a  third  of  Garrod's  cases  there  was 
a  history  of  gout  in  the  family ;  of  rheumatism  in  only  64  cases. 

Exposure  to  cold,  wet  and  damp,  errors  in  diet,  worry  and  care,  and  local 
injuries  are  all  spoken  of  as  possible  exciting  causes. 

At  present  two  chief  views  prevail  as  to  the  etiology  of  arthritis  deformans 
— one  that  it  is  of  nervous  origin,  the  other  that  it  is  a  chronic  infection. 

The  Eelation  of  Arthritis  Deformans  to  Diseases  op  the  Nervous 
System. — Various  forms  of  arthritis  may  occur  with  lesions  of  the  spinal  cord, 
and  it  has  been  held  by  J.  K.  Mitchell  (Sr.)  that  changes  in  the  nervous 
system  are  the  cause  of  the  joint  lesions.  This  does  not  seem  to  be  supported 
by  recent  work,  which  rather  supports  the  view  that  the  disease  is  the  result 
of  a  chronic  infection.     The  rapid  muscular  atrophy,  the  associated  neuritis, 

389 


390  CONSTITUTIONAL  DISEASES. 

the  pain,  the  increase  in  the  reflexes,  and  the  nutritional  disturbances  suggest 
a  change  in  tlie  nervous  system,  but  tliis  may  be  secondary  to  an  infective  or 
toxic  process. 

Arthritis  Deformans  as  a  Chronic  Infection. — In  recent  years  this 
view  has  been  gaining  ground,  althougli  as  3'et  positive  bacteriological  evidence 
is  lacking.  The  infection  may  be  with  a  specific  organism  or  perhaps  with 
various  ones.  Bannatyne,  Po}Titon  and  Pa^me,  Chauffard.  and  others  have 
obtained  organisms  from  the  joints,  and  suggestive  results  have  followed  the 
injection  of  the  cultures  in  animals.  But  no  constant  association  with  any 
organism  has  Ijeen  proved.  The  influence  of  various  infections  such  as  gon- 
orrhoea, influenza,  etc.,  is  important.  Some  writers  have  reported  ■  a  large 
proportion  of  eases  Avith  a  previous  history  of  gonorrhoea,  but  this  was  given 
in  only  13  per  cent  of  my  series. 

The  acute  onset  vrith  fever,  the  polyarthritis,  the  presence  of  enlarged 
glands,  and  the  frequent  enlargement  of  the  spleen  are  all  suggestive  of  an 
infection.  In  a  small  number  cardiac  complications  occur.  The  attack  may 
subside,  leaving  more  or  less  damage,  to  recur  later  with  the  same  features. 

And,  lastly,  a  consideration  of  the  form  in  children  described  by  Still 
lends  weight  to  this  view,  particularly  in  the  wide-spread  enlargement  of  the 
lymph-glands  and  the  swelling  of  the  spleen.  A  number  of  the  very  best 
students  of  the  disease,  as  Baumler,  of  Freiburg,  have  accepted  the  infective 
theory  of  origin,  which  is  gaining  adherents,  though  it  still  lacks  demon- 
stration. 

Morbid  Anatomy. — The  changes  in  the  joints  differ  essentially  from  those 
of  gout  in  the  absence  of  deposits  of  urate  of  soda,  and  from  chronic  rheuma- 
tism in  the  existence  of  extensive  structural  alterations,  particularly  in  the 
cartilages.  We  are  largely  indebted  to  the  magnificent  work  of  Adams  for 
our  knowledge  of  the  anatomy  of  this  disease. 

The  usual  descriptions  are  of  the  late  stages  of  the  disease  when  extensive 
damage  has  occurred.  There  have  been  few  opportunities  to  study  the  early 
changes,  although  more  frequent  operations  should  extend  our  knowledge. 
The  radiographs  have  aided  much  in  the  study  of  the  disease.  There  are 
three  main  types :  ( 1 )  With  lesions  principally  in  the  sjoiovial  membranes 
and  peri-articular  tissues,  (3)  with  atrophic  changes  in  the  cartilage  and 
bones  predominating,  and  (3)  with  hypertrophy  and  overgrowth  of  bone.  The 
first  and  second  are  seen  especially  in  the  joints  of  the  extremities,  the  third 
in  the  spine.  Whether  these  are  distinct  processes  or  different  manifestations 
of  the  same  disease  it  is  difficult  to  say.  The  synovial  membrane  is  usually 
thickened,  and  may  form  large  fringes  and  villi.  The  peri-articular  tissues 
show  infiltration  and  swelling.  The  enlargement  is  more  often  due  to  swelling 
about  the  joint  than  to  bony  changes.  The  cartilage  may  become  soft  and 
gradually  be  absorbed  or  thinned.  This  seems  to  begin  opposite  the  point 
of  greatest  involvement  of  the  sjoiovial  membrane.  The  ends  of  the  bones 
may  become  smooth  and  eburnated,  which  is  usually  found  in  long-standing 
cases  and  in  old  persons.  With  this  there  may  be  marked  atrophy  of  the 
shaft  of  the  bone.  Proliferation  of  bone  usually  occurs  at  the  margins  of 
the  joints  in  the  form  of  irregular  nodules — the  osteophytes.  On  the  knuckles 
these  are  known  as  Haygarth's  nodosities.  These  may  lock  the  joint.  The 
formation  of  bone  may  also  occur  in  the  ligaments,  especially  in  the  spine. 


ARTHRITIS  DEFORMANS.  391 

which  may  be  converted  into  a  rigid  bony  column.  Bony  anchylosis  rarely 
occurs  in  the  peripheral  joints^,  but  is  common  in  the  spine. 

There  may  be  extensive  secondary  changes.  Muscular  atrophy  is  common 
and  may  appear  with  great  rapidity.  Subluxation  may  occur,  especially  in 
the  knee  and  finger  joints.  The  hands  often  show  great  deformity,  especially 
ulnar  deflection.  Contractures  ma}^  follow  and  the  joint  become  fixed  in  a 
flexed  position.  Neuritis  and  trophic  disturbances  may  be  associated.  The 
neuritis  is  sometimes  due  to  direct  extension  of  the  inflammatory  process. 
Subcutaneous  fibroid  nodules  are  occasionally  met  with. 

The  radiographs  of  arthritis  deformans  are  very  instructive.  The  changes 
in  the  bones  are  very  evident.  The  thinning  due  to  atrophy  and  the  bony 
overgrowth  can  be  readily  recognized.  Erosion  of  the  cartilages  is  easily  seen. 
In  the  type  with  predominant  peri-articular  changes  the  bones  show  little 
alteration. 

Symptoms. — For  convenience  the  forms  may  be  described  as  those  with 
Heberden's  nodes,  general  progressive  arthritis,  the  mono-articular  form,  the 
vertebral  form,  and  the  arthritis  deformans  of  children. 

Heberden's  Nodes. — In  this  form  the  fingers  are  affected,  and  "little 
hard  knobs  "  develop  gradually  at  the  sides  of  the  distal  phalanges.  They 
are  much  more  common  in  women  than  in  men.  They  begin  usually  between 
the  thirtieth  and  fortieth  year.  The  subjects  may  have  had  digestive  troubles 
or  gout.  Heberden,  however,  says  "  they  have  no  connection  with  gout,  being 
found  in  persons  who  never  had  it."  In  the  early  stage  the  joints  may  be 
swollen,  tender,  and  slightly  red,  particularly  when  knocked.  The  attacks  of 
pain  and  swelling  may  come  on  in  the  joints  at  long  intervals  or  follow 
indiscretion  in  diet.  The  little  tubercles  at  the  sides  of  the  dorsal  surface 
of  the  second  phalanx  increase  in  size,  and  give  the  characteristic  appearance 
to  the  affection.  The  cartilages  also  become  soft,  and  the  ends  of  the  bones 
eburnated.  Urate  of  soda  is  never  deposited  (Charcot).  The  condition  is 
not  curable ;  but  there  is  this  hopeful  feature — the  subjects  of  these  nodosities 
rarely  have  involvement  of  the  larger  joints.  They  have  been  regarded,  too, 
as  an  indication  of  longevity.  Charcot  states  that  in  women  with  these  nodes 
cancer  seems  more  frequent. 

General  Progressive  Form. — This  occurs  in  two  varieties,  acute  and 
chronic.  The  acute  form  may  resemble,  at  its  outset,  ordinary  rheumatic 
fever.  There  is  involvement  of  many  joints;  swelling,  particularly  of  the 
synovial  sheaths  and  bursas;  not  often  redness;  but  there  is  moderate  fever. 
Howard  describes  this  condition  as  most  frequent  in  j^oung  women  from  twenty 
to  thirty  years  of  age,  often  in  connection  with  recent  delivery,  lactation,  or 
rapid  child-bearing.  Acute  cases  may  occur  at  the  menopause.  It  may  also 
come  on  in  children.  "  These  patients  suffer  in  their  general  health,  become 
weak,  pale,  depressed  in  spirits,  and  lose  flesh.  In  several  cases  of  this  form 
marked  intervals  of  improvement  have  occurred;  the  local  disease  has  ceased 
to  progress,  and  tolerable  comfort  has  been  experienced  perhaps  until  preg- 
nancy, delivery,  or  lactation  again  determines  a  fresh  outbreak  of  the  disease  " 
(Howard). 

The  chronic  form  is  by  far  the  most  common.  Most  of  these  have  had  at 
some  time  an  acute  attack.  The  joints  are  usually  involved  symmetrically. 
The  first  symptoms  are  pain  on  movement  and  slight  swelling,  which  may  be 


392  CONSTITUTIONAL  DISEASES. 

in  the  joint  itself  or  in  the  peri-articular  sheaths.  In  some  cases  the  effusion 
is  marked,  in  others  slight.  The  local  conditions  vary  greatly,  and  periods 
of  improvement  alternate  with  attacks  of  swelling,  redness,  and  pain.  At 
first  onl}'  one  or  two  joints  are  affected;  usually  the  joints  of  the  hands,  then 
the  knees  and  feet;  gradually  other  articulations  are  involved,  and  in  extreme 
cases  every  joint  in  the  body  is  affected.  Pain  is  an  extremely  variable  sjmip- 
tom.  Some  cases  proceed  to  the  most  extreme  deformity  without  it ;  in  others 
the  suffering  is  very  great,  particularly  at  night  and  during  exacerbations  of 
the  disease.  There  are  cases  in  which  pain  of  an  agonizing  character  is  an 
almost  constant  s}Taptom,  requiring  for  years  the  use  of  morpliia. 

Gradually  the  shape  of  the  joints  is  great!}'  altered,  partly  by  the  presence 
of  osteophytes,  partly  by  the  great  thickening  of  the  capsular  ligaments,  and 
still  more  by  the  retraction  of  the  muscles.  In  moving  the  affected  joint 
crepitation  can  be  felt,  due  to  the  eburnation  of  the  articular  surfaces.  TJlti- 
matel}^  the  joints  become  completely  locked,  not  by  a  true  bon}^  anchylosis,  it 
may  be  by  the  osteophytes  which  form  around  the  articular  surfaces,  like  ring- 
bone in  the  horse,  but  is  more  often  dtte  to  adhesions  and  peri-articular  thick- 
enings. The  muscles  about  the  joints  undergo  important  changes.  Atrophy 
from  disuse  gradually  supervenes,  and  contractures  tend  to  flex  the  thigh 
upon  the  abdomen  and  the  leg  upon  the  thigh.  There  are  cases  with  rapid 
muscular  wasting,  sj'mmetrical  involvement  of  the  joints,  increased  reflexes, 
and  trophic  changes,  which  strongly  suggest  a  central  origin.  Xumbness, 
tingling,  pigmentation  or  glossiness  of  the  skin,  and  onychia  may  be  present. 
In  extreme  cases  the  patient  is  completely  helpless,  and  lies  on  one  side  with 
the  legs  drawn  up,  the  arms  fixed,  and  all  the  articulations  of  the  extremities 
locked.  Fortunately,  it  often  happens  in  these  severe  general  cases  that  the 
joints  of  the  hand  are  not  so  much  affected,  and  the  patient  may  be  able  to 
knit  or  to  write,  though  unable  to  walk  or  to  use  the  arms.  In  many  cases, 
after  involving  two  or  three  joints,  the  disease  becomes  arrested,  and  no 
further  development  occurs.  It  may  be  limited  to  the  wrists,  or  to  the  knees 
and  wrists,  or  to  the  knees  and  anldes.  A  majority  of  the  patients  finally 
reach  a  quiescent  stage,  in  which  they  are  free  from  pain  and  enjoy  excellent 
health,  suffering  only  from  the  inconvenience  and  crippling  necessarily  asso- 
ciated with  the  disease.  Coincident  affections  are  not  uncommon.  In  the 
active  stage  the  patients  are  often  ansemic  and  suffer  from  dyspepsia,  which 
may  recur  at  intervals.  A  small  percentage  show  cardiac  lesions.  The  pulse 
rate  is  frequently  higher  than  normal. 

The  PARTIAL  or  moxo-aeticular  form  affects  chiefly  old  persons,  and  is 
seen  particularly  in  the  hip,  the  knee,  the  spinal  column,  or  shoulder.  It 
is,  in  its  anatomical  features,  identical  with  the  general  disease.  In  the 
hip  and  shoulder  the  muscles  early  show  wasting,  and  in  the  hip  the  condi- 
tion ultimately  becomes  that  already  described  as  morhus  coxce  senilis.  These 
cases  seem  not  infrequently  to  follow  an  injury.  They  differ  from  the 
polyarticular  form  in  occurring  chiefly  in  men  and  at  a  later  period 
of  life. 

The  Vertebral  Form. — There  is  a  progressive  anchylosis  of  the  verte- 
bra, causing  rigidity  of  the  spine — "  poker-back  " — spondylitis  deformans. 
There  are  two  varieties.  In  one  (von  Bechterew).  in  which  the  disease  may 
follow  trauma  or  be  hereditary,  the  spine  alone  is  involved,  and  there  are 


ARTHRITIS  DEFORMANS.  393 

pronounced  nerve-root  symptoms — pain,  anesthesia,  atrophy  of  muscles,  and 
ascending  degeneration  in  the  cord;  in  the  other — Striimpell-Marie  type — 
the  hip  and  shoulder  Joints  may  be  involved  (spondylose  rhizomelique) ,  and 
the  nervous  symptoms  are  less  prominent.  I  believe  they  are  both  forms  of 
arthritis  deformans,  and  should  neither  be  regarded  nor  described  as  separate 
diseases.  The  cases  are  more  frequent  in  males  than  in  females;  the  onset 
may  be  in  the  upper  or  in  the  lower  part  of  the  spine.  The  involvement  of 
the  spine  in  the  lumbar  region  may  cause  sciatica.  It  may  be  limited  to  the 
neck.  There  is  gradually  induced  complete  immobility,  with  some  kyphosis. 
The  other  joints  may  not  be  affected,  or  the  hips  and  shoulders  may  be  anchy- 
losed.  The  ribs  are  fixed,  the  thorax  immobile,  and  the  breathing  abdominal. 
Pressure  on  the  nerve-roots  may  cause  great  pain,  pargesthesia,  and  atrophy 
of  muscles.  Von  Bechterew  thinks  that  it  begins  as  a  meningitis,  leads -to 
compression  of  the  nerve-roots,  loss  of  function  of  the  spinal  muscles,  atrophy 
of  the  intervertebral  disks,  and  gradually  anchylosis  of  the  spines.  Seguin 
reported  three  children  in  one  family  with  the  disease. 

Aethkitis  Deformans  in  Children. — Some  cases  resemble  closely  the 
disease  in  adults,  in  others  there  are  very  striking  differences.  A  very  inter- 
esting variety  has  been  differentiated  by  George  F.  Still,  in  which  the  general 
enlargement  of  the  joints  is  associated  with  swelling  of  the  l3!mph-glands  and 
of  the  spleen.  He  has  studied  22  cases  of  this  character.  The  following  are 
among  the  more  striking  peculiarities :  The  onset  is  almost  always  before  the 
second  dentition.  Girls  are  more  frequently  affected  than  boys.  The  symp- 
toms complained  of  are  usually  slight  stiffness  in  one  or  two  joints ;  gradually 
others  become  involved.  The  onset  may  be  more  acute  with  fever,  or  even 
with  chills.  The  enlargement  of  the  joints  is  due  rather  to  a  general  thick- 
ening of  the  soft  tissues  than  to  a  bony  enlargement.  There  is  no  bony 
grating.  The  limitation  of  movement  may  be  extreme,  owing  to  the  fixation 
of  the  joints,  and  there  may  be  much  muscular  wasting.  The  enlargement 
of  the  lymph-glands  is  most  striking,  and  may  be  general;  even  the  supra- 
trochlear glands  may  be  as  large  as  hazel-nuts.  They  increase  with  the 
fever.  The  edge  of  the  spleen  can  usually  be  felt  below  the  costal  margin. 
Sweating  is  often  profuse  and  there  may  be  anemia,  but  heart  complica- 
tions are  rare.  The  children  look  puny  and  generally  show  arrest  of  devel- 
opment. 

Diagnosis. — The  early  stages  may  be  difficult  to  diagnose  from  acute  rheu- 
matism. The  involvement  of  the  smaller  joints  and  the  persistence  of  the 
condition  in  a  joint  when  once  attacked  are  important  points.  In  an  advanced 
stage  it  can  rarely  be  mistaken  for  either  rheumatism  or  gout.  Latfe  cases 
are  difficult  or  impossible  to  distinguish  from  chronic  rheumatism.  It  is 
important  to  distinguish  from  the  mono-articular  form  the  local  arthritis  of 
the  shoulder-joint  which  is  characterized  by  pain,  thickening  of  the  capsule 
and  of  the  ligaments,  wasting  of  the  shoulder-girdle  muscles,  and  somfitimes 
by  neuritis.  This  is  an  affection  which  is  quite  distinct  from  arthritis  de- 
formans, and  is,  moreover,  in  a  majority  of  cases  curable. 

Treatment. — Once  established,  the  disease  is  rarely  curable.  After  attack- 
ing two  or  three  joints  it  may  be  arrested.  Too  often  it  is  a  slow,  but  pro- 
gressive, crippling  of  the  joints,  with  a_  disability  that  makes  the  disease  one 
of  the  most  terrible  of  human  afflictions. 


394  CONSTITUTIONAL  DISEASES. 

In  the  acute  febrile  form,  usually  mistaken  for  rheumatic  fever,  moderate 
doses  of  the  salic34ates  should  be  given,  and  the  joints  require  the  local  meas- 
ures mentioned  in  the  section  on  acute  rheumatism. 

The  treatment  of  the  ordinary  form  may  be  considered  under : 

(1)  Medicixal. — ISTo  single  remedy  is  of  special  value.  General  tonics 
are  indicated.  Arsenic  in  full  doses  is  helpful  in  some  cases.  The  syrup  of 
the  iodide  of  iron  is  useful,  alternating  with  arsenic.  Potassium  iodide  is 
useful  in  the  form  ^vith  much  periarthritis. 

(3)  Gexeral  Hygiene  and  Diet. — The  disease  is  one  of  progressive  de- 
bility, and  measures  of  a  supporting  character  are  indicated.  Fresh  air  and 
careful  attention  to  personal  h3'giene  are  most  essential.  The  question  of 
diet  is  of  the  first  importance.  There  is  one  rule — let  the  patient  eat  all 
the  good  food  she  can  digest.  So  many  persons  are  afflicted  not  only  vi^ith  the 
disease,  but  reduced  by  dieting,  that  I  often  find  "  full  diet "  the  best  pre- 
scription. One  has  to  remember  that  gastro-intestinal  disturbances  are  com- 
mon in  the  disease. 

(3)  Hydrotherapy. — The  Hot  Springs,  Bath  County,  Va.,  and  the  Hot 
Springs,  Ark.,  in  the  United  States,  and  those  of  Bath,  England,  sometimes 
give  very  good  results.  Many  of  our  cases  seem  to  have  been  made  much 
worse  by  the  treatment  at  Spas,  largely,  I  believe,  from  over-use  of  baths 
and  a  reducing  diet.  Much  may  be  effected  at  home  by  hot-air  baths,  hot 
baths,  and  compresses  at  night  to  the  tender  joints. 

(4)  Local  Treatment. — Vigorous  measures  should  be  taken  early.  It 
is  a  disease  to  be  fought  actively  at  every  stage.  Massage,  carefully  given, 
reduces  the  peri-articular  infiltrations,  increases  the  mobility  of  stiffened 
joints,  and,  most  important  of  all,  prevents  the  atrophy  of  the  muscles  adja- 
cent to  the  affected  joints.  The  hot-air  treatment,  thoroughly  carried  out, 
helps  many  cases,  and  should  be  given  a  trial.  Systematic  exercises  by  the 
patients  are  very  useful. 

And  lastly,  surgical  measures  may  be  needed.  The  thermo-cautery  is  most 
useful  in  relieving  the  pain  and  in  lessening  the  ligamentous  thickening, 
Eepeated  applications  are  helpful  along  the  spine  in  the  spondylitis  defor- 
mans. The  jacket  is  useful  in  the  spinal  cases  until  the  acute  symptoms  are 
past.  Goldthwaite  and  others  have  reported  good  results  from  the  breaking 
up  of  adhesions  and  the  use  of  orthopsedic  appliances. 

II.     CHRONIC    RHEUMATISM. 

Etiology. — This  affection  may  follow  an  acute  or  subacute  attack,  but 
more  commonly  comes  on  insidiously  in  persons  who  have  passed  the  middle 
period  of  life.  In  my  experience  it  is  extremely  rare  as  a  sequence  of  acute 
rheumatism.  It  is  most  common  among  the  poor,  particularly  washer- 
women, day-laborers,  and  those  whose  occupation  exposes  them  to  cold  and 
damp. 

Morbid  Anatomy. — The  sjmovial  membranes  are  injected,  but  there  is  usu- 
ally not  much  effusion.  The  capsule  and  ligaments  of  the  joints  are  thick- 
ened, and  the  sheaths  of  the  tendons  in  the  neighborhood  imdergo  similar 
alterations,  so  that  the  free  play  of  the  joint  is  greatly  imptired.  In  long- 
standing cases  the  cartilages  also  undergo  changes,  and  may  show  erosions. 


CHRONIC  RHEUMATISM.  395 

Even  in  cases  with  the  severest  symptoms,  the  joint  may  be  very  slightly 
altered  in  appearance.  Important  changes  take  place  in  the  muscles  and 
nerves  adjacent  to  chronically  inflamed  joints,  particularly  in  the  mono- 
articular lesions  of  the  shoulder  or  hip.  Muscular  atrophy  supervenes  partly 
from  disuse,  partly  through  nervous  influences,  either  centric  or  reflex  (Vul- 
pian),  or  as  a  result  of  peripheral  neuritis.  In  some  cases  when  the  joint  is 
much  distended  the  wasting  may  he  due  to  pressure,  either  on  the  muscles 
themselves  or  on  the  vessels  supplying  them. 

Symptoms. — Stiffness  and  pain  are  the  chief  features  of  chronic  rheuma- 
tism. The  latter  is  very  liable  to  exacerbations,  especially  during  changes  in 
the  weather.  The  joints  may  be  tender  to  the  touch  and  a  little  swollen,  but 
are  seldom  reddened.  As  a  rule,  many  joints  are  affected;  but  there  are 
instances  in  which  the  disease  is  confined  to  one  shoulder,  knee,  or  hip.  The 
stiffness  and  pain  are  more  marked  after  rest,  and  as  the  day  advances  the 
joints  may,  with  exertion,  become  much  more  supple.  The  general  health 
may  not  be  seriously  impaired.  The  disease  is  not  immediately  dangerous. 
Anchylosis  may  occur,  and  ultimately  the  joints  may  become  much  distorted. 
In  many  instances,  particularly  those  in  which  the  pain  is  severe,  the  general 
health  may  be  seriously  involved  and  the  subjects  become  anemic  and  very 
apt  to  suffer  with  neuralgia  and  dyspepsia.  Valvular  lesions,  due  to  slow 
sclerotic  changes,  are  not  uncommon.  They  are  associated  with,  not  dependent 
upon,  the  articular  disease. 

Prognosis. — The  prognosis  is  not  favorable,  as  a  majority  of  the  cases 
resist  all  methods  of  treatment.  It  is,  however,  a  disease  which  persists  indefi- 
nitely, and  does  not  necessarily  shorten  life. 

Treatment. — Internal  remedies  are  of  little  service.  It  is  important  to 
maintain  the  digestive  functions  and  to  keep  the  general  health  at  a  high 
standard.  Potassium  iodide,  sarsaparilla,  and  guaiacum  are  sometimes  bene- 
ficial.    The  salicylates  are  useless. 

Local  treatment  is  very  beneficial.  "  Firing  "  with  the  Paquelin  cautery 
relieves  the  pain,  and  it  is  perhaps  the  best  form  of  counter-irritation.  Mas- 
sage, with  passive  motion,  helps  to  reduce  swelling,  and  prevents  anchylosis. 
It  is  particularly  useful  in  cases  which  are  associated  with  atrophy  of  the 
muscles.  Electricity  is  not  of  much  benefit.  Climatic  treatment  is  very 
advantageous.  Many  cases  are  greatly  helped  by  prolonged  residence  in 
southern  Europe  or  Southern  California  or  by  spending  the  winters  in  Egypt. 
Eich  patients  should  always  winter  in  the  South,  and  in  this  way  avoid  the 
cold,  damp  weather. 

Hydrotherapeutic  measures  are  specially  beneficial.  Great  relief  is  afforded 
by  wrapping  the  affected  joints  in  cold  cloths,  covered  with  a  thin  layer  of 
blanket,  and  protected  with  oiled  silk.  The  Turkish  bath  is  useful,  but  the 
full  benefit  of  this  treatment  is  rarely  seen  except  at  bathing  establishments. 
The  hot  alkaline  waters  are  particularly  useful,  and  a  residence  at  Bath, 
England,  the  Hot  Springs  of  Virginia,  Arkansas,  or  Santa  Rosalia,  Mexico, 
or  at  Banff,  in  the  Rocky  Mountains,  on  the  Canadian  Pacific  Railway,  will 
sometimes  cure  even  obstinate  cases. 


396  CONSTITUTIONAL  DISEASES. 


III.     MUSCULAR    RHEUMATISM    (Myalgia). 

Definition. — A  painful  affection  of  the  volimtary  muscles  and  of  the  fasciae 
and  periosteum  to  which  they  are  attached.  The  affection  has  received  various 
names,  according  to  its  seat,  as  torticollis,  lumbago,  pleurodynia,  etc. 

Etiology. — The  attacks  follow  cold  and  exposure.  It  is  by  no  means 
certain  that  the  muscular  tissues  are  the  seat  of  the  disease.  Many  writers 
claim,  perhaps  correctly,  that  it  is  a  neuralgia  of  the  sensory  nerves  of  the 
muscles.  Until  our  knowledge  is  more  accurate,  however,  it  may  be  con- 
sidered under  the  rheumatic  affections. 

It  is  most  commonly  met  with  in  men,  partieularl}-  those  exposed  to  cold 
and  whose  occupations  are  laborious.  It  is  apt  to  follow  exposure  to  a  draught 
of  air,  as  from  an  open  window  in  a  railway  carriage.  A  sudden  chilling 
after  heavy  exertion  may  also  bring  on  an  attack  of  lumbago.  Persons  of  a 
rheumatic  or  gouty  habit  are  certainly  more  prone  to  this  affection.  One 
attack  renders  an  Individual  more  liable  to  another.  It  is  usually  acute,  but 
may  become  subacute  or  even  chronic. 

Symptoms. — The  affection  is  entirel}^  local.  The  constitutional  disturb- 
ance is  slight,  and,  even  in  severe  cases,  there  may  be  no  fever.  Pain  is  a 
prominent  symptom.  It  may  be  constant,  or  may  occur  only  when  the  muscles 
are  drawn  into  certain  positions.  It  may  be  a  dull  ache,  like  the  pain  of  a 
bruise,  or  sharp,  severe,  and  cramp-like.  It  is  often  sufficiently  intense  to 
cause  the  patient  to  cry  out.  Pressure  on  the  affected  part  usually  gives 
relief.  As  a  rule,  myalgia  is  a  transient  affection,  lasting  from  a  few  hours 
to  a  few  days.  Occasionally  it  is  prolonged  for  several  weeks.  It  is  very 
apt  to  recur. 

The  following  are  the  principal  varieties: 

(1)  Lumbago,  one  of  the  most  common  and  painful  forms,  affects  the 
muscles  of  the  loins  and  their  tendinous  attachments.  It  occurs  chiefl}^  in 
workingmen.  It  comes  on  suddenly,  and  in  very  severe  cases  completely 
incapacitates  the  patient,  who  may  be  unable  to  turn  in  bed  or  to  rise  from 
the  sitting  posture. 

( 2 )  Stiff  xeck  or  torticollis  affects,  the  muscles  of  the  antero-lateral 
region  of  the  neck.  It  is  very  common,  and  occurs  most  frequently  in  the 
young.  The  patient  holds  the  head  in  a  peculiar  manner,  and  rotates  the  whole 
body  in  attempting  to  turn  it.  Usually  the  attack  is  confined  to  one  side. 
The  muscles  at  the  back  of  the  neck  may  also  be  affected. 

(3)  Pleurodyxia  involves  the  intercostal  muscles  on  one  side,  and  in 
some  instances  the  pectorals  and  serratus  magnus.  This  is,  perhaps,  the  most 
painful  form  of  the  disease,  as  the  chest  can  not  be  at  rest.  It  is  more  common 
on  the  left  than  on  the  right  side.  A  deep  breath,  or  coughing,  causes  very 
intense  pain,  and  the  respiratory  movements  are  restricted  on  the  affected 
side.  There  may  be  pain  on  pressure,  sometimes  over  a  very  limited  area. 
It  may  be  difficult  to  distinguish  from  intercostal  neuralgia,  in  which  affec- 
tioHj  however,  the  pain  is  usually  more  circumscribed  and  paroxj^smal,  and 
there  are  tender  points  along  the  course  of  the  nerves.  It  is  sometimes  mis- 
taken for  pleurisy,  but  careful  physical  examination  readily  distinguishes 
between  the  two  affections. 


GOUT.  397 

(4)  Among  other  forms  which  may  be  mentioned  are  cephalodynia, 
affecting  the  muscles  of  the  head ;  scapulodynia,  omodynia,  and  dorsodynia, 
affecting  the  muscles  about  the  shoulder  and  upper  part  of  the  back.  Myal- 
gia may  also  occur  in  the  abdominal  muscles  and  in  the  muscles  of  the 
extremities. 

Treatment. — Rest  of  the  affected  muscles  is  of  the  first  importance.  Strap- 
ping the  side  will  sometimes  completely  relieve  pleurodynia.  No  belief  is 
more  wide-spread  among  the  public  than  in  the  efficacy  of  porous  plasters,  for 
muscular  pains  vi  all  sorts,  particularly  those  about  the  trunk.  If  the  pain 
is  severe  and  agonizing,  a  hypodermic  of  morphia  gives  immediate  relief. 
For  lumbago  acupuncture  is,  in  acute  cases,  the  most  efficient  treatment. 
Needles  of  from  three  to  four  inches  in  length  (ordinary  bonnet- needles, 
sterilized,  will  do)  are  thrust  into  the  lumbar  muscles  at  the  seat  of  the  pain, 
and  withdrawn  after  five  or  ten  minutes.  In  many  instances  the  relief  is 
immediate,  and  I  can  corroborate  fully  the  statements  of  Einger,  who  taught 
me  this  practice,  as  to  its  extraordinary  and  prompt  efficacy  in  many  in- 
stances. The  constant  current  is  sometimes  very  beneficial.  In  many  forms 
of  myalgia  the  thermo-cautery  gives  great  relief.  In  obstinate  cases  blisters 
may  be  tried.  Hot  fomentations  are  soothing,  and  at  the  outset  a  Turkish 
bath  may  cut  short  the  attack.  In  chronic  cases  potassium  iodide  may  be 
used,  and  both  guaiacum  and  sulphur  have  been  strongly  recommended.  Per- 
sons subject  to  this  affection  should  be  warmly  clothed,  and  avoid,  if  possible, 
exposure  to  cold  and  damp.  In  gouty  persons  the  diet  should  be  restricted 
and  the  alkaline  mineral  waters  taken  freely.  Large  doses  of  nux  vomica 
are  sometimes  beneficial. 

IV.    GOUT    (Podagra). 

Definition. — A  nutritional  disorder,  one  factor  of  which  is  an  excess  of 
uric  acid  in  the  circulating  blood,  characterized  clinically  by  attacks  of  acute 
arthritis,  by  the  gradual  deposition  of  sodium  biurate  in  and  about  the  joints, 
and  by  the  occurrence  of  irregular  constitutional  symptoms. 

Etiology. — The  precise  nature  of  the  disturbance  in  metabolism  is  not 
known.  There  is  probably  defective  oxidation  of  the  foodstuffs,  combined 
with  imperfect  elimination  of  the  waste  products  of  the  body. 

(1)  Predisposing  Etiological  Factors. — Hereditary  Influences. — Sta- 
tistics show  that  in  from  50  to  60  per  cent  of  all  cases  the  disease  existed  in 
the  parents  or  grandparents.  The  transmission  is  supposed  to  be  more  marked 
from  the  male  side.  Cases  with  a  strong  hereditary  taint  have  been  knoM^n 
to  occur  before  puberty.  The  disease  has  been  seen  even  in  infants  at  the 
breast.  Males  are  more  subject  to  the  disease  than  females.  It  rarely  is  seen 
before  the  thirtieth  year,  and  in  a  large  majority  of  the  cases  the  first  mani- 
festations appear  before  the  age  of  fifty. 

Alcohol  is  the  most  potent  factor  in  the  etiology  of  the  disease.  Fer- 
mented liquors  favor  its  occurrence  much  more  than  distilled  spirits,  and  it 
prevails  most  extensively  in  countries  like  England  and  Germany,  which  con- 
sume the  most  beer  and  ale.  The  lighter  beers  used  in  this  country  are  much 
less  liable  to  produce  gout  than  the  heavier  English  and  Scotch  ales.  Many 
cases  occur  in  bartenders  and  brewery  men. 


398  CONSTITUTIONAL  DISEASES. 

Food  plaj^s  a  role  equal  in  importance  to  that  of  alcohol.  Overeating 
without  active  bodily  exercise  is  regarded  as  a  very  special  predisposing  cause. 
A  form  of  gouty  dyspepsia  has  been  described.  A  robust  and  active  digestion 
is,  however,  often  met  in  gouty  persons.  Gout  is  by  no  means  confined  to 
the  rich.  In  England  the  combination  of  poor  food,  defective  hygiene,  and 
an  excessive  consumption  of  malt  liquors  makes  the  "  poor  man's  gout "  a 
common  affection. 

Lead. — Garrod  has  shown  that  workers  in  lead  are  specially  prone  to  gout. 
In  30  per  cent  of  the  hospital  cases  the  patients  had  been  painters  or  workers 
in  lead.  The  association  is  probably  to  be  sought  in  the  production  by  this 
poison  of  arterio-sclerosis  and  chronic  nephritis.  In  the  United  States, 
chronic  lead-poisoning  is  frequently  associated  with  arterio-sclerosis  and  con- 
tracted kidneys,  but  lead-gout  is  comparatively  rare.  Gouty  deposits  are, 
however,  to  be  found  in  the  big-toe  joint  and  in  the  kidneys  in  cases  of 
chronic  plumbism. 

The  colored  race  does  not  escape.  Of  59  cases  of  gout  admitted  to  the 
medical  wards  of  the  Johns  Hopkins  Hospital  up  to  April  1,  1905,  3  were 
in  negroes.  In  two  the  diagnosis  was  confirmed  at  autopsy  and  in  the  third 
by  the  presence  of  tophi  in  the  ears.     Only  2  of  the  59  were  females. 

(2)  ExciTixG  Causes. — ^AVorry  or  a  sudden  mental  shock  may  bring  on 
an  attack  within  ten  or  twelve  hours.  In  susceptible  persons  a  slight  injury 
or  an  accident  of  any  sort  or  a  surgical  operation  may  be  followed  by  an  acute 
arthritis. 

(3)  Metabolic  Causes. — The  nature  of  gout  is  unlmown.  That  there 
is  faulty  metabolism,  associated  in  some  very  special  way  with  the  chemistry 
of  uric  acid,  we  know,  but  nothing  more.  The  remainder  is  theory,  awaiting 
refutation  or  confirmation.  Notwithstanding  attempts  to  minimize  the  im- 
portance of  uric  acid  as  a  factor,  until  more  convincing  evidence  to  the  con- 
trar}'  is  advanced  we  must  adhere  to  the  uric  acid  theor}^  The  conditions 
of  life  favorable  to  the  development  of  gout  are  present  in  too  many  of  us 
after  the  middle  period  of  life — more  fuel  in  the  form  of  meat  and  drink 
than  the  machine  needs — the  condition  which  Francis  Hare  describes  as  hj^er- 
pjTsemia.  G.  B.  Balfour  puts  it  well  when  he  says :  '^  The  gouty  diathesis  is 
only  a  comprehensive  term  for  all  those  changes  in  the  character  and  com- 
position of  the  blood  induced  by  the  evils  of  civilization — deficient  exercise 
and  excess  of  nutriment.  .  .  .  Gout,  on  the  other  hand,  is  the  name  given 
to  all  those  modifications  of  our  metabolism  caused  by  the  gouty  diathesis, 
as  well  as  to  all  the  symptoms  to  which  those  modifications  give  rise.'' 

The  views  regarding  uric  acid  and  its  relation  to  gout  are  very  numerous. 

Although  we  are  still  ignorant  of  the  actual  seat  of  formation  of  uric  acid, 
yet  its  source  has  been  pretty  accurately  determined.  It  constitutes  one  of  the 
"  purin "  bodies  of  Fischer,  the  xanthin  or  nuclein  bases  comprising  the  re- 
mainder. All  are  closely  related  chemically.  Horbaczewski  and  others  have 
demonstrated  that  uric  acid  is  largely,  if  not  entirely,  derived  from  nuclein 
resulting  from  nuclear  disintegration.  According  to  Burian  and  Schur,  the 
uric  acid  formed  in  the  system  is  from  two  sources.  The  "  endogenous  "  uric 
acid  is  derived  from  the  nucleins  of  the  body,  while  the  "  exogenous  "  uric  acid 
is  formed  from  the  nucleins  of  the  ingested  food.  The  uric  acid  derived  from 
the  intake  of  exogenous  oxj'purins  (nucleo-proteids)  constitutes  from  40  to 


GOUT.  399 

60  per  cent  of  the  total  purin  content  of  the  body.  We  do  not  know  in  what 
form  uric  acid  exists  in  the  circulating  blood.  It  is  not  as  uric  acid  itself. 
Bence  Jones,  and  Eoberts  held  that  it  occurs  as  a  very  soluble  quadriurate 
consisting  of  a  molecule  of  uric  acid  in  loose  combination  with  an  acid  urate 
molecule.  Many  think  that  such  a  compound  is  not  capable  of  existing  in 
a  medium  with  a  composition  such  as  the  blood  has.  Minkowski  claims  that 
it  exists  normally  in  the  blood  in  organic  combination  with  nucleotin-phos- 
phoric  acid.  Garrod  was  the  first  to  point  out  that  there  was  an  excess  of 
uric  acid  in  the  blood.  This  is  about  the  only  feature  of  the  disease  on  which 
there  seems  general  agreement.  Magnus-Levy  made  34  analyses  in  17  cases 
of  gout  and  found  the  uric  acid  in  the  blood  to  range  between  0.021  and  0.10 
grams  in  1,000  cc.  It  has  not  been  definitely  established  that  the  amount  is 
increased  during  the  acute  attack.  Of  the  three  possible  causes  for  this 
increase — increased  formation,  diminished  destruction  or  oxidation,  and  di- 
minished excretion — the  balance  of  evidence  favors  the  latter.  Schmoll  found 
that  there  is  a  nitrogen  retention  in  gout,  which  supports  this  view.  Min- 
kowski and  His  believe  that  in  gouty  individuals  the  uric  acid  circulates 
in  the  blood  in  a  different  organic  combination  than  in  the  blood  of 
healthy  persons,  and  that  consequently  the  kidneys  are  functionally  in- 
capable of  eliminating  it  as  in  normal  conditions.  The  studies  of  the 
alkalinity  of  the  blood,  even  with  the  most  modern  methods,  are  very  conflict- 
ing. Magnus-Levy's  investigations  seem  to  show  that  there  is  no  constant 
diminution  in  the  alkalinity  of  the  blood  in  gout,  also  that  there  is  no  greater 
diminution  in  the  alkalinity  during  the  acute  attacks  than  in  the  intervals. 
The  methods  of  determining  the  alkalinity  of  the  blood  are  notoriously  inac- 
curate. It  has  been  held  that  the  uric  acid  excess  in  the  blood  is  due  to 
deficient  alkalinity,  thus  preventing  solubility  and  easy  excretion  of  the  uric 
acid.  There  is  now  no  evidence  to  support  this  view.  The  recent  electro- 
potential  measurements  of  Fakkas,  Fraenkel,  and  Hoeber  seem  to  show  that 
the  reaction  of  the  blood  normally  is  neutral  and  not  alkaline. 

The  excretion  of  uric  acid  by  a  healthy  individual  on  an  average  mixed 
diet  ranges  normally  between  0.4  and  1.0  gramme  daily.  Hammarsten  gives 
the  average  as  0.7  gramme.  Of  the  total  purin  or  alloxuric  bodies  of  the  urine, 
nine-tenths  exist  as  uric  acid  and  one-tenth  as  the  purin  or  xanthin  bases. 
Quantitative  determinations  show  that  the  excretion  of  uric  acid  in  gout  is 
usually  far  below  the  lower  limit  for  normal  in  the  intervals  between  attacks, 
particularly  just  before  an  acute  exacerbation.  With  the  onset  of  an  acute 
attack  the  excretion  gradually  increases  until  in  three  or  four  days  the  amount 
of  uric  acid  may  reach  or  occasionally  exceed  the  upper  limit  for  normal. 
The  cause  of  this  increase  is  not  clear.  Quantitative  determinations  of  uric 
acid  in  the  blood  show  no  constant  increase  in  the  uric  acid  during  the  acute 
attacks,  nor  has  there  been  found  any  constant  variation  in  the  chemical  reac- 
tion of  the  blood  at  this  time. 

Garrod  holds  that  with  lessened  alkalinity  of  the  blood  there  is  an  increase 
in  the  uric  acid,  due  chiefly  to  diminished  elimination.  He  attributes  the 
deposition  of  the  sodium  urate  to  the  diminished  alkalinity  of  the  plasma, 
which  is  unable  to  hold  it  in  solution.  In  an  acute  paroxysm  there  is  an 
accumulation  of  the  urates  in  the  blood,  and  the  inflammation  is  caused 
by  their  sudden  deposit  in  crystalline  form  about  the  joint. 


400  CONSTITUTIONAL  DISEASES. 

Haig  thinks  that  there  is  no  increased  formation  of  uric  acid  in  gout,  but 
tliat  the  blood  is  less  alkaline  than  normal^  and  less  able  to  hold  the  uric 
acid  or  its  salts  in  solution. 

According  to  Sir  William  Roberts,  owing  to  deficient  elimination  the 
soluble  quadriurate  accumulates  in  the  blood.  This  quadriurate,  circulating 
in  a  medium  rich  in  sodium  carbonate,  takes  on  an  additional  atom  of  the 
base  and  becomes  converted  into  the  insoluble  biurate,  which  becomes  depos- 
ited in  the  tissues,  particularly  about  the  joints. 

Ebstein  thinks  that  the  first  change  is  a  nutritive  tissue  disturbance,  which 
leads  to  necrosis,  and  in  the  necrotic  areas  the  urates  are  deposited — a  view 
which  has  been  modified  by  von  Noorden,  who  holds  that  a  special  ferment 
leads  to  the  tissue  change,  to  which  the  deposit  of  the  urates  is  secondary. 
Ebstein  designates  these  as  "  primary  Joint-gout "  cases.  Most  cases  belong 
to  this  group.  He  also  describes  what  he  terms  "  primary  kidney -gout " 
cases.  Owing  to  primary  disease  of  the  kidneys  the  uric  acid  is  not  properly 
eliminated  and  secondary  joint  manifestations  ensue.  These  cases  are  rare, 
and  he  states  that  they  must  not  be  confused  with  the  secondary  nephritis. 

Cullen  held  that  gout  was  primarily  an  affection  of  the  nervous  system. 
On  this  nervous  theory  of  gout  there  is  a  basic,  arthritic  stock — a  diathetic 
habit,  of  which  gout  and  rheumatism  are  two  distinct  branches.  The  gouty 
diathesis  is  expressed  in  (a)  a  neurosis  of  the  nerve-centres,  which  may  be 
inherited  or  acquired;  and  (&)  "a  peculiar  incajDacit}^  for  normal  elaboration 
within  the  whole  body,  not  merely  in  the  liver  or  in  one  or  two  organs,  of 
food,  whereby  uric  acid  is  formed  at  times  in  excess,  or  is  incapable  of  being 
duly  transformed  into  more  soluble  and  less  noxious  products"  (Duckworth). 
The  explosive  neuroses  and  the  influence  of  depressing  circumstances,  physical 
or  mental,  point  strongh'  to  the  part  played  by  the  nervous  system  in  the 
disease.  For  a  full  discussion  of  the  various  theories  and  an  elaborate  consid- 
eration of  the  clinical  chemistry  of  the  subject  the  reader  is  referred  to  von 
ISToorden's  Treatise  on  Diseases  of  Metabolism  (English  edition)  and  to 
Futcher's  article  in  m}"  System  of  Medicine. 

Morbid  Anatomy. — The  hJood  is  stated  to  have  an  excess  of  uric  acid.  It 
may  be  obtained  from  the  blood-serum  by  the  method  known  as  Garrod's 
uric-acid  thread  experiment,  or  from  the  serum  obtained  from  a  blister.  To 
3  ij  of  serum  add  TIX  v-vj  of  acetic  acid  in  a  watch-glass.  A  thread  immersed 
in  this  may  show  in  a  few  hours  an  incrustation  of  uric  acid.  The  experi- 
ment is  rarely  successful  even  in  cases  of  manifest  gout.  This  excess,  also, 
is  not  peculiar  to  gout,  but  occurs  in  leukgemia  and  chlorosis. 

The  "  perinuclear  basophilic  granules  "  about  the  nuclei  of  the  leucocytes, 
described  b}"  Xeusser  in  1894  and  regarded  by  him  as  practically  pathogno- 
monic of  gout  or  a  gouty  diathesis,  were  subsequently  shown  to  be  artifacts 
produced  during  the  process  of  staining.  The  red  cells  in  the  "  lead-gout " 
cases  may  show  basophilic  granular  staining. 

The  important  changes  are  in  the  articular  tissues.  The  first  joint  of  the 
great  toe  is  most  frequently  involved;  then  the  ankles,  knees,  and  the  small 
joints  of  the  hands  and  wrists.  The  deposits  may  be  in  all  the  joints  of  the 
lower  limbs  and  absent  from  those  of  the  upper  limbs  (ISTorman  Moore).  If 
death  takes  place  during  an  acute  paroxysm,  there  are  signs  of  inflammation, 
hypersemia,  swelling  of  the  ligamentous  tissues,  and  of  effusion  into  the  joint. 


GOUT.  401 

The  primary  change,  according  to  Ebstein,  is  a  local  necrosis,  due  to  the 
presence  of  an  excess  of  urates  in  the  blood.  This  is  seen  in  the  cartilage 
and  other  articular  tissues  in  which  the  nutritional  currents  are  slow.  His 
and  Mordhorst  hold  that  the  deposition  of  the  urates  is  primary,  and  that 
the  tissue  necrosis  takes  place  as  a  result  of  this  deposit.  In  these  areas  of 
coagulation  necrosis  the  reaction  is  always  acid  and  the  neutral  urates  are 
deposited  in  crystalline  form,  as  insoluble  acid  urate.  The  articular  cartilages 
are  first  involved.  The  gouty  deposit  may  be  uniform,  or  in  small  areas. 
Though  it  looks  superficial,  the  deposit  is  invariably  interstitial  and  cov- 
ered by  a  thin  lamina  of  cartilage.  The  deposit  is  thickest  at  the  part  most 
distant  from  the  circulation.  The  ligaments  and  fibro-cartilage  ultimately 
become  involved  and  are  infiltrated  with  biurate  deposits,  the  so-called  chalk- 
stones,  or  tophi.  These  are  usually  covered  by  skin;  but  in  some  cases,  par- 
ticularly in  the  metacarpo-phalangeal  articulations,  this  ulcerates  and  the 
chalk-stones  appear  externally.  The  synovial  fluid  may  also  contain  crystals. 
In  very  long-standing  cases,  owing  to  an  excessive  deposit,  the  joint  becomes 
immobile.  The  marginal  outgrowths  in  gouty  arthritis  are  true  exostoses 
(Wynne).  The  cartilage  of  the  ear  may  contain  tophi,  which  are  seen  as 
whitish  nodules  at  the  margin  of  the  helix.  The  cartilages  of  the  nose, 
eyelids,  and  larynx  are  less  frequently  affected.  Somewhat  analogous  to 
these  tophi  in  man  are  the  deposits  characterizing  the  "guanin  gout"  of 
hogs.  Under  certain  conditions  in  pigs  one  sees  in  the  muscles,  liga- 
ments, and  articular  tissues  small  whitish  deposits  which  are  made  up  of 
guanin.  These  are  frequently  seen  in  the  Smithfield  and  Westphalian 
hams. 

Of  changes  in  the  internal  organs,  those  in  the  renal  and  vf-scular  systems 
are  the  most  important.  The  kidney  changes  believed  to  be  characteristic 
of  gout  are:  (a)  A  deposit  of  urates  chiefly  in  the  region  of  the  papillae. 
This,  however,  is  less  common  than  is  usually  supposed.  Norman  Moore 
found  it  in  only  13  out  of  80  cases.  The  apices  of  the  pyramids  show  lines 
of  whitish  deposit.  On  microscopical  examination  the  material  is  seen  to  be 
largely  in  the  intertubular  tissue.  In  some  instances,  however,  the  deposit 
seems  to  be  both  in  the  tissue  and  in  the  tubules.  Ebstein  has  described  and 
figured  areas  of  necrosis  in  both  cortex  and  medulla,  in  the  interior  of  which 
were  crystalline  deposits  of  urate  of  soda.  The  presence  of  these  uratic  con- 
cretions at  the  apices  of  the  pyramids  is  not  a  positive  indication  of  gout. 
( & )  An  interstitial  nephritis,  either  the  ordinary  "  contracted  kidney  "  or  the 
arterio-sclerotic  form,  neither  of  which  is  in  any  way  distinctive.  It  is  not 
possible  to  say  in  a  given  case  that  the  condition  has  been  due  to  gout  unless 
marked  evidences  of  the  disease  coexist. 

The  metatarso-phalangeal  joint  of  the  big  toe  should  be  carefully  exam- 
ined, as  it  may  show  typical  lesions  of  gout  without  any  outward  token  of 
arthritis. 

Arterio-sclerosis  is  a  very  constant  lesion.  With  it  the  heart,  particularly 
the  left  ventricle,  is  found  hyper trophied.  According  to  some  authors,  con- 
cretions of  urate  of  soda  may  occur  on  the  valves.  Myocarditis  is  a  frequent 
occurrence  in  chronic  cases. 

Changes  in  the  respiratory  system  are  rare.  Deposits  have  been  found  in 
the  vocal  cords,  and  uric-acid  crystals  have  been  met  in  the  sputa  of  a  gouty 
27 


402 


CONSTITUTIONAL  DISEASES. 


patient  (J.  W.  Moore).  Emphysema  is  a  very  constant  condition  in  old 
cases. 

Symptoms, — Gont  is  usually  divided  into  acute,  chronic,  and  irregular 
forms. 

Acute  Gout. — Premonitory  symptoms  are  common — twinges  of  pain  in 
the  small  joiats  of  the  hands  or  feet,  nocturnal  restlessness,  irritability  of 


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Chart  XIV. — Showing  Uric  Acid  and  Phosphoric  Acid  Output  in  Case  of  Acute  Govt. 


temper,  and  dyspepsia.  The  urine  is  acid,  scanty,  and  high-colored.  It  de- 
posits urates  on  cooling,  and  there  may  be,  according  to  Garrod,  transient 
albuminuria.     There  may  be  traces  of  sugar  (gouty  glycosuria).     Before  an 


GOUT.  403 

attack  the  output  of  uric  acid  is  low  and  is  also  diminished  in  the  early  part 
of  the  paroxysm.  The  relation  of  uric  and  phosphoric  acids  to  the  acute 
attacks  is  well  represented  in  Chart  XIV,  prepared  by  Futcher.  Both  were 
extremely  low  in  the  intervals,  but  reached  within  normal  limits  shortly  after 
the  onset  of  the  acute  symptoms.  The  phosphoric  acid  and  uric  acid  show 
almost  parallel  curves.  The  patient  was  on  a  very  light  fixed  diet  at  the 
time  the  determinations  were  made.  Bain  holds  that  the  phosphoric  .acid 
excretion  varies  directly  with  that  of  the  uric  acid.  Watson  claims  that  there 
is  no  relationship  between  the  two.  In  some  instances  the  throat  is  sore,  and 
there  may  be  asthmatic  symptoms.  The  attack  sets  in  usually  in  the  early 
morning  hours.  The  patient  is  aroused  by  a  severe  pain  in  the  metatarso- 
phalangeal articulation  of  the  big  toe,  and  more  commonly  on  the  right  than 
on  the  left  side.  The  pain  is  agonizing,  and,  as  Sydenham  says,  "  insinuates 
itself  with  the  most  exquisite  cruelty  among  the  numerous  small  bones  of  the 
tarsus  and  metatarsus,  in  the  ligaments  of  which  it  is  lurking."  The  joint 
swells  rapidly,  and  becomes  hot,  tense,  and  shiny.  The  sensitiveness  is  ex- 
treme, and  the  pain  makes  the  patient  feel  as  if  the  joint  were  being  pressed 
in  a  vise.  There  is  fever,  and  the  temperature  may  rise  to  103°  or  103°. 
Toward  morning  the  severity  of  the  symptoms  subsides,  and,  although  the 
joint  remains  swollen,  the  day  may  be  passed  in  comparative  comfort.  The 
symptoms  recur  the  next  night,  and  the  fit,  as  it  is  called,  usually  lasts  for 
from  five  to  eight  days,  the  severity  of  the  symptoms  gradually  abating.  There 
is  usually  a  moderate  leucocytosis  during  the  acute  manifestations.  Occasion- 
ally other  joints  are  involved,  particularly  the  big  toe  of  the  opposite  foot. 
The  inflammation,  however  intense,  never  goes  on  to  suppuration.  With  the 
subsidence  of  the  swelling  the  skin  desquamates.  After  the  attack  the  general 
health  may  be  much  improved.  As  Aretaeus  remarks,  a  person  in  the  interval 
has  won  the  race  at  the  Olympian  games.  Eecurrences  are  frequent.  Some 
patients  have  three  or  four  attacks  in  a  year ;  others  suffer  at  longer  intervals. 

The  term  retrocedent  or  suppressed  gout  is  applied  to  serious  internal 
symptoms,  coincident  with  a  rapid  disappearance  or  improvement  of  the  local 
signs.  Very  remarkable  manifestations  may  occur  under  these  circumstances. 
The  patient  may  have  severe,  gastro-intestinal  symptoms — pain,  vomiting,  diar- 
rhoea, and  great  depression — and  death  may  occur  during  such  an  attack.  Or 
there  may  be  cardiac  manifestations — dyspnoea,  pain,  and  irregular  action 
of  the  heart.  In  some  instances  in  which  the  gout  is  said  to  attack  the  heart, 
an  acute  pericarditis  proves  fatal.  So,  too,  there  may  be  marked  cerebral 
manifestations — delirium  or  coma,  and  even  apoplexy — but  in  a  majority  of 
these  instances  the  symptoms  are,  in  all  probability,  urasmic. 

Gout  in  America. — While  not  so  common  as  in  England  and  Germany, 
the  disease  is  by  no  means  infrequent,  and  is  perhaps  on  the  increase.  It  is 
only  one-third  less'  frequent  at  the  Johns  Hopkins  Hospital  than  at  Saint 
Bartholomew's  Hospital.  It  is  more  common  among  the  lower  classes,  who 
drink  beer,  than  among  the  well-to-do,  who  have  become  of  late  much  more 
temperate.  Among  about  18,000  cases  in  my  wards  there  were  59  cases  of 
gout.    All  were  whites  but  three,  and  all  males  but  two  (Futcher). 

Chronic  Gout. — With  increased  frequency  in  the  attacks,  the  articular 
symptoms  persist  for  a  longer  time,  and  gradually  many  joints  become  affected. 
Deposits  of  urates  take  place,  at  first  in  the  articular  cartilages  and  then  in 


404  CONSTITUTIONAL  DISEASES. 

the  ligaments  and  capsular  tissues;  so  that  in  the  course  of  years  the  joints 
become  swollen,  irregular,  and  deformed.  The  feet  are  usually  first  affected, 
then  the  hands.  In  severe  cases  there  may  be  extensive  concretions  about  the 
elbows  and  knees  and  along  the  tendons  and  in  the  bursse.  The  tophi  appear 
in  the  ears.  Finally,  a  unique  clinical  picture  is  produced  which  can  not  be 
mistaken  for  that  of  any  other  affection.  The  skin  over  the  tophi  may  rupture 
or  ulcerate,  and  about  the  knuckles  the  chalk-stones  may  be  freely  exposed. 
Patients  with  chronic  gout  are  usually  dyspeptic,  often  of  a  sallow  complexion, 
and  show  signs  of  arterio-sclerosis.  The  pulse  tension  is  increased,  the  vessels 
are  stiff,  and  the  left  ventricle  is  hypertrophied.  The  urine  is  increased  in 
amount,  is  of  low  specific  gravity,  and  usually  contains  a  slight  amount  of 
albumin,  with  a  few  hyaline  casts.  Severe  cramps  involving  the  calf,  abdom- 
inal, and  thoracic  muscles  may  occur.  Intercurrent  attacks  of  acute  poly- 
arthritis may  develop,  in  which  the  joints  become  inflamed,  and  the  tempera- 
ture ranges  from  101°  to  103°,  There  may  be  pain,  redness,  and  swelling  of 
several  joints  without  fever.  Ursemia,  pleurisy,  pericarditis,  peritonitis,  and 
meningitis  are  common  terminal  affections.  The  victim  of  gout  may  show 
remarkable  mental  and  even  bodily  vigor.  Certain  of  the  most  distinguished 
members  of  our  profession  have  been  terrible  sufferers  from  this  disease, 
notably  the  elder  Scaliger,  Jerome  Cardan,  and  Sydenham,  whose  statement 
that  "  more  wise  men  than  fools  are  victims  of  the  affection "  still  holds 
good. 

Irregular  Gout. — This  is  a  motley,  ill-defined  group  of  symptoms,  mani- 
festations of  a  condition  of  disordered  nutrition,  to  which  the  terms  gouty 
diathesis  or  litlicemic  state  have  been  given.  Cases  are  seen  in  members  of 
gouty  families,  who  may  never  themselves  have  suffered  from  the  acute  dis- 
ease, and  in  persons  who  have  lived  not  wisely  but  too  well,  who  have  eaten 
and  drunk  largely,  lived  sedentary  lives,  and  yet  have  been  fortunate  enough 
to  escape  an  acute  attack.  It  is  interesting  to  note  the  various  manifestations 
of  the  disease  in  a  family  with  marked  hereditary  disposition.  The  daughters 
often  escape,  while  one  son  may  have  gouty  attacks  of  great  severity,  even 
though  he  lives  a  temperate  life  and  tries  in  every  way  to  avoid  the  conditions 
favoring  the  disorder.  Another  son  has,  perhaps,  only  the  irregular  mani- 
festations and  never  the  acute  articular  affection.  While  the  irregular  features 
are  perhaps  more  often  met  with  in  the  hereditary  affection,  they  are  by  no 
means  infrequent  in  persons  who  appear  to  have  acquired  the  disease.  The 
tendency  in  some  families  is  to  call  every  affection  gouty.  Even  infantile 
complaints,  such  as  scald-head,  naso-pharyngeal  vegetations,  and  enuresis,  are 
often  regarded,  without  sufficient  grounds,  I  believe,  as  evidences  of  the  family 
ailment.  Among  the  commonest  manifestations  of  irregular  gout  are  the 
following : 

(fl)  Cutaneous  Eruptions. — Garrod  and  others  have  called  special  atten- 
tion to  the  frequent  association  of  eczema  with  the  gouty  habit.  The  French 
in  particular  insist  upon  the  special  liability  of  gouty  persons  to  skin  affec- 
tions, the  artliritides,  as  they  call  them. 

(6)  Gastro-intestinal  Disorders. — Attacks  of  what  is  termed  biliousness, 
in  which  the  tongue  is  furred,  the  breath  foul,  the  bowels  constipated,  and 
the  action  of  the  liver  torpid,  are  not  uncommon  in  gouty  persons.  A  gouty 
parotitis  is  described. 


GOUT.  405 

(c)  Cardio-vascular  Symptoms. — With  the  lithaBmia,  arterio-sclerosis  is 
frequently  associated.  The  blood  tension  is  persistently  high,  the  vessel  walls 
become  stiff,  and  cardiac  and  renal  changes  gradually  occur.  In  this  condition 
the  manifestations  may  be  renal,  as  when  the  albuminuria  becomes  more 
marked,  or  dropsical  symptoms  supervene.  The  manifestations  may  be  car- 
diac, when  the  hypertrophy  of  the  left  ventricle  fails  and  there  are  palpitation, 
irregular  action,  and  ultimately  a  condition  of  asystole.  Or,  finally,  the  mani- 
festations may  be  vascular,  and  thrombosis  of  the  coronary  arteries  may  cause 
sudden  death.  Aneurism  may  occur  and  prove  fatal,  or,  as  most  frequently 
happens,  a  blood-vessel  gives  way  in  the  brain,  and  the  patient  dies  of  apo- 
plexy. It  makes  but  little  difference  whether  we  regard  this  condition  as 
primarily  an  arterio-sclerosis,  or  as  a  gouty  nephritis;  the  point  to  be  remem- 
bered is  that  the  nutritional  disorder  with  which  an  excess  of  uric  acid  is 
associated  induces  in  time  increased  tension,  arterio-sclerosis,  chronic  inter- 
stitial nephritis,  and  change's  in  the  myocardium.  Pericarditis  is  not  an 
infrequent  terminal  complication  of  gout.    Phlebitis  occasionally  occurs. 

(d)  Nervous  Manifestations. — Headache  and  megrim  attacks  are  not  in- 
frequent. Haig  attributes  them  to  an  excess  of  uric  acid.  Neuralgias  are  not 
uncommon;  sciatica  and  parsesthesias  may  develop.  A  common  gouty  mani- 
festation, upon  which  Duckworth  has  laid  stress,  is  the  occurrence  of  hot  or 
itching  feet  at  night.  Plutarch  mentions  that  Strabo  called  this  symptom 
"  the  lisping  of  the  gout."  Cramps  in  the  legs  may  also  be  very  troublesome. 
Hutchinson  has  called  attention  to  hot  and  itching  eyeballs  as  a  frequent  sign 
of  masked  gout.  Associated  or  alternating  with  this  symptom  there  may  be 
attacks  of  episcleral  congestion.  Apoplexy  is  a  common  termination  of  gout. 
Meningitis  may  occur,  usually  basilar. 

(e)  Urinary  Disorders. — The  urine  is  highty  acid  and  high-colored,  and 
may  deposit  on  standing  crystals  of  uric  acid.  Transient  and  temporary 
increase  in  this  ingredient  can  not  be  regarded  as  serious.  In  many  cases  of 
chronic  gout  the  amount  may  be  diminished,  and  increased  only  at  certain 
periods,  forming  the  so-called  uric-acid  showers.  The  chart  on  page  403 
illustrates  this  very  well.  A  sediment  of  uric  acid  in  a  urine  does  not 
necessarily  mean  an  excess.  It  is  often  dependent  on  the  inability  of  the 
urine  to  hold  it  in  solution.  Sugar  is  found  intermittently  in  the  urine  of 
gouty  persons — gouty  glycosuria.  It  may  pass  into  true  diabetes,  but  is  usually 
very  amenable  to  treatment.  Oxaluria  may  also  be  present.  Gouty  persons 
are  specially  prone  to  calculi,  Jerome  Cardan  to  the  contrary,  who  reckoned 
freedom  from  stone  among  the  chief  of  the  dona  podagrce.  Minute  quantities 
of  albumin  are  very  common  in  persons  of  gouty  dyscrasia,  and,  when  the 
renal  changes  are  well  established,  tube-casts.  Urethritis,  with  a  purulent 
discharge,  may  arise,  so  it  is  stated,  usually  at  the  end  of  an  attack.  It  may 
occur  spontaneously,  or  follow  a  pure  connection. 

(f)  Pulmonary  Disorders. — There  are  no  characteristic  changes,  but,  as 
Greenhow  has  pointed  out,  chronic  bronchitis  occurs  with  great  frequency  in 
persons  of  a  gouty  habit. 

(g)  Of  eye  affections,  iritis,  glaucoma,  hgemorrhage  retinitis,  and  sup- 
purative panophthalmitis  have  been  described. 

Diagnosis. — Recurring  attacks  of  arthritis,  limited  to  the  big  toe  and  to 
the  tarsus,  occurring  in  a  member  of  a  gouty  family,  or  in  a  man  who  has 


406  CONSTITUTIONAL  DISEASES. 

lived  too  well,  leave  no  question  as  to  the  nature  of  the  trouble.  There  are 
many  cases  of  gout,  however,  in  which  the  feet  do  not  suffer  most  severely. 
After  an  attack  or  two  in  one  toe,  other  joints  may  be  affected,  and  it  is 
just  in  such  cases  of  polyarthritis  that  the  difficulty  in  diagnosis  is  apt  to 
arise.  We  have  had  of  late  years  several  cases  admitted  for  the  third  or  fourth 
time  with  involvement  of  three  or  more  of  the  larger  joints.  The  presence 
of  tophi  has  settled  the  nature  of  a  trouble  which  in  the  previous  attacks  had 
been  regarded  as  rheumatic.  The  following  are  suggestive  points  in  such 
ca^es:  (1)  The  patient's  habits  and  occupation.  In  the  United  States  the 
brewery  men  and  barkeepers  are  often  affected.  (2)  The  presence  of  tophi. 
The  ears  should  alwaj's  be  inspected  in  a  case  of  polyarthritis.  The  diagnosis 
may  rest  with  a  small  tophus.  The  student  should  learn  to  recognize  on  the 
ear  margin,  Woolner's  tip,  fibroid  nodules,  and  small  sebaceous  tumors.  The 
last  are  easily  recognized  microscopically.  The  needle-shaped  sodium  biurate 
crystals  are  distinctive  of  the  tophi.  (3)  The  condition  of  the  urine.  As 
shown  in  Chart  XIY,  the  uric-acid  output  is  usually  very  low  during  the  inter- 
vals of  the  paroxysm.  At  the  height  of  the  attack  the  elimination,  as  a  rule, 
is  greatly  increased.  The  ratio  of  the  uric  acid  to  the  urea  excretion  is  dis- 
turbed in  gouty  cases,  and  may  fall  as  low  as  1  to  100  or  1  to  150.  (4)  The 
gouty  polyarthritis  may  be  afebrile.  A  patient  with  three  or  four  joints  red, 
swollen,  and  painful  in  acute  rheumatism  has  fever,  and,  while  pyrexia  may 
be  present  and  often  is  in  gout,  its  absence  is,  I  think,  a  valuable  diagnostic 
sign.  Many  cases  go  a-begging  for  a  diagnosis.  A  careful  study  of  the 
patient's  habits  as  to  beer  drinking,  of  the  location  of  the  initial  arthritic 
attacks,  and  the  examination  for  tophi  in  the  ears  will  prevent  many  cases 
being  mistaken  for  rheumatism  or  arthritis  deformans. 

Treatment, — Hygiexic. — Individuals  who  have  inherited  a  tendency  to 
gout,  or  who  have  shown  any  manifestations  of  it,  should  live  temperately, 
abstain  from  alcohol,  and  eat  moderately.  An  open-air  life,  with  plenty  of 
exercise  and  regular  hours,  does  much  to  counteract  an  inborn  tendency  to 
the  disease.  The  skin  should  be  kept  active:  if  the  patient  is  robust,  by  the 
morning  cold  bath  with  friction  after  it ;  but  if  he  is  weak  or  debilitated  the 
evening  warm  bath  should  be  substituted.  An  occasional  Turkish  bath  with 
active  shampooing  is  very  advantageous.  The  patient  should  dress  warmly, 
avoid  rapid  alterations  in  temperature,  and  be  careful  not  to  have  the  skin 
suddenly  chilled. 

Dietetic. — With  few  exceptions,  persons  over  forty  eat  too  much,  and 
the  first  injunction  to  a  gouty  person  is  to  keep  his  appetite  within  reasonable 
bounds,  to  eat  at  stated  hours,  and  to  take  plenty  of  time  at  his  meals.  In 
the  matter  of  food,  quantity  is  a  factor  of  more  importance  than  quality  with 
many  gouty  persons.  As  Sir  William  Eoberts  well  says,  "  N'owhere  perhaps 
is  it  more  necessary  than  in  gout  to  consider  the  man  as  well  as  the  ailment, 
and  very  often  more  the  man  than  the  ailment." 

Very  remarkable  differences  of  opinion  exist  as  to  the  most  suitable  diet 
in  this  disease,  some  urging  warmly  a  vegetable  diet,  others  allowing  a  very 
liberal  amount  of  meat.  On  the  one  hand,  the  author  just  quoted  says :  "  The 
most  trustworthy  experiments  indicate  that  fat,  starch,  and  sugar  have  not 
the  least  direct  influence  on  the  production  of  uric  acid;  but  as  the  free  con- 
sumption of  these  articles  naturally  operates  to  restrict  the  intake  of  the 


GOUT.  407 

nitrogenous  food,  their  use  has  indirectly  the  effect  of  diminishing  the  aver- 
age production  of  uric  acid."  On  the  other  hand,  W.  H.  Draper  says :  "  The 
conversion  of  azotized  food  is  more  complete  with  a  minimum  of  carbohydrates 
than  it  is  with  an  excess  of  them;  in  other  words,  one  of  the  best  means  of 
avoiding  the  accumulation  of  lithie  acid  in  the  blood  is  to  diminish  the  carbo- 
hydrates rather  than  the  azotized  foods."  The  weight  of  opinion  leans  to  the 
use  of  a  modified  nitrogenous  diet,  without  excess  in  starchy  and  saccharine 
articles  of  food.  Animal  foods  rich  in  nuclear  material,  such  as  sweetbfeads, 
liver,  kidneys,  and  brain,  should  be  avoided.  Beef  extracts  are  injurious,  owing 
to  their  richness  in  extractives  belonging  to  the  xanthin  group.  Milk  and  eggs 
are  particularly  useful,  owing  to  their  not  containing  any  nuclein.  Fresh 
vegetables  and  fruits  may  be  used  freely,  but  among  the  latter  strawberries 
and  bananas  should  be  avoided. 

Ebstein  urges  strongly  the  use  of  fat  in  the  form  of  good  fresh  butter, 
from  2^  to  d^  ounces  in  the  day.  He  says  that  stout  gouty  subjects  not  only 
do  not  increase  in  weight  with  plenty  of  fat  in  the  food,  but  that  they  actually 
become  thin  and  the  general  condition  improves  very  much.  Hot  bread  of 
all  sorts  and  the  various  articles  of  food  prepared  from  Indian  corn  should, 
as  a  rule,  be  avoided.  Eoberts  advises  gouty  patients  to  restrict  as  far  as 
practicable  the  use  of  common  salt  with  their  meals,  since  the  sodium  biurate 
very  readily  crystallizes  out  in  tissues  with  a  high  percentage  of  sodium  salts. 

In  this  matter  of  diet  each  individual  case  must  receive  separate  con- 
sideration. 

There  are  very  few  conditions  in  the  gouty  in  which  stimulants  of  any 
sort  are  reqnired.  Whenever  indicated,  whisky  will  be  found  perhaps  the 
most  serviceable.  While  all  are  injurious  to  these  patients,  some  are  much 
more  so  than  others,  particularly  malted  liquors,  champagne,  port,  and  a  very 
large  proportion  of  all  the  light  wines. 

Mineral  Waters. — All  forms  may  be  said  to  be  beneficial  in  gout,  as  the 
main  element  is  the  water,  and  the  ingredients  are  usually  indifferent.  Much 
of  the  humbuggery  in  the  profession  still  lingers  about  mineral  waters,  more 
particularly  about  the  so-called  lithia  waters. 

The  question  of  the  utility  of  alkalies  in  the  treatment  of  gout  is  closely 
connected  with  this  subject  of  mineral  waters.  This  deep-rooted  belief  in  the 
profession  was  rudely  shaken  a  few  years  ago  by  Sir  William  Roberts,  who 
claims  to  have  shown  conclusively  that  alkalescence  as  such  has  no  influence 
whatever  on  the  sodium  biurate.  The  sodium  salts  are  believed  by  this  author 
to  be  particularly  harmful,  but,  in  spite  of  all  the  theoretical  denunciation 
of  the  use  of  the  sodium  salts  in  gout,  the  gouty  from  all  parts  of  the  world 
flock  to  those  very  Continental  springs  in  which  these  salts  are  most  predomi- 
nant.   Bain  urges  the  use  of  potassium  salts. 

Of  the  mineral  springs  best  suited  for  the  gouty  may  be  mentioned,  in  the 
United  States,  those  of  Saratoga,  Bedford,  and  the  White  Sulphur;  Buxton 
and  Bath,  in  England;  in  France,  Aix-les-Bains  and  Contrexeville ;  and  in 
Germany,  Carlsbad,  Wildbad,  and  Homburg. 

The  efficacy  in  reality  is  in  the  water,  in  the  way  it  is  taken,  on  an  empty 
stomach,  and  in  large  quantities;  and,  as  every  one  knows,  the  important 
accessories  in  the  modified  diet,  proper  hours,  regular  exercise,  with  baths, 
douches,  etc.,  play  a  very  important  role  in  the  "  cure." 


408  CONSTITUTIONAL  DISEASES. 

Medicinal  Treatmext. — In  an  acute  attack  the  limb  should  be  elevated 
and  the  aflPected  joint  wrapped  in  cotton-wool.  Warm  fomentations,  or 
Fiiller's  lotion,  may  be  used.  The  local  hot-air  treatment  may  be  tried.  A 
brisk  mercurial  purge  is  always  advantageous  at  the  outset.  The  wine  or 
tincture  of  eolchicum,  in  doses  of  20  to  30  minims,  may  be  given  every  four 
hours  in  combination  with  the  citrate  of  potash  or  the  citrate  of  lithium. 
The  action  of  the  eolchicum  should  be  carefully  watched.  It  has,  in  a  major- 
ity of  the  cases,  a  powerful  influence  over  the  symptoms — ^relieving  the  pain, 
and  reducing,  sometimes  with  great  rapidity,  the  swelling  and  redness.  It 
should  be  promptly  stopped  so  soon  as  it  has  relieved  the  pain.  In  cases  in 
which  the  pain  and  sleeplessness  are  distressing  and  do  not  yield  to  colchicimi, 
morphia  is  necessary.  The  patient  should  be  placed  on  a  diet  chiefly  of  milk 
and  barley-water,  but  if  there  is  any  debility,  strong  broths  may  be  given,  or 
eggs.  It  is  occasionally  necessary  to  give  small  quantities  of  stimulants. 
During  convalescence  meats  and  fish  and  game  may  be  taken,  and  gradually 
the  patient  may  resume  the  diet  previously  laid  down. 

In  some  of  the  subacute  intercurrent  attacks  of  arthritis  in  old,  deformed 
joints,  the  sodium  salicylate  is  occasionally  useful,  but  its  administration  must 
be  watched  in  cases  of  cardiac  and  renal  insufficiency.  It  is  also  much  advo- 
cated by  Haig  in  the  uric-acid  habit. 

The  chronic  and  irregular  forms  of  gout  are  best  treated  by  the  dietetic 
and  hygienic  measures  already  referred  to.  Potassium  iodide  is  sometimes 
useful,  and  preparations  of  guaiacum,  quinine,  and  the  bitter  tonics  combined 
vdth  alkalies  are  undoubtedly  of  benefit. 

Piperazin  has  been  much  lauded  as  an  efficient  aid  in  the  solution  of  uric 
acid.  The  clinical  results,  however,  are  very  discordant.  It  may  be  employed 
in  doses  of  from  15  to  30  grains  in  the  day,  and  is  conveniently  given  in 
aerated  water  containing  5  grains  to  the  tumblerful.  Piperazin,  as  a  uric 
acid  solvent,  was  rapidly  followed  by  lysidin,  urotropin,  urea,  and  urol  among 
others — a  sure  indication  of  their  therapeutic  worthlessness.  . 

Albu  speaks  favorably  of  lemon-juice  as  a  remedy.  The  vegetable  acids 
are  converted  in  the  system  into  alkaline  carbonates,  thus  enabling  the  blood 
to  keep  the  uric  acid  compounds  in  solution,  and  consequently  facilitating 
their  elimination  by  the  kidneys. 

Where  the  arthritic  attacks  are  confined  to  one  joint,  such  as  the  great-toe 
joint,  surgical  interference  may  be  considered.  Eiedel  reports  two  successful 
cases  in  which  he  removed  the  entire  joint  capsule  of  the  big-toe  joint,  with 
permanent  relief. 

V.     DIABETES    MELLITUS. 

Definition. — A  disorder  of  nutrition,  in  which  sugar  accumulates  in  the 
blood  and  is  excreted  in  the  urine,  the  daily  amount  of  which  is  greatly 
increased. 

For  a  case  to  be  considered  one  of  diabetes  mellitus  it  is  necessary 
that  the  form  of  sugar  eliminated  in  the  urine  be  grape  sugar,  that  it 
must  be  eliminated  for  weeks,  months,  or  years,  and  that  the  excretion  of 
sugar  must  take  place  after  the  ingestion  of  moderate  amounts  of  carbo- 
hydrates. 


DIABETES  MELLITUS.  409 

Etiology. — Incidence. — According  to  recent  statistics  diabetes  appears 
about  as  frequent  in  the  United  States  as  in  European  countries.  The  last 
census  gave  9.3  deaths  per  100,000  population  in  the  former  compared  with 
from  5  to  14  in  the  latter.  In  England  and  Wales  the  death-rate  from 
diabetes  in  1903  was  8.7  per  100,000  of  population.  The  death-rate  has  been 
gradually  on  the  increase  in  Paris  during  the  last  three  or  four  decades, 
reaching  14  to  the  100,000  of  population  in  1891.  The  disease  is  gradually 
■on  the  increase  in  the  United  States.  The  statistics  for  1870  gave  2.1 ;  for 
1880,  2.8 ;  for  1890,  3.8 ;  and  for  1900,  9.3  deaths  to  the  100,000  population. 
This  apparent  increase  may  be  in  part  due  to  more  accurate  vital  statistics 
records.  In  this  region  the  incidence  of  the  disease  may  be  gathered  from 
the  fact  that  among  99,000  patients  admitted  to  the  medical  wards  and  medi- 
cal dispensary  of  the  Johns  Hopkins  Hospital  in  nearly  sixteen  years  there 
were  226  cases  of  diabetes,  or  0.22  per  cent.  Among  18,000  ward  cases  there 
were  147  diabetics. 

Hereditary  influences  play  an  important  role,  and  cases  are  on  record  of 
its  occurrence  in  many  members  of  the  same  family.  Morton,  who  calls  the 
■disease  hydrops  ad  matulam  (Phthisiologia,  1689)  records  a  remarkable  family 
in  which  four  children  were  affected,  one  of  whom  recovered  on  a  milk  diet 
and  diascordium.  An  analysis  of  the  cases  in  my  series  gave  only  6  cases 
with  a  history  of  diabetes  in  relatives  (Pleasants).  Naunyn  obtained  a  fam- 
ily history  of  diabetes  in  35  out  of  201  private  cases,  but  in  only  7  of  157  hos- 
pital cases.  There  are  instances  of  the  coexistence  of  the  disease  in  man  and 
wife.  Among  516  married  pairs  collected  by  Senator,  in  which  either  hus- 
l)and  or  wife  was  diabetic,  in  18  cases  the  second  partner  had  become  diabetic. 
It  is  not  easy  to  explain  this  conjugal  diabetes.  The  suggestion  of  contagion 
seems  scarcely  tenable. 

8ex. — Men  are  more  frequently  affected  than  women,  the  ratio  being  about 
three  to  two.  Up  to  April  1,  1905,  226  cases  of  diabetes  had  been  treated 
in  the  medical  wards  and  medical  dispensary  of  the  Johns  Hopkins  Hospital, 
131  of  which  were  in  males  and  95  in  females  (Futcher).  It  is  a  disease  of 
adult  life;  a  majority  of  the  cases  occur  from  the  third  to  the  sixth  decade. 
Of  the  226  cases,  the  largest  number — 63,  or  27  per  cent — occurred  between 
fifty  and  sixty  years  of  age.  These  figures  agree  fairly  closely  with  those  of 
Frerichs,  Seegen,  and  Pavy,  all  of  whom  found  the  largest  number  of  cases 
in  the  sixth  decade,  their  percentages  being  26,  30,  and  30.7  respectively.  It 
is  rare  in  childhood,  but  cases  are  on  record  in  children  under  one  year 
■of  age. 

In  the  above  series  there  were  no  cases  in  the  first  hemi-decade,  2  in  the 
second,  7  in  the  third,  and  6  in  the  fourth. 

Persons  of  a  neurotic  temperament  are  often  affected.  It  is  a  disease  of 
the  higher  classes.  Von  ^oorden  states  that  the  statistics  for  London  and 
Berlin  show  that  the  number  of  cases  in  the  upper  ten  thousand  exceeds  that 
in  the  lower  hundred  thousand  inhabitants. 

Race. — Hebrews  seem  especially  prone  to  it;  one-fourth  of  Frerichs'  pa,- 
tients  were  of  the  Semitic  race.  I  have  been  much  impressed  with  the  fre- 
quency of  the  disease  among  them.  Diabetes  is  comparatively  rare  in  the 
colored  race,  but  not  so  uncommon  as  was  formerly  supposed.  Of  the  series 
■of  226  cases,  23,  or  11.3  per  cent,  were  in  negroes.  The  ratio  of  males  to 
28 


410  CONSTITUTIONAL  DISEASES. 

females  affected  is  almost  exactly  the  reverse  of  that  in  the  white  race;  15 
of  the  23  were  in  females  and  8  in  males. 

Olesity. — In  a  considerable  proportion  of  the  cases  of  diabetes  the  sub- 
jects have  been  excessively  fat  at  the  beginning  of,  or  prior  to,  the  onset  of 
the  disease.  A  slight  trace  of  sugar  is  not  very  uncommon  in  obese  persons. 
This  so-called  lipogenic  glycosuria  is  not  of  grave  significance,  and  is  only 
occasionally  followed  by  true  diabetes.  On  the  other  hand,  as  von  Noorden 
has  shown,  there  may  be  a  "  diabetogenous  obesity,"  in  which  diabetes  and 
obesity  develop  in  early  life,  and  these  cases  are  very  unfavorable.  There 
are  instances  on  record  in  which  obesity  with  diabetes  has  occurred  in 
three  generations.  Diabetes  is  more  common  in  cities  than  in  country 
districts.  Gout,  S3^philis,  and  malaria  have  been  regarded  as  predisposing 
causes. 

Nervous  Influences. — Mental  shock,  severe  nervous  strain,  and  worry  pre- 
cede many  cases.  In  one  case  the  symptoms  came  on  suddenly  after  the 
patient  had  been  nearly  suffocated  by  smoke  from  having  been  confined  in  a 
cell  of  a  burning  jail.  Shock  and  the  toxic  effects  of  the  smoke  may  both 
have  been  factors  in  this  case.  The  combination  of  intense  application  to 
business,  over-indulgence  in  food  and  drink,  with  a  sedentary  life,  seems 
particularly  prone  to  induce  the  disease.  Glycosuria  may  set  in  during  preg- 
nancy, and  in  rare  instances  may  only  occur  at  this  period.  Trousseau 
thought  that  the  offspring  of  phthisical  parents  were  particularly  prone  to 
diabetes. 

Injury  to  or  disease  of  the  spinal  cord  or  brain  has  been  followed  by 
diabetes.  In  the  carefully  analyzed  cases  of  Frerichs  there  were  30  instances 
of  organic  disease  of  these  parts.  The  medulla  is  not  always  involved.  In 
only  4  of  his  cases,  which  showed  organic  disease,  was  there  sclerosis  or  other 
anomaly  of  this  part.  An  irritative  lesion  of  Bernard's  diabetic  centre  in  the 
medulla  is  an  occasional  cause.  I  saw  with  Eeiss,  at  the  Friedrichshain, 
Berlin,  a  woman  who  had  anomalous  cerebral  symptoms  and  diabetes,  and 
in  whom  there  was  found  post  mortem  a  C3'sticercus  in  the  fourth  ventricle. 
Glycosuria  sometimes  occurs  in  tumors  of  the  hypophysis  such  as  accompany 
acromegaly.  Ebstein  has  recorded  4  cases  in  which  there  was  a  coincident 
occurrence  of  epilepsy  and  diabetes  mellitus.  He  thinks  that  in  the  majority 
of  cases  the  two  diseases  are  dependent  on  a  common  cause.  He  believes  that 
the  association  would  be  found  much  more  commonly  in  Jacksonian  epilepsy 
than  has  been  the  case  heretofore,  if  more  careful  and  systematic  examina- 
tions of  the  urine  were  made.  A  transitory  glycosuria  occasionally  follows 
cerebral  haemorrhage  and  also  severe  gall-stone  colic. 

The  disease  has  occasionalh'  followed  the  infectious  fevers.  Cases  have 
been  recorded  as  occurring  during  or  immediately  after  diphtheria,  influenza, 
rheumatism,  enteric  fever,  and  syphilis. 

Experimental  Diabetes. — Leo  believes  that  diabetes  is  due  to  a  toxic  agent. 
He  has  produced  glycosuria  in  dogs  b}^  administering  both  fresh  and  fer- 
mented diabetic  urine.  In  1901,  Blum  reported  that  the  subcutaneous  injec- 
tion of  an  aqueous  solution  of  adrenalin  produced  glycosuria  in  22  out  of  25 
animals  experimented  upon.  Herter  confirmed  these  results,  and  found  that 
the  direct  application  of  the  solution  to  the  surface  of  the  pancreas  caused  a 
marked  glycosuria.     Adrenalin  is  a  powerful  reducing  substance,  and  Herter 


DIABETES  MELLITUS.  411 

thinks  that  the  glycosuria  results  from  interference  with  normal  oxidation 
processes  in  the  pancreatic  cells.  Phloridzin  administered  internally  or  hypo- 
dermically  produces  a  marked  temporary  glycosuria.  There  is  no  accom- 
panying hyperglycsemia.  The  phloridzin  acts  primarily  on  the  renal  epi- 
thelium, destroying  its  power  of  keeping  back  the  sugar.  Naunyn  and  Klem- 
perer  hold  the  view  that  there  is  a  renal  form  of  diabetes. 

Metabolism  in  Diabetes. — Our  ignorance  of  the  metabolic  disturbances  in 
diabetes  has  been  largely  due  to  the  fact  that  we  have  not  known  how  the 
carbohydrates  are  eventually  disposed  of  in  the  body  in  health.  Normally  the 
carbohydrates  of  the  food  are  stored  in  the  liver  and  muscles  as  glycogen. 
Pavy  holds  that  a  part  of  the  ingested  carbohydrates  is  converted  by  the  villi 
of  the  intestinal  mucosa  into  fat  and  carried  thence  by  the  lacteals  to  the 
blood.  By  a  splitting-off  process  another  portion  is  incorporated  with  nitroge- 
nous matters  and  carried  away  in  the  form  of  proteid.  He  thinks  that  only 
a  portion  of  the  carbohydrates  reaches  the  liver  as  glucose,  where  the  hepatic 
cells  convert  this  monosaccharid  into  the  polysaccharid  glycogen.  Glycogen 
can  also  be  formed  from  the  proteids  of  the  food;  and  under  certain  circum- 
stances sugar  can  be  directly  formed  from  the  body  proteids.  In  health  the 
amount  of  glucose  in  the  circulating  blood  ranges  between  0.1  and  0.2  per 
cent.  If  it  were  not  for  the  reservoir  action  of  the  liver  and  muscles  in  storing 
up  the  excess  of  carbohydrates  after  a  meal  as  glycogen,  we  would  have 
more  than  0.2  per  cent  of  glucose  in  the  blood,  a  hyperglycemia  would  occur 
and  a  glycosuria  ensue.  In  health  the  glycogen  is  reconverted  into  glucose, 
which  is  distributed  to  the  muscles  by  the  circulating  blood  and  there  burnt 
up,  producing  heat  and  energy. 

The  manner  in  which  this  final  combustion  is  effected  has  hitherto  not 
been  known.  Cohnheim^s  (Jr.)  published  researches  in  1903  and  1904 
throw  much  light  on  this  subject.  By  a  specially  constructed  press  he 
obtained  the  juice  from  the  pancreas  and  muscles  of  dogs  and  cats.  Each 
Juice  added  independently  to  solutions  of  glucose  was  inert.  When,  however, 
the  pancreatic  juice  was  added  to  a  mixture  of  muscle  juice  and  glucose  there 
was  a  rapid  breaking  up  of  the  latter  into  alcohol  and  carbonic  acid.  Cohn- 
heim  holds  that  this  remarkable  effect  is  analogous  to  Pavlow's  observation 
that  trypsinogen  is  only  made  active  for  proteid  digestion  by  being  converted 
into  trypsin  by  the  "  enterokinase  "  of  the  succus  entericus.  He  believes  that 
the  muscles  produce  a  proenzyme  which  is  only  made  active  for  carbohydrate 
combustion  by  the  action  of  another  substance  produced  in  the  pancreas  and 
conveyed  to  the  muscles  by  the  blood  stream.  He  showed  that  the  glycolytic 
substance  produced  by  the  pancreas  is  not  a  true  ferment  but  a  body  closely 
related  in  its  characteristics  with  other  well-known  constituents  of  internal 
secretions  as  adrenalin  and  iodothyrin.  He  also  found  that  when  too  large 
a  quantity  of  the  juice  of  the  pancreas  is  used  carbohydrate  combustion  is 
retarded  or  even  stopped.  The  pancreas  juice  is  supposed  to  supply  the  am- 
boceptors and  the  muscle  juice  the  complement.  The  retarding  action  of  an 
excess  of  pancreas  juice  is  believed  to  be  due  to  an  overabundance  of  ambo- 
ceptors. According  to  these  researches  the  carbohydrates  normally  are  burnt 
up  in  the  muscles,  producing  heat  and  energy,  by  the  combined  action  of  two 
glycolytic  bodies,  one  produced  in  the  muscles  and  the  other  in  the  pancreas. 
This  important  work  awaits  confirmation. 


412  CONSTITUTIONAL  DISEASES. 

Wlien  the  percentage  of  glucose  in  the  circulating  blood  exceeds  0.3  per 
cent  a  glycosuria  occurs.    This  may  theoretically  be  produced  as  follows : 

(a)  By  functional  or  organic  disease  of  the  islands  of  Langerhans  in  the 
pancreas.  These  islands  of  cells  probably  produce  a  glycol}rtic  ferment  or 
body.  This  substance  seems  necessary  for  the  proper  burning  up  of  the  car- 
bohydrates. If  the  islands  be  diseased  the  ferment  is  not  produced,  glucose 
accumulates  in  the  blood,  and  glycosuria  results.  This  substance  may  act  on 
the  carbohydrates  independently,  or,  as  Cohnheim  believes,  is  necessary  to 
render  active  a  pro-ferment  manufactured  by  the  muscle  cells, 

(&)  By  the  sudden  ingestion  of  a  greater  quantity  of  carbohydrates  than 
can  for  the  time  being  be  stored  up  in  the  liver  as  glycogen.  A  healthy  per- 
son can  take  from  180  to  250  grams  of  glucose  on  an  empty  stomach  without 
glycosuria  occurring.  Larger  amounts  will  produce  a  so-called  alimentary 
glycosuria,  or  glycosuria  e  saccharo.  In  a  healthy  person  no  amount  of 
carbohydrates  in  the  form  of  starch  will  produce  a  glycosuria  owing  to  the 
comparative  slowness  of  its  transformation  into  glucose.  If,  however,  the 
person's  "  assimilation  limit,"  or  power  of  warehousing  carbohydrates,  be 
lowered,  a  glycosuria  e  am3io  may  occur. 

(c)  By  changes  in  the  liver  function:  (1)  Changes  in  the  circulation 
under  nervous  influences.  Puncture  of  the  medulla,  lesions  of  the  cord,  and 
central  irritation  of  various  kinds  are  followed  by  glycosuria,  which  is 
attributed  to  a  vasomotor  paralysis  induced  by  these  causes,  resulting  in  a 
greater  quantity  of  blood  flowing  through  the  liver.  On  this  view  the  disease 
is  a  neurosis.  (2)  Instability  of  the  glycogen,  owing  either  to  imperfect 
formation  or  to  conditions  in  the  cells  which  render  it  less  stable. 

Morbid  Anatomy. — Saundby  (Lectures  on  Diabetes,  1891)  has  given  a 
good  summary  of  the  anatomical  changes : 

The  nervous  system  shows  no  constant  lesions.  In  a  few  instances  there 
have  been  tumors  or  sclerosis  in  the  medulla,  or,  as  in  the  case  above  men- 
tioned, a  cysticercus  has  pressed  on  the  floor.  Cysts  have  been  met  with  in 
the  white  matter  of  the  cerebrum  and  perivascular  changes  have  been  de- 
scribed. A  secondary  multiple  neuritis  is  not  rare,  and  to  it  the  so-called 
diabetic  tabes  is  probably  due.  E.  T.  Williamson  has  found  changes  in  the 
posterior  columns  of  the  cord  similar  to  those  which  occur  in  pernicious 
anaemia. 

In  the  sjTupathetic  system  the  ganglia  have  been  enlarged  and  in  some 
instances  sclerosed.  The  hlood  may  contain  as  high  as  0.4  per  cent  of  sugar 
Instead  of  0.15  per  cent.  The  plasma  is  usually  loaded  with  fat,  the  mole- 
cules of  which  may  be  seen  as  fine  particles.  When  drawn,  a  white  creamy 
layer  coats  the  coagulum,  and  there  may  be  lipasmic  clots  in  the  small  vessels. 
There  are  no  special  changes  in  the  red  or  white  corpuscles.  The  polynuclear 
leucocytes  contain  glycogen.  Glycogen  can  occur  in  normal  blood,  but  it  is 
here  extracellular.  It  has  been  also  found  in  the  poljTiuclear  leucocytes  in 
leukaemia.  The  heart  is  hypertrophied  in  some  cases.  Endocarditis  is  very 
rare.  Arterio-sclerosis  is  common.  The  lungs  show  important  changes. 
Acute  broncho-pneumonia  or  croupous  pneumonia  (either  of  which  may  ter- 
minate in  gangrene)  and  tuberculosis  are  common.  The  so-called  diabetic 
phthisis  is  always  tuberculous  and  results  from  a  caseating  broncho-pneu- 
monia.    In  rare  cases  there  is  a  chronic  interstitial  pneumonia,  non-tubercu- 


DIABETES  MELLITUS.  413 

lous.  Fat  embolism  of  the  pulmonary  vessels  has  been  described  in  connection 
with  diabetic  coma. 

The  liver  is  usually  enlarged;  fatty  degeneration  is  common.  In  the  so- 
called  diabetic  cirrhosis — the  cirrhose  pigmentaire — the  liver  is  enlarged  and 
sclerotic,  and  a  cachexia  develops  with  melanoderma.  This  condition  is  prob- 
ably identical  with  hsemochromatosis.     Dilatation  of  the  stomach  is  common. 

The  Pancreas  in  Diabetes. — Our  scientific  knowledge  of  the  relationship 
of  the  pancreas  to  glycosuria  dates  from  1889,  when  Minkowski  and  von 
Mering  published  the  results  of  their  experiments  on  extirpation  of  the  pan- 
creas in  animals.  The  present  status  may  be  thus  summarized:  (a)  Extir- 
pation of  the  gland  in  dogs  (and  occasionally  in  man — W.  T.  Bull)  is 
followed  by  glycosuria.  If  a  small  portion  remains,  sugar  does  not  appear. 
(&)  In  a  considerable  percentage  of  cases  of  diabetes  lesions  of  the  pan- 
creas are  found;  50  per  cent  (Hansemann,  Williamson)  show  a  chronic 
interstitial  inflammation,  (c)  In  view  of  the  experimental  work,  it  is 
reasonable  to  infer  that  the  diabetes  is  secondary  to  the  pancreatic  lesion. 
The  organ  has,  like  the  liver,  a  double  secretion — an  external,  which  is 
poured  into  the  intestines,  and  an  internal,  of  the  nature  either  of  a  ferment 
or  of  a  body  similar  in  chemical  characteristics  to  those  of  adrenalin  or 
iodothyrin,  as  Cohnheim  claims,  which  seems  necessary  for  the  proper  com- 
bustion of  glucose  in  the  muscles.  Disease  of  the  pancreas  causes  diabetes 
by  preventing  the  formation  of  this  glycolytic  body.  The  fact  that  if  a 
small  portion  of  the  gland  is  left,  in  the  experiments  upon  dogs,  diabetes 
does  not  occur,  is  analogous  to  the  remarkable  circumstance  that  a  small 
fragment  of  the  thyroid  is  sufficient  to  prevent  the  occurrence  of  artificial 
myxoedema. 

It  is  probable  that  the  observations  of  Opie  from  Dr.  Welch's  laboratory, 
confirmed  by  those  of  Weichselbaum  and  Stange,  give  a  key  to  the  problem. 
Imbedded  in  the  gland  are  the  peculiar  bodies  known  as  the  islands  of  Lan- 
gerhans,  composed  of  polygonal  cells  arranged  in  irregular  columns,  between 
which  are  wide  anastomosing  capillaries.  The  lumina  of  the  ducts  do  not 
enter  the  islands,  which  are  in  reality  ductless  glands,  like  the  para-thyroid, 
the  thyroid,  the  pituitary;  etc.  The  intimate  relation  of  the  columns  of  cells 
to  the  rich  network  of  blood-vessels  suggests,  as  advanced  by  Schafer,  that 
they  furnish  the  internal  secretion  of  the  gland.  It  is  probable  that  the  glyco- 
l3rtic  body  found  by  Cohnheim  is  produced  by  these  specialized  cells..  Ex- 
perimental evidence  is  defective,  but  changes  in  the  islands  have  been  found 
in  diabetes.  In  a  diabetic  woman,  aged  twenty-four,  from  my  wards,  dead 
of  tuberculosis  of  the  lungs,  Opie  found  the  glandular  tissue  of  the  pancreas 
well  preserved  and  healthy,  but  the  islands  of  Langerhans  were  everywhere 
"  represented  by  a  sharply  circumscribed  hyaline  structure  composed  of  par- 
ticles of  homogeneous  material."  In  two  other  cases  lesions  of  the  islands 
were  found,  but  there  was  also  chronic  pancreatitis  (Opie,  Jour.  Exper.  Med., 
vol.  v).  Hoppe-Seyler  has  recently  described  a  clinical  form  of  pancreatic 
diabetes  due  to  arterio-sclerosis  of  the  pancreatic  vessels.  These  arterial 
changes  were  found  in  a  series  of  autopsies. 

Of  15  autopsies  from  my  own  27  cases,  in  9  on  gross  examination  the 
pancreas  was  found  to  be  atrophic.  In  one  of  these  fat  necroses,  and  in 
another  calculi,  were  present. 


414  CONSTITUTIONAL  DISEASES. 

The  kidneys  show  usually  a  diffuse  nephritis  with  fatty  degeneration.  A 
hyaline  change  occurs  in  the  tubal  epithelium,  particularly  of  the  descending 
limb  of  the  loop  of  Henle,  and  also  in  the  capillary  vessels  of  the  tufts. 

Symptoms. — Acute  and  chronic  forms  are  recognized,  but  there  is  no 
essential  difference  between  them,  except  that  in  the  former  the  patients  are 
younger,  the  course  is  more  rapid,  and  the  emaciation  more  marked.  Acute 
eases  may  occur  in  the  aged.  I  saw  with  Sowers  in  Washington  a  man  aged 
seventy-three  in  whom  the  entire  course  of  the  disease  was  less  than  three 
weeks. 

It  is  also  possible  to  divide  the  cases  into  (1)  lipogenic  or  dietetic,  which 
includes  the  transient  glycosuria  of  stout  persons;  (2)  neurotic,  due  to  in- 
juries or  functional  disorders  of  the  nervous  system;  and  (3)  pancreatic, 
in  which  there  is  a  lesion  of  the  pancreas.  It  is,  however,  by  no  means  easy 
to  discriminate  in  all  cases  between  these  forms.  Attempts  have  been  made 
to  separate  a  clinical  variety  analogous  to  experimental  pancreatic  diabetes. 
Hirsehfeld,  from  Guttman's  clinic^  has  described  cases  running  a  rapid  and 
severe  course  usually  in  young  and  -  middle-aged  persons.  The  polyuria  is 
less  common  or  even  absent,  and  there  is  a  striking  defect  in  the  assimilation 
of  the  albuminoids  and  fats,  as  sho\^Ti  by  the  examination  of  the  fgeces  and 
urine.  In  4  of  7  eases  autopsies  were  made  and  the  pancreas  was  found 
atrophic  in  two,  cancerous  in  one,  and  in  the  fourth  exceedingly  soft. 

The  onset  of  the  disease  is  gradual,  and  either  frequent  micturition  or 
inordinate  thirst  first  attracts  attention.  Very  rarely  it  sets  in  rapidly,  after 
a  sudden  emotion,  an  injury,  or  after  a  severe  chill.  When  fully  established 
the  disease  is  characterized  by  great  thirst,  the  passage  of  large  quantities 
of  saccharine  urine,  a  voracious  appetite,  and,  as  a  rule,  progressive  ema- 
ciation. 

Among  the  general  symptoms  of  the  disease  thirst  is  one  of  the  most 
distressing.  Large  quantities  of  water  are  required  to  keep  the  sugar  in 
solution  and  for  its  excretion  in  the  urine.  The  amount  of  fluid  consumed 
will  be  found  to  bear  a  definite  ratio  to  the  quantity  excreted.  Instances, 
however,  are  not  uncommon  of  pronounced  diabetes  in  which  the  thirst  is 
not  excessive;  but  in  such  cases  the  amount  of  urine  passed  is  never  large. 
The  thirst  is  most  intense  an  hour  or  two  after  meals.  As  a  rule,  the  diges- 
tion is  good  and  the  appetite  inordinate.  The  condition  is  sometimes  termed 
'bulimia  or  polyphagia.     Lumbar  pain  is  common. 

The  tongue  is  usually  dry,  red,  and  glazed,  and  the  saliva  scanty.  The 
gums  may  become  swollen,  and  in  the  later  stages  aphthous  stomatitis  is 
common.     Constipation  is  the  rule. 

In  spite  of  the  enormous  amount  of  food  consumed  a  patient  may  be- 
come rapidly  emaciated.  This  loss  of  flesh  bears  some  ratio  to  the  polyuria, 
and  when,  under  suitable  diet,  the  sugar  is  reduced,  the  patient  may  quickly 
gain  in  flesh.  The  skin  is  dry  and  harsh,  and  sweating  rarely  occurs,  except 
when  phthisis  coexists.  Drenching  sweats  have  been  known  to  alternate 
with  excessive  polyuria.  General  pruritus  or  pruritus  pudendi  may  be  very 
distressing,  and  occasionally  is  one  of  the  earliest  symptoms.  The  tempera- 
ture is  often  subnormal;  the  pulse  is  usually  frequent,  and  the  tension  in- 
creased. Many  diabetics,  however,  do  not  show  marked  emaciation.  Patients 
past  the  middle  period  of  life  may  have  the  disease  for  years  without  much 


DIABETES  MELLITUS.  415 

disturbance  of  the  healthy  and  may  remain  well  nourished.  These  are  the 
cases  of  the  diahete  gras  in  contradistinction  to  diahete  maigre. 

The  Ueine. — The  amount  varies  from  3  to  4  litres  in  mild  cases  to 
15  to  20  litres  in  very  severe  cases.  In  rare  instances  the  quantity  of  urine 
is  not  much  increased.  Under  strict  diet  the  amount  is  much  lessened,  and 
in  intercurrent  febrile  affections  it  may  be  reduced  to  normal.  The  specific 
gravity  is  high,  ranging  from  1.025  to  1.045;  but  in  exceptional  cases  it 
may  be  low,  1.013  to  1.020.  The  highest  specific  gravity  recorded,  ^o  far 
as  I  know,  is  by  Trousseau — 1.074.  Very  high  specific  gravities — 1.070  -|- 
— suggest  fraud.  The  urine  is  pale  in  color,  almost  like  water,  and  has  a 
sweetish  odor  and  a  distinctly  sweetish  taste.  The  reaction  is  acid.  Sugar 
is  present  in  varying  amounts.  In  mild  cases  it  does  not  exceed  1^  or  2  per 
cent,  but  it  may  reach  from  5  to  10  per  cent.  The  total  amount  excreted  in 
the  twenty-four  hours  may  range  from  10  to  20  ounces  (320  to  640  grammes) 
and  in  exceptional  cases  from  1  to  2  pounds.  The  following  are  the  most 
satisfactory  tests: 

Fehling's  Test. — The  solution  consists  of  sulphate  of  copper  (grs.  90^), 
neutral  tartrate  of  potassium  (grs.  364),  solution  of  caustic  soda  (fl.  ozs.  4), 
and  distilled  water  to  make  up  6  ounces.  Put  a  drachm  of  this  in  a  test- 
tube  and  boil  (to  test  the  reagent)  ;  add  an  equal  quantity  of  urine  and  boil 
again,  when,  if  sugar  is  present,  the  yellow  suboxide  of  copper  is  thrown 
down.    The  solution  must  be  freshly  prepared,  as  it  is  apt  to  decompose. 

Trommer's  Test. — To  a  drachm  of  urine  in  a  test-tube  add  a  few  drops 
of  a  dilute  sulphate-of-copper  solution  and  then  as  much  liquor  potasscB  as 
urine.  On  boiling,  the  copper  is  reduced  if  sugar  be  present,  forming  the 
yellow  or  orange-red  suboxide.  There  are  certain  fallacies  in  the  copper 
tests.  Thus,  a  substance  called  glycuronic  acid  is  met  with  in  the  urine 
after  the  use  of  certain  drugs — chloral,  phenacetin,  morphia,  chloroform, 
etc. — which  reduces  copper.  Alcaptonuria  may  also  be  a  source  of  error 
(see  Alcaptonuria). 

Fermentation  Test. — This  is  free  from  all  doubt.  Place  a  small  frag- 
ment of  yeast  in  a  test-tube  full  of  urine,  which  is  then  inverted  over  a  glass 
vessel  containing  the  same  fluid.  There  are  now  specially  devised  fermenta- 
tion tubes.  If  sugar  is  present,  fermentation  goes  on  with  the  formation 
of  carbon  dioxide,  which  accumulates  in  the  upper  part  of  the  tube  and 
gradually  expels  the  urine.  In  doubtful  cases  a  control  test  should  always 
be  used. 

Folariscope  Test. — For  laboratory  work  the  polariscope  test  is  of  great 
value.  Glucose  is  dextro-rotatory.  The  percentage  of  sugar  can  be  quickly 
estimated  by  the  degree  of  rotation,  and  for  quantitative  determination  is 
the  most  serviceable  method.  The  presence  of  )8-oxybutyric  acid,  which  is 
Isevo-rotatory,  will  neutralize  some  of  the  dextro-rotatory  action  of  the  glucose. 

Nylanders  Bismuth  Test. — Nylander's  solution  is  prepared  by  dissolving 
4  grammes  of  Eochelle  salt  in  100  cc.  of  10  per  cent  caustic  soda  solution  and 
adding  2  grammes  of  bismuth  subnitrate  and  digesting  on  the  water-bath  until 
as  much  of  the  bismuth  salt  is  dissolved  as  possible.  To  10  cc.  of  urine  add 
1  cc.  of  the  Nylander's  solution  and  boil  for  a  few  minutes.  If  glucose  be 
present  a  black  deposit  of  bismuth  occurs. 

Of  other  ingredients  in  the  urine,  the  urea  is  increased,  the  uric  acid 


416  CONSTITUTIONAL  DISEASES. 

does  not  show  special  changes,  and  the  phosphates  may  be  greatly  in  excess. 
The  calcium  salts  are  markedly  increased.  The  same  holds  true  for  the 
ammonia  in  all  severe  cases,  and  particularly  in  diabetic  coma.  Ralfe  has 
described  a  great  increase  in  the  phosphates,  and  in  some  of  these  cases, 
with  an  excessive  excretion,  the  symptoms  may  be  very  similar  to  those  of 
diabetes,  though  the  sugar  may  not  be  constantly  present.  The  term  phos- 
phatic  diabetes  has  sometimes  been  applied  to  them.  Acetone  and  acetone- 
forming  substances  are  not  infrequently  present.  Lieben's  test  is  as  follows : 
The  urine  is  distilled  and  a  few  cubic  centimetres  of  the  distillate  are  ren- 
dered alkaline  with  liquor  potassae.  A  few  drops  of  Lugol's  solution  are 
then  added,  when,  if  acetone  be  present,  the  distillate  assumes  a  turbid  yellow 
color,  due  to  the  formation  of  iodoform,  which  is  recognized  by  its  odor  and 
by  the  formation  of  minute  hexagonal  and  stellate  crystals,  Diacetic  acid- 
is  sometimes  present,  and  may  be  recognized  from  the  fact  that  a  solution 
of  the  chloride  of  iron  yields  a  beautiful  Bordeaux-red  color.  Other  sub- 
stances, as  formic,  carbolic,  and  salicylic  acids,  give  the  same  reaction  in 
both  fresh  and  previously  boiled  urine,  while  diacetic  acid  does  not  give 
the  reaction  in  urine  previously  boiled.  In  testing  for  diacetic  acid  perfectly 
fresh  urine  should  be  used,  as  it  rapidly  becomes  broken  up  into  acetone  and 
carbonic  acid,  ^-oxybutyric  acid,  the  recognized  cause  of  coma,  should  be 
tested  for  in  all  severe  cases.  As  it  is  lasvo-rotatory,  its  presence  is  indicated 
by  Isevo-rotation  in  completely  fermented  urine,  as  well  as  by  the  greater 
percentage  of  sugar  demonstrable  with  Fehling's  than  with  the  polariscopic 
method.  The  occurrence  of  acetone  and  diacetic  acid  in  the  urine,  both 
derivative  products  of  /8-ox3^butyric  acid,  is  conclusive  evidence  that  yS'-oxy- 
butyrie  acid  is  being  produced  in  the  body. 

Bremer  finds  that  diabetic  urine  has  the  power  of  dissolving  gentian  violet, 
whereas  normal  urine  fails  to  do  so.  Unfortunately,  the  urine  in  diabetes 
insipidus  and  in  certain  forms  of  polyuria  reacts  similarly.  Frohlich  has 
recently  devised  a  test  based  on  the  fact  that  diabetic  urine  has  the  property 
of  decolorizing  solutions  of  methylene  blue. 

Glycogen  has  also  been  described  as  present  in  the  urine. 

Albumin  is  not  infrequent.  It  occurred  in  nearly  37  per  cent  of  the 
examinations  made  by  Lippman  at  Carlsbad. 

Pneumaturia,  the  formation  of  gas  in  the  urine,  due  to  fermentative 
processes  in  the  bladder,  is  occcasionally  met  with. 

Gammidge  found  glycerine  in  the  urine  in  one  case  of  pancreatic  diabetes. 
This  results  from  fat  necroses  due  to  the  action  of  a  fat-splitting  ferment. 

Fat  may  be  passed  in  the  urine  in  the  form  of  a  fine  emulsion  (lipuria). 

Blood  in  Diabetes. — In  true  diabetes  hyperglycsemia  is  constant.  As 
coma  supervenes,  y8-oxybutyric  acid  occurs.  Polycythsemia,  with  the  red 
cells  between  6,000,000  and  8,000,000  per  cmm.,  is  not  uncommon  in  the 
desiccated  cases  with  marked  polyuria.  Coma  is  accompanied  by  a  moderate 
leucocytosis.  Lipgemia  occurs  in  a  certain  number  of  cases.  It  is  recognized 
by  the  presence  of  innumerable  dancing  particles  between  the  red  cells  in  a 
fresh  preparation,  and  by  the  creamy  appearance  of  the  serum  of  centrif- 
ugalized  blood.  Normal  blood  contains  between  0.16  to  0.325  per  cent  of 
fat  (Becquerel  and  Eodier).  Fraser  found  16.44  per  cent  of  fat  in  the  blood 
of  a  diabetic.     Opinions  vary  as  to  the  source  of  the  fat. 


DIABETES  MELLITUS.  417 

Diabetes  in  Children. — Stern  has  analyzed  117  cases  in  children.  They 
usually  occur  among  the  better  classes.  Six  were  under  one  year  of  age. 
Hereditary  influences  were  marked.  The  course  of  the  disease  is,  as  a  rule, 
much  more  rapid  than  in  adults.  The  shortest  duration  was  two  days.  In 
7  cases  it  did  not  last  a  month.  One  case  is  mentioned  of  a  child  apparently 
born  with  the  glycosuria,  who  recovered  in  eight  months. 

Complications. —  (a)  Cutaneous. — Boils  and  carbuncles  are  extremely 
common.  Painful  onychia  may  occur.  Eczema  is  also  met  with,  and  at 
times  an  intolerable  itching.  In  women  the  irritation  of  the  urine  may  cause 
the  most  intense  pruritus  pudendi,  and  in  men  a  balanitis.  Earer  affections 
are  xanthoma  and  purpura.  Gangrene  is  not  uncommon,  and  is  associated 
usually  with  arterio-sclerosis.  William  Hunt  has  analyzed  64  cases.  In  50 
the  localities  were  as  follows:  Feet  and  legs,  37;  thigh  and  buttock,  2;  nucha, 
2 ;  external  genitals,  1 ;  lungs,  3 ;  fingers,  3 ;  back,  1 ;  eyes,  1.  Perforating 
ulcer  of  the  foot  may  occur.  Bronzing  of  the  skin  (diaiete  bronze)  occurs 
in  certain  cases  in  which  the  diabetes  arises  as  a  late  event  in  the  disease 
known  as  htemochromatosis,  which  is  further  characterized  by  pigmentary 
cirrhosis  of  the  liver  and  pancreas.  With  the  onset  of  severe  complications 
the  tolerance  of  the  carbohydrates  is  much  increased.  Profuse  sweats  may 
occur. 

(&)  Pulmonary. — The  patients  are  not  infrequently  carried  off  by  aade 
pneumonia^  which  may  be  lobar  or  lobular.  Gangrene  is  very  apt  to  super- 
vene, but  the  breath  does  not  necessarily  have  the  foul  odor  of  ordinary 
gangrene.     Abscess  following  lobar  pneumonia  occurred  in  one  of  my  cases. 

Tuberculous  hronclio- pneumonia  is  very  common.  It  was  formerly  thought, 
from  its  rapid  course  and  the  limitation  of  the  disease  to  the  lung,  that  this 
was  not  a  true  tuberculous  affection ;  but  in  the  cases  which  have  come  under 
my  notice  the  bacilli  have  been  present,  and  the  condition  is  now  generally 
regarded  as  tuberculous. 

(c)  Renal. — Albuminuria  is  a  tolerably  frequent  complication.  The 
amount  varies  greatly,  and,  when  slight,  does  not  seem  to  be  of  much  mo- 
ment. CEdema  of  the  feet  and  ankles  is  not  an  infrequent  symptom.  ,Greneral 
anasarca  is  rare,  however,  owing  to  the  marked  polyuria.  It  is  sometimes 
associated  with  arterio-sclerosis.  It  occasionally  precedes  the  occurrence  of 
the  diabetic  coma.    Occasionally  cystitis  develops. 

(d)  Nervous  System. — (1)  Diabetic  coma,  first  studied  by  Kussmaul, 
comes  on  in  a  considerable  proportion  of  all  cases,  particularly  in  the  young. 
Stephen  Mackenzie  states  that  of  the  fatal  cases  of  diabetes  at  tilie  London 
Hospital,  all  under  the  age  of  twenty-five,  with  but  one  exception,  had  died 
in  coma.  In  Naunyn's  44  fatal  cases  it  occurred  in  12.  It  preceded  death 
in  28  of  Williamson's  40  cases.  It  occurred  in  15  of  27  fatal  cases  in  my 
series.  Frerichs  recognized  three  groups  of  cases:  (a)  Those  in  which  after 
exertion  the  patients  were  suddenly  attacked  with  weakness,  syncope,  som- 
nolence, and  gradually  deepening  unconsciousness;  death  occurring  in  a  few 
hours,  (ft)  Cases  with  preliminary  gastric  disturbance,  such  as  nausea  and 
vomiting,  or  some  local  affection,  as  pharyngitis,  phlegmon,  or  a  pulmonary 
complication.  In  such  cases  the  attack  begins  with  headache,  delirium,  great 
distress,  and  dyspnoea,  affecting  both  inspiration  and  expiration,  a  condition 
called  by  Kussmaul  air-hunger.     Cyanosis  may  or  may  not  be  present.     If  it 


418  CONSTITUTIONAL  DISEASES. 

is,  the  pulse  becomes  rapid  and  weak  and  the  patient  gradually  sinks  into 
coma;  the  attack  lasting  from  one  to  five  days.  There  may  be  a  very  heavy 
sweetish  odor  of  the  breath,  due  to  the  presence  of  acetone,  (y)  Cases  in 
which,  without  an,y  previous  dyspncea  or  distress,  the  patient  is  attacked  with 
headache  and  a  feeling  of  intoxication,  and  rapidly  falls  into  a  deep  and 
fatal  coma.  There  are  atypical  cases  in  which  the  coma  is  due  to  uraemia, 
to  apoplexy,  or  to  meningitis. 

There  has  been  much  dispute  as  to  the  nature  of  these  symptoms,  but 
clinical  laboratory  investigations  have  practically  afforded  a  satisfactory  ex- 
planation. For  years  the  coma  symptoms  were  ascribed  to  the  toxic  effects 
of  acetone  and  later  to  those  of  diacetic  acid.  Experimental  work,  however, 
showed  that  these  views  were  incorrect.  The  almost  universal  opinion  now 
is  that  the  coma  is  due  to  an  acid  intoxication,  or,  as  Naunyn  terms  it,  an 
acidosis.  The  ofEending  agent  is  believed  to  be  y8-oxybutyric  acid,  which 
accumulates  in  the  tissues  and  circulating  blood  in  enormous  quantities,  and 
is  eliminated  in  the  urine  in  combination  with  various  base-forming  elements, 
but  never  free.  In  1884  Stadelmann,  Kiilz,  and  Minkowski  almost  simul- 
taneously found  this  acid  in  the  urine  of  patients  with  diabetic  coma.  Sub- 
sequent researches,  particularly  those  published  from  Naunyn's  clinic,  have 
fully  confirmed  these  results,  and  it  is  now  almost  universally  accepted  that 
^-oxybutyric  acid  is  the  cause  of  diabetic  coma.  The  amount  of  the  acid 
excreted  in  the  twenty-four  hours  may  be  enormous.  Kiilz  found  in  3  cases 
67,  100,  and  226  grammes  respectively.  Magnus-Levy  has  estimated  that 
from  100  to  200  grammes  are  often  contained  in  the  tissues  of  fatal  cases. 
This  author  is  of  the  belief  that  the  ^-oxybutyric  acid  is  derived  from  the 
fats  of  the  body,  whereas  most  observers,  including  Naunyn,  trace  it  to  the 
disintegration  of  the  tissue  albumins.  Acetone  and  diacetic  acid  are  deriva- 
tive products  of  the  j8-oxybut}Tic  acid. 

Saunders  and  Hamilton  have  described  cases  in  which  the  lung  capillaries 
were  blocked  with  fat.  They  attributed  the  symptoms  to  fat  embolism,  but 
there  are  many  cases  on  record  in  which  this  condition  was  not  found,  though 
lipgemia  is  by  no  means  infrequent  in  diabetes. 

Albuminuria  frequently  precedes  or  accompanies  the  attack,  and  numer- 
ous small,  short,  hyaline,  and  finely  granular  casts  are  demonstrable. 

(2)  Peripheral  Neuritis. — The  neuralgias^  numbness,  and  tingling,  which 
are  not  uncommon  symptoms  in  diabetes,  are  probably  minor  neuritic  mani- 
festations. The  involvement  may  be  general  of  the  upper  and  lower  extrem- 
ities. Sometimes  it  is  unilateral,  or  the  neuritis  may  be  in  a  single  nerve — 
the  sciatic  or  the  third  nerve.  Herpes  zoster  may  occur.  Perforating  ulcer 
of  the  foot  may  develop. 

Diabetic  Tabes  (so-called). — This  is  a  peripheral  neuritis,  characterized 
by  lightning  pains  in  the  legs,  loss  of  knee-jerk — which  may  occur  without 
the  other  symptoms — and  a  loss  of  power  in  the  extensors  of  the  feet.  The 
gait  is  the  characteristic  steppage,  as  in  arsenical,  alcoholic,  and  other  forms 
of  neuritic  paralysis.  Charcot  states  that  there  may  be  atrophy  of  the  optic 
nerves.  Changes  in  the  posterior  columns  of  the  cord  have  been  found  by 
Williamson  and  others. 

Diabetic  Paraplegia. — This  is  also  in  all  probability  due  to  neuritis. 
There  are  cases  in  which  power  has  been  lost  in  both  arms  and  legs. 


DIABETES  MELLITUS.  419 

(3)  Mental  Symptoms. — The  patients  are  often  morose,  and  there  is  a 
strong  tendency  to  become  hypochondriacal.  General  paralysis  has  been  met 
with.  Some  patients  display  an  extraordinary  degree  of  restlessness  and 
anxiety. 

(4)  Special  Senses. — Cataract  is  liable  to  occur,  and  with  rapidity  in 
young  persons.  Diabetic  retinitis  closely  resembles  the  albuminuric  form. 
Haemorrhages  are  common.  Sudden  amaurosis,  similar  to  that  which  occurs 
in  uraemia,  may  occur.  Paralysis  of  the  muscles  of  accommodation  may  be 
present;  and  lastly,  atrophy  of  the  optic  nerves.  Aural  symptoms  may  come 
on  with  great  rapidity,  either  an  otitis  media,  or  in  some  instances  inflamma- 
tion of  the  mastoid  cells. 

(5)  Sexual  Function. — Impotence  is  common,  and  may  be  an  early  symp- 
tom. Conception  is  rare;  if  it  occurs,  abortion  is  apt  to  follow.  A  diabetic 
mother  may  bear  a  healthy  child ;  there  is  no  known  instance  of  a  dia- 
betic mother  bearing  a  diabetic  child.  The  course  of  the  disease  is  usually 
aggravated  after  delivery. 

Course. — In  children  the  disease  is  rapidly  progressive,  and  may  prove 
fatal  in  a  few  days.  In  young  persons  death  almost  invariably  results  from 
diabetic  coma.  It  may  be  stated,  as  a  general  rule,  that  the"  older  the  patient 
at  the  time  of  onset  the  slower  the  course.  Cases  without  hereditary  influ- 
ences are  the  most  favorable.  In  stout,  elderly  men  diabetes  is  a  much  more 
hopeful  disease  than  it  is  in  thin  persons.  Middle-aged  patients  may  live  for 
many  years,  and  persons  are  met  with  who  have  had  the  disease  for  ten, 
twelve,  or  even  fifteen  years. 

Diagnosis. — As  stated  in  the  definition,  for  a  case  to  be  considered  diabetes 
the  sugar  eliminated  in  the  urine  must  be  grape  sugar,  it  should  be  present 
for  weeks,  months,  or  years,  and  the  excretion  of  sugar  must  take  place  after 
the  ingestion  of  moderate  amounts  of  carbohydrates.  Alimentary  or  dietetic 
glycosuria  must  not  be  confused  with  true  diabetes.  As  a  rule,  there  is  no 
difficulty  in  determining  the  presence  of  diabetes.  The  diagnosis  must  be 
made  chiefly  by  the  urine  tests  already  given.  More  than  one  test  must  be 
used,  and  where  there  is  any  doubt  the  fermentation  test,  the  most  reliable 
single  test,  must  be  made.  One  must  always  exclude  the  possibility  of  the 
copper  sulphate  reduction  being  due  to  glycuronic  acid  compounds  and  to 
homogentisic  acid,  the  latter  the  cause  of  alcaptonuria.  Bremer  showed  that 
the  red  cells  in  diabetic  blood  fail  to  take  the  red  stain  as  normal  reds  do. 
The  test  may  be  of  some  service  when  a  patient  is  first  seen  in  coma,  which 
may  be  thought  to  be  diabetic,  and  where  urine  is  not  at  once  available. 
Williamson  found  that  diabetic  blood  possesses  the  power  of  decolorizing 
weak  alkaline  solutions  of  methylene  blue  to  a  yellowish-green  or  yellow 
color. 

Occasionally  intermittent  glycosuria  occurs.  It  is  advisable  in  these  cases 
to  determine  the  assimilation  limit  for  carbohydrates.  According  to  Kaunyn, 
100  grammes  of  glucose  given  in  solution  two  hours  after  a  breakfast  of  a 
roll  and  butter  with  coffee  ought  not  to  cause  a  glycosuria.  If  it  does,  the 
individual's  power  of  warehousing  carbohydrates  is  lowei'ed  and  a  permanent 
glycosuria — ^true  diabetes — may  eventually  ensue. 

Deception  may  be  practised.  A  young  girl  under  my  care  had  urine  with 
a  specific  gravity  of  1.065,    The  reactions  were  for  cane  sugar.    There  is  one 


420  CONSTITUTIONAL  DISEASES. 

case  in  the  literature  in  which,  after  the  cane-sugar  fraud  was  detected,  the 
woman  bought  grape  sugar  and  put  it  into  her  bladder ! 

Prognosis. — In  true  diabetes  instances  of  cure  are  rare.  On  the  other 
hand,  the  transient  or  intermittent  glycosuria,  met  with  in  stout  overfeeders, 
or  in  persons  who  have  undergone  a  severe  mental  strain,  is  very  amenable 
to  treatment.  Not  a  few  of  the  cases  of  reputed  cures  belong  to  this  division. 
Practically,  in  cases  under  forty  years  of  age  the  outlook  is  bad;  in  older 
persons  the  disease  is  less  serious  and  much  more  amenable  to  treatment.  It 
is  a  good  plan  at  the  outset  to  determine  whether  the  urine  of  a  patient  con- 
tains sugar  or  not  on  a  diet  absolutely  free  from  carbohydrates.  If  the  sugar 
disappears  the  case  may  be  regarded  as  a  mild  one.  If,  on  the  other  hand, 
sugar  continues  to  be  excreted,  it  is  a  severe  one,  and  the  patient  is  manu- 
facturing sugar  from  his  body  proteids.  The  presence  of  ^-oxybutyric  or 
diacetic  acids  in  the  urine  is  usually  of  serious  import,  and  should  warn  the 
physician  of  the  possible  occurrence  of  coma.  Occasionally  diacetic  acid  may 
be  present  for  months,  apparently  without  serious  consequences. 

Treatment. — In  families  with  a  marked  predisposition  to  the  disease  the 
use  of  starchy  and  saccharine  articles  of  diet  should  be  restricted. 

The  personal  hygiene  of  a  diabetic  patient  is  of  the  first  importance. 
Sources  of  worry  should  be  avoided,  and  he  should  lead  an  even,  quiet  life,, 
if  possible  in  an  equable  climate.  Flannel  or  silk  should  be  worn  next  to 
the  skin,  and  the  greatest  care  should  be  taken  to  promote  its  action.  A 
lukewarm,  or,  if  tolerably  robust,  a  cold  bath,  should  be  taken  every  day.  An 
occasional  Turkish  bath  is  useful.  Systematic,  moderate  exercise  should  be 
taken.  When  this  is  not  feasible,  massage  should  be  given.  It  is  well  to 
study  accurately  the  dietetic  capabilities  of  each  case.  No  two  cases  can  be 
treated  alike.  The  weight  should  be  recorded  weekly.  A  patient  who  is 
glycosuric  and  losing  weight  on  a  non-carbohydrate  diet  must  be  regarded 
as  doing  badly.  By  the  addition  of  a  certain  amount  of  starchy  food  the 
same  person  may  excrete  a  moderate  amount  of  sugar  and  hold  or  even  gain 
in  weight. 

Diet. — Our  injunctions  to-day  are  those  of  Sydenham :  "  Let  the  patient 
eat  food  of  easy  digestion,  such  as  veal,  mutton,  and  the  like,  and  abstain 
from  all  sorts  of  fruit  and  garden  stuff." 

When  a  diabetic  patient,  in  private  or  hospital  practice,  comes  under  treat- 
ment, it  is  well  to  keep  him  for  three  or  four  days  on  the  ordinary  diet,  which 
contains  moderate  amounts  of  carbohydrates,  in  order  to  ascertain  the  amount 
of  sugar  excretion.  For  two  days  more  the  starches  are  gradually  cut  off. 
He  is  then  placed  on  the  following  non-carbohydrate  diet,  modified  in  each 
case  according  to  the  patient's  age  and  weight,  and  arranged  from  a  list 
recommended  by  von  Noorden: 

Breakfast:  7.30,  200  cc.  (o^i)  of  tea  or  coffee:  150  grammes  (§iv)  of 
beefsteak,  mutton-chops  without  bone,  or  boiled  ham ;  one  or  two  eggs. 

Lunch:  12.30,  200  grammes  (§vi)  cold  roast  beef;  60  grammes  (^ij) 
celery,  fresh  cucumbers  or  tomatoes  with  vinegar,  olive  oil,  pepper  and  salt 
to  taste;  20  cc.  (5v)  whisky  with  400  cc.  (o^iij)  water;  60  cc.  (oij)  coffee, 
without  milk  or  sugar. 

Dinner:  6  p.m.,  200  cc.  clear  bouillon;  250  grammes  (§  viiss)  roast  beef; 
10  grammes'  (.Diiss)  butter;  80  grammes  (oij)  green  salad,  with  10  grammes 


DIABETES  MELLITUS.  421 

(Siiss)  vinegar  and  20  grammes  (ov)  olive  oil,  or  three  tablespoonfuls  of 
some  well-cooked  green  vegetable;  three  sardines  a  I'huile;  20  cc.  (3  v)  whisky, 
with  400  cc.  (gxiij)  water. 

Supper:  9  p.  m.,  two  eggs  (raw  or  cooked)  ;  400  cc.  (§xiij)  water. 

This  diet  contains  about  200  grammes  of  albumin  and  about  135  gramtnes 
of  fat.  The  effect  of  the  diet  on  the  sugar  excretion  is  remarkable.  In  many 
cases  there  is  an  entire  disappearance  of  the  sugar  from  the  urine  in  three 
or  four  days.  Chart  XV  shows  very  graphically  the  remarkable  drop  in  the 
sugar  excretion  for  the  first  twenty-four  hours.  In  cases  in  which  the  urine 
becomes  free  from  sugar,  gradually  increasing  quantities  of  starch  up  to  20, 
50,  and  100  grammes  are  added  daily.  White  bread  contains  fifty- five  per 
cent  of  starch.  The  efl'ect  of  the  non-carbohydrate  diet,  according  to  von 
Noorden,  is  to  improve  the  metabolic  functions  so  that  the  system  can  ware- 
house considerable  quantities  of  carbohydrates  without  sugar  appearing  in  the 
urine.  Naunyn  emphasizes  the  importance  of  removing  the  hyperglycsemia 
and  making  the  patient  aglycosuric.  In  patients  on  a  strict  diet  who  con- 
tinue to  excrete  from  0.1  to  0.5  per  cent  of  glucose,  he  advises  a  "  hunger-day," 
during  which  all  food  is  cut  off  for  twenty-four  hours.  In  many  such  instances 
aglycosuria  occurs,  and  the  patient's  power  of  assimilating  carbohydrates  is 
thought  to  be  increased. 

In  cases  in  which  a  standard  diet  is  not  ordered  it  is  well  to  begin  cutting 
off  article  by  article  until  the  sugar  disappears  from  the  urine.  Within  a 
month  or  two  the  patient  may  be  allowed  a  more  liberal  diet,  testing  the 
different  kinds  of  food. 

The  oatmeal  diet,  introduced  by  von  Noorden,  is  most  excellent,  particularly 
in  the  severer  forms.  Two  hundred  and  fifty  grammes  of  oatmeal,  the  same 
amount  of  butter  and  the  whites  of  six  or  eight  eggs  constitute  the  day's  food. 
The  oatmeal  is  cooked  for  two  hours,  and  the  butter  and  albumin  stirred 
in.  It  may  be  taken  in  four  portions  during  the  day.  Coffee,  tea,  or  whisky 
and  water  may  be  taken  with  it. 

The  following  is  a  list  of  articles  which  diabetic  patients  may  take : 

Liquids:  Soups — ox-tail,  turtle,  bouillon,  and  other  clear  soups.  Lemon- 
ade, coffee,  tea,  chocolate,  and  cocoa ;  these  to  be  taken  without  sugar,  but 
they  may  be  sweetened  with  saccharin.  Potash  or  soda  water,  and  Apol- 
linaris,  or  the  Saratoga- Vichy,  and  milk  in  moderation,  may  be  used. 

Of  animal  food:  Fish  of  all  sorts,  including  crabs,  lobsters,  and  oysters; 
salt  and  fresh  butcher's  meat  (with  the  exception  of  liver),  poultry,  and 
game.    Eggs,  butter,  buttermilk,  curds,  and  cream  cheese. 

Of  bread:  Gluten  and  bran  bread,  and  almond  and  cocoanut  biscuits. 
Aleuronat  and  roborat  fiours  are  made  from  wheat  and  contain  large  quan- 
tities of  albumin  and  but  little  starch.  They  may  be  used  in  making  bread 
or  biscuits,  and  are  highly  recommended  by  Ebstein. 

Of  vegetables :  Lettuce,  tomatoes,  spinach,  chicory,  sorrel,  radishes,  aspara- 
gus, water-cress,  cucumbers,  celery,  endives,  mustard  and  various  pickles. 

Fruits:  Lemons  and  oranges.  Currants,  plums,  cherries,  pears,  apples 
(tart),  melons,  raspberries,  and  strawberries  may  be  taken  in  moderation. 
Nuts  are,  as  a  rule,  allowable. 

Among  prohibited  articles  are  the  following :  Thick  soups  and  liver. 

Ordinary  bread  of  all  sorts  (in  quantity),  rye,  wheaten,  brown,  or  white. 


422 


CONSTITUTIONAL  DISEASES. 


All  farinaceous  preparations,  sucli  as  hominv,  rice,  tapioca,  semolina,  arrow- 
root, sago,  and  vermicelli. 

Of  vegetables :  Potatoes,  turnips,  parsnips,  squashes,  vegetable-marrows 
of  all  kinds,  beets,  corn,  artichokes. 

Of  liquids :  Beer,  sparkling  wine  of  all  sorts,  and  the  sweet  aerated 
drinks. 

In  feeding  a  diabetic  patient  one  of  the  greatest  difficulties  is  in  arranging 
a  substitute  for  bread.  Of  the  gluten  foods,  many  are  very  unpalatable; 
others  are  frauds. 


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Black,  Sugar  in  grammes                                                                         :  -,  Urine  in  c  ; 

Chart  XY. — Illustrating  Ixfluexce  of  Diet  ox  Sugar  axb  Amouxt  of  Urixe. 


Other  substitutes  are  the  almond  food,  the  Aleuronat  bread,  and  soya 
bread,  but  these  and  other  substitutes  are  not  satisfactory  as  a  rule.  For 
sweetening  purposes  saccharin  may  be  used,  of  which  tablets  are  prepared. 
Mosse  has  shown  that  potato  starch  is  more  easily  assimilated  than  wheat 
starch,  and  this  view  has  been  on  the  whole  confirmed  by  comparative  tests 
in  my  wards.  He  allows  as  much  as  a  kilo  (2^  pounds)  of  potatoes,  weighed 
fresh,  to  a  diabetic  dailv.     Thev  are  best  baked. 


DIABETES  MELLITUS.  423 

Medicinal  Treatment. — This  is  most  unsatisfactory,  and  no  one  drug 
appears  to  have  a  directly  curative  influence.  Opium  alone  stands  the  test 
of  experience  as  a  remedy  capable  of  limiting  the  progress  of  the  disease. 
Diabetic  patients  seem  to  have  a  special  tolerance  for  this  drug.  Codeia  is 
preferred  by  Pavy,  and  has  the  advantage  of  being  less  constipating  than 
morphia,  A  patient  may  begin  with  half  a  grain  three  times  a  day,  which 
may  be  gradually  increased  to  6  or  8  grains  in  the  twenty-four  hours.  Not 
much  effect  is  noticed  unless  the  patient  is  on  a  rigid  diet.  When  the  Sugar 
is  reduced  to  a  minimum,  or  is  absent,  the  opium  should  be  gradually  with- 
drawn. The  patients  not  only  bear  well  these  large  doses  of  the  drug,  but 
they  stand  its  gradual  reduction.  Potassium  bromide  is  often  a  useful 
adjunct.  The  arsenite  of  bromine,  a  solution  of  arsenious  acid  with  bromine 
in  glycerin  (dose,  3  to  5  minims  after  meals),  has  been  very  highly  recom- 
mended, but  it  is  by  no  means  so  certain  as  opium.  Arsenic  alone  may  be 
used.  Antipyrin  may  be  given  in  doses  of  10  grains  three  times  a  day,  and 
in  cases  with  a  marked  neurotic  constitution  is  sometimes  satisfactory.  The 
salicylates,  iodoform,  nitroglycerin,  jambul,  the  lithium  salts,  strychnine, 
creasote,  and  lactic  acid  have  been  employed. 

Preparations  of  the  pancreas  (glj^cerin  extracts  of  the  dried  and  fresh 
gland)  have  been  used  in  the  hope  that  they  would  supply  the  internal  secre- 
tion necessary  to  normal  sugar  metabolism.  The  success  has  not,  however, 
been  in  any  way  comparable  with  that  obtained  with  the  thyroid  extract  in 
myxoedema.  Lepine  has  isolated  a  glycolytic  ferment  from  the  pancreas  and 
also  from  the  malt  diastase,  and  has  used  it  with  some  success  in  4  cases. 

As  yet  no  practical  therapeutic  results  have .  followed  Cohnheim's  obser- 
vations. 

Of  the  complications,  the  pruritus  and  eczema  are  best  treated  by  cooling 
lotions  of  boric  acid  or  hyposulphite  of  soda  (1  ounce;  water,  1  quart),  or 
the  use  of  ichthyol  and  lanolin  ointment. 

In  the  thin,  nervous  cases  the  bowels  should  be  kept  open  and  the  urine 
tested  at  short  intervals  for  acetone  and  diacetic  acid — the  derivatives  of 
^-oxybutyric  acid. 

The  coma  is  an  almost  hopeless  complication.  Inhalations  of  oxygen  have 
been  recommended.  The  use  of  bicarbonate  of  soda  in  very  large  doses  is 
recommended  to  neutralize  the  acid  intoxication.  It  may  be  used  intra- 
venously; as  much  as  80  grammes  have  been  injected.  The  solution  used 
for  intravenous  injection  is  a  1  to  2  per  cent  solution  of  sodium  bicarbonate 
in  normal  salt  solution.  A  litre  may  be  injected  slowly  into  a  vein  every  six 
hours  in  desperate  cases.  In  the  less  serious  cases  administration  should  be 
made  by  mouth,  or  mouth  and  rectum.  This  treatment  was  first  recom- 
mended by  Stadelmann,  and  has  undoubtedly  given  the  best  results.  Naun}Ti 
and  Magnus-Levy  report  cases  of  recovery  from  coma  by  its  use.  I  have  had 
one  recovery.  The  sodium  bicarbonate  should  be  pushed  until  the  urine  is 
alkaline.  As  much  as  100  grammes  should  be  given  daily.  All  diabetics  with 
a  marked  diacetic  acid  reaction  in  the  urine  should  be  placed  on  sodium 
bicarbonate.  JSText  to  the  antacid  treatment,  subcutaneous  or  intravenous 
injections  of  normal  salt  solution  have  given  the  best  results.  The  im- 
provement, unfortunately,  is  only  temporary  with  this  line  of  treatment. 
Eeynolds  published  2  eases  of  recovery  after  the  administration  of  a  dose  of 


424  CONSTITUTIONAL  DISEASES. 

castor  oil,  followed  by  30  to  60  grains  of  citrate  of  potassium  every  hour  in 
copious  draughts  of  water.  The  bowels  of  a  diabetic  patient  should  be  kept 
acting  freely,  as  constipation  is  believed  to  predispose  to  the  development 
of  coma. 

VI.     DIABETES    INSIPIDUS. 

Definition. — A  chronic  affection  characterized  by  the  passage  of  large 
quantities  of  normal  urine  of  low  specific  gravity. 

The  condition  is  to  be  distinguished  from  diuresis  or  pohniria,  which  is 
a  frequent  s}"mptom  in  hysteria,  in  Bright's  disease,  and  occasionally  in  cere- 
bral or  other  affections.  Willis,  in  1674,  first  recognized  the  distinction 
between  a  saccharine  and  non-saccharine  form  of  diabetes. 

Etiology. — The  disease  is  most  common  in  young  persons.  Of  the  85 
cases  collected  by  Strauss,  9  were  under  five  years;  12  between  five  and  ten 
years;  36  between  ten  and  twent^^-five  years.  Males  are  more  frequently 
attacked  than  females.  The  affection  may  be  congenital.  A  hereditary 
tendency  has  been  noted  in  many  instances,  the  most  extraordinary  of  which 
has  been  reported  by  Weil.  Of  91  members  in  four  generations,  23  had 
persistent  polyuria  without  any  deterioration  in  health. 

CLiifiCAL  Classificatiox. — There  are  two  forms :  primary  or  idiopathic, 
in  which  there  is  no  evident  organic  basis,  and  secondary  or  S}Tnptomatic,  in 
which  there  is  evidence  of  disease  in  the  brain  or  elsewhere.  Of  9  cases  re- 
ported from  my  clinic  by  Futcher,  4  belonged  to  the  former  and  5  to  the 
latter  group.  Trousseau  stated  that  the  parents  of  children  vdth  diabetes 
insipidus  frequently  have  glycosuria  or  albuminuria.  Ealfe  claimed  that  mal- 
nutrition is  an  important  predisposing  factor  in  children.  The  disease  has 
followed  rapidly  the  copious  drinking  of  cold  water,  or  a  drinking  bout,  or 
has  set  in  during  the  convalescence  from  an  acute  disease. 

The  secondary  or  symptomatic  form  is  almost  always  associated  with  in- 
jury or  disease  of  the  nervous  system,  traumatism  to  the  head,  or,  in  some 
cases,  to  the  trunk.  It  occurs  in  30  per  cent  of  the  cases,  according  to  Stoer- 
mer.  Tumors  of  the  brain,  lesions  of  the  medulla,  cerebral  hemorrhage,  have 
been  met  with  in  some  cases.  There  is  a  remarkable  association  between 
diabetes  insipidus  and  brain  s}'philis;  5  of  the  9  cases  reported  by  Futcher 
were  in  syphilitics.  The  lesion  is  usualh"  at  the  base,  and  meningitic.  Hemi- 
anopsia is  present  in  a  number  of  these  cases;  it  occurred  in  2  of  Futcher's 
series.  It  is  not  necessary  that  the  lesion  should  involve  the  medulla.  It  has 
been  met  with  in  spinal  cord  lesions.  In  tumors  and  aneurisms  in  the  abdo- 
men, in  tuberculous  jjeritonitis,  and  in  carcinoma  there  may  be  polyuria  of 
an  extreme  grade. 

The  most  reasonable  view  of  the  production  of  the  polyuria  is  that  it 
results  from  a  vaso-motor  disturbance  of  the  renal  vessels,  due  either  to  local 
irritation,  as  in  a  case  of  abdominal  tumor,  to  central  disturbance  in  cases 
of  brain-lesion,  or  to  functional  irritation  of  the  centre  in  the  medulla,  giving 
rise  to  continuous  renal  congestion. 

Morbid  Anatomy. — There  are  no  constant  anatomical  lesions.  The  I'id- 
neys  have  been  found  enlarged  and  congested.  The  bladder  has  been  found 
h^-pertrophied.    Dilatation  of  the  ureters  and  of  the  pelves  of  the  kidneys  has 


DIABETES  INSIPIDUS.  425 

been  present.  Death  has  not  infrequently  resulted  from  chronic  pulmonary- 
disease.     Very  varied  lesions  have  been  met  with  in  the  nervous  system. 

Symptoms. — The  disease  may  come  on  rapidly,  as  after  a  fright  or  an 
injury;  more  commonly  it  is  gradual.  According  to  Ealfe,  the  patients  often 
complain  in  the  early  stages  of  severe  racking  pains  in  the  lumbar  region 
shooting  down  the  thighs.  A  copious  secretion  of  urine,  with  increased  thirst, 
are  the  prominent  features  of  the  disease.  The  amount  of  urine  in  the  twen- 
ty-four hours  may  range  from  20  to  40  pints,  or  even  more.  Trousseau  speaks 
of  a  patient  who  consumed  50  pints  of  fluid  daily  and  passed  about  56  pints 
of  urine  in  the  twenty-four  hours.  In  two  of  our  cases,  the  amount  passed 
was  greater  than  that  ingested  in  liquids  and  solids.  The  specific  gravity  is 
low,  1.001  to  1.005;  the  color  is  extremely  pale  and  watery.  The  total  solid 
constituents  may  not  be  reduced.  The  amount  of  urea  has  sometimes  been 
found  in  excess.  Abnormal  ingredients  are  rare.  Muscle-sugar,  inosite,  has 
been  occasionally  found.  Albumin  is  rare.  Traces  of  sugar  have  been  met 
with.  Naturally,  with  the  passage  of  such  enormous  quantities  of  urine,  there 
is  a  proportionate  thirst,  and  the  only  inconvenience  of  the  disease  is  the 
necessity  for  frequent  micturition  and  frequent  drinking.  The  appetite  i^ 
usually  good,  rarely  excessive  as  in  diabetes  mellitus;  but  Trousseau  tells 
of  the  terror  inspired  by  one  of  his  patients  in  the  keepers  of  those  eating- 
houses  where  bread  was  allowed  without  extra  charge  to  the  extent  of  each 
customer's  wishes,  and  says  that  the  man  was  paid  to  stay  away.  The  patients 
may  be  well  nourished  and  healthy-looking.  The  disease  in  many  instances 
does  not  appear  to  interfere  in  any  way  with  the  general  health.  The  per- 
spiration is  naturally  slight  and  the  skin  is  harsh.  The  amount  of  saliva  is 
small  and  the  mouth  usually  dry.  The  tolerance  of  alcohol  is  remarkable, 
and  patients  have  been  known  to  take  a  couple  of  pints  of  brandy,  or  a  dozen 
or  more  bottles  of  wine,  in  the  day. 

The  course  depends  entirely  upon  the  nature  of  the  primary  trouble. 
Sometimes,  with  organic  disease,  either  cerebral  or  abdominal,  the  general 
health  is  much  impaired ;  the  patient  becomes  thin,  and  rapidly  loses  strength. 
In  the  essential  or  idiopathic  cases,  good  health  may  be  maintained  for  an 
indefinite  period,  and  the  affection  has  been  known  to  persist  for  fifty  years. 
Death  usually  results  from  some  intercurrent  affection.  Spontaneous  cure 
may  take  place. 

Dia^osis. — A  low  specific  gravity  and  the  absence  of  sugar  in  the  urine 
distinguish  the  disease  from  diabetes  mellitus.  Hysterical  polyuria  may 
sometimes  simulate  it  very  closely.  The  amount  of  urine  excreted  may  be 
enormous,  and  only  the  development  of  other  hysterical  manifestations  may 
enable  the  diagnosis  to  be  made.  This  condition  is,  however,  always  transi- 
tory. 

In  certain  cases  of  chronic  Bright's  disease  a  very  large  amount  of  urine 
of  low  specific  gravity  may  be  passed,  but  the  presence  of  albumin  and  of 
hyaline  casts,  and  the  existence  of  heightened  arterial  tension,  stiff  vessels, 
and  hypertrophied  left  ventricle  make  the  diagnosis  easy. 

Treatment. — The  treatment  is  not  satisfactory.  No  attempt  should  be 
made  to  reduce  the  amount  of  liquid.  Opium  is  highly  recommended,  but 
is  of  doubtful  service.  The  preparations  of  valerian  may  be  tried ;  either  the 
powdered  root,  beginning  with  5  grains  three  times  a  day,  and  increasing 


426  CONSTITUTIONAL  DISEASES. 

until  2  drachms  are  taken  in  the  day,  or  the  valerianate  of  zinc,  in  15-grain 
doses,  gradually  increased  to  30  grains,  three  times  a  day.  Anti-syphilitic 
treatment  should  be  thoroughly  tried  in  those  cases  with  a  suspicious  history. 
Ergot,  ergotin,  antipyrin,  the  salicylates,  arsenic,  strychnine,  turpentiae,  and 
the  bromides  ha^e  been  recommended.     Electricity  may  be  used. 

VII.     RICKETS    (Rhachitis). 

Definition. — A  disease  of  infants,  characterized  by  impaired  nutrition  of 
the  entire  body  and  alterations  in  the  growing  bones. 

Glisson,  the  anatomist  of  the  liver,  accurately  described  the  disease  in 
1650.  The  name  is  derived  from  the  old  English  word  wriclcken,  to  twist, 
Glisson  suggested  to  change  the  name  to  rhachitis,  from  the  Greek,  pd.xi-% 
the  spine,  as  it  was  one  of  the  first  parts  affected,  and  also  from  the  similarity 
in  the  sound  to  rickets. 

Etiology. — Eickets  exists  in  all  parts  of  the  world,  but  is  particularly 
marked  among  the  poor  of  the  larger  cities,  who  are  badly  housed  and  ill  fed. 
It  is  much  more  common  in  Europe  than  in  America.  In  Vienna  and 
London  from  50  to  80  per  cent  of  all  the  children  at  the  clinics  present 
signs  of  rickets.  It  is  a  comparatively  rare  disease  in  Canada.  In  the  cities 
of  the  United  States  it  is  very  prevalent,  particularly  among  the  children  of 
the  negro  and  of  the  Italian  races.  Want  of  sunlight,  impure  air,  confinement, 
and  lack  of  exercise  are  important  factors.  Prolonged  lactation  and  suckling 
the  child  during  pregnancy  are  accessory  influences  in  some  cases. 

There  is  no  evidence  that  the  disease  is  hereditary. 

Eickets  affects  male  and  female  children  equally.  It  is  a  disease  of  the 
first  and  second  years  of  life,  rarely  beginning  before  the  sixth  month.  Jenner 
has  described  a  late  rickets,  in  which  form  the  disease  may  not  appear  until 
the  ninth  or  even  until  the  twelfth  year,  or  later  (the  osteomalacia  of  pu- 
berty). Eickets  has  been  regarded  as  a  manifestation  of  congenital  syphilis 
(Parrot).  Syphilitic  bones  rarely,  if  ever,  present  the  spongy  tissue  peculiar 
to  rickets,  and  rhachitic  bones  never  show  the  multiple  osteophytes  of  syphi- 
lis. "  Syphilis  modifies  rickets;  it  does  not  create  it"  (Cheadle).  A  faulty 
diet  is  the  essential  factor  in  the  production  of  the  disease.  Like  scurvy, 
rickets  may  be  found  in  the  families  of  the  wealthy  under  perfect  hygienic 
conditions.  It  is  most  common  in  children  fed  on  condensed  milk,  the  vari- 
ous proprietary  foods,  cow's  milk,  and  food  rich  in  starches.  "  An  analysis 
of  the  foods  on  which  rickets  is  most  frequently  and  certainly  produced  shows 
invariably  a  deficiency  in  two  of  the  chief  elements  so  plentiful  in  the  standard 
food  of  young  animals — ^namely,  animal  fat  and  proteid"  (Cheadle).  Bland 
Sutton's  interesting  experiment  with  the  lion's  cubs  at  the  "  Zoo  "  illustrates 
this  point.  When  milk,  pounded  bones,  and  cod-liver  oil  were  added  to  the 
meat  diet  the  rickets  disappeared,  and  for  the  first  time  in  the  history  of  the 
societ}^  the  cubs  were  reared.  Associated  with  the  defect  in  food  is  a  lack  of 
proper  assimilation  of  the  lime  salts. 

Morbid  Anatomy. — Glisson's  original  description  of  the  external  appear- 
ances of  the  body  of  a  rickety  child  is  remarkably  complete;  indeed,  the 
entire  monograph  is  an  enduring  monument  to  the  skill  and  powers  of  obser- 
vation of  this  great  physician,     "(1)  ko.  irregular  or  unusual  proportion  of 


RICKETS.  427 

its  parts.  The  head  is  evidently  larger  than  normal,  and  the  face  fatter  in 
respect  to  the  other  parts.  .  .  .  (2)  The  external  members  and  muscles 
of  the  whole  body  are  seen  to  be  delicate  and  emaciated,  as  though  consumed 
by  atrophy  or  tabes,  and  this  (so  far  as  we  know)  is  always  observed  in  those 
dead  of  this  affection.  (3)  The  whole  skin,  both  the  true  and  the  fleshy  and 
fatty  layers,  is  flaccid  and  rather  pendulous,  like  a  loose  glove,  so  that  you 
think  it  could  hold  much  more  flesh.  (4)  About  the  Joints,  especially  in  the 
wrists  and  ankles,  there  are  certain  protuberances  which,  if  opened,  are  seen 
to  arise,  not  in  the  fleshy  or  membranous  parts,  but  in  the  ends  of  the  bones 
themselves,  especially  in  their  epiphyses.  (5)  The  joints,  limbs,  and  habitus 
of  all  these  external  parts  are  less  firm  and  rigid,  less  inflexible  than  in 
other  dead  bodies,  and  the  neck  scarcely  becomes  rigid,  a  frigore  post  mor- 
tem, or  to  a  less  extent  than  in  other  cadavers.  (6)  The  chest  externally  is 
thin  and  much  narrowed,  especially  beneath  the  scapulae,  as  though  com- 
pressed from  the  sides,  and  the  sternum  accuminated  like  the  keel  of  a  ship 
or  the  breast  of  a  fowl.  (7)  The  ends  of  the  ribs  which  join  with  the 
cartilages  of  the  sternum  are  nodular,  like  the  ends  of  the  wrists  and 
ankles." 

He  also  describes  the  prominent  abdomen,  the  enlarged  liver,  and  the 
changes  in  the  mesenteric  glands. 

The  bones  show  the  most  important  changes,  particularly  the  ends  of  the 
long  bones  and  the  ribs.  Between  the  shaft  and  epiphyses  a  slight  bulging 
is  apparent,  and  on  section  the  zone  of  proliferation,  which  normally  is 
represented  by  two  narrow  bands,  is  greatly  thickened,  bluish  in  color,  more 
irregular  in  outline,  and  very  much  softer.  The  width  of  this  cushion  of 
cartilage  varies  from  5  to  15  mm.  The  line  of  ossification  is  also  irregular 
and  more  spongy  and  vascular  than  normal.  The  periosteum  strips  off  very 
readily  from  the  shaft,  and  beneath  it  there  may  be  a  spongy  tissue  not 
unlike  decalcified  bone.  The  practical  outcome  of  these  changes  is  an  im- 
perfect ossification,  so  that  the  bone  has  neither  the  natural  rate  of  growth 
nor  the  normal  firmness.  In  the  cranium  there  may  be  large  areas,  particu- 
larly in  the  parieto-occipital  region,  in  which  the  ossification  is  delayed,  pro- 
ducing the  so-called  cranio-tabes,  so  that  the  bone  yields  readily  to  pressure 
with  the  finger.  There  are  localized  depressed  spots  of  atrophy,  which,  on 
pressure,  give  the  so-called  "  parchment  crackling."  Flat  hyperostoses  arise 
on  the  outer  table,  particularly  on  the  frontal  and  parietal  bones,  producing 
the  characteristic  broad  forehead  with  prominent  frontal  eminences,  a  con- 
dition sometimes  mistaken  for  hydrocephalus. 

Kassowitz,  the  leading  authority  on  the  anatomy  of  rickets,  regards  the 
hypersemia  of  the  periosteum,  the  marrow,  the  cartilage,  and  of  the  bone 
itself  as  the  primary  lesion,  out  of  which  all  the  others  arise.  This  disturbs 
the  normal  development  of  the  growing  bone  and  excites  changes  in  that 
already  formed.  The  cartilage  cells  in  consequence  proliferate,  the  matrix 
is  softer,  and  as  a  result  the  bone  which  is  formed  from  this  unhealthy  car- 
tilage is  lacking  in  firmness  and  solidity.  In  the  bone  already  formed  this 
excessive  vascularity  exaggerates  the  normal  processes  of  absorption,  so  that 
the  relation  between  removal  and  deposition  is  disturbed,  absorption  taking 
place  too  rapidly.  The  new  material  is  poor  in  lime  salts.  Kassowitz  has 
proved  experimentally  that  hypergemia  of  bone  results  in  defective  deposition 


428  CONSTITUTIONAL  DISEASES. 

of  lime  salts.  It  is  interesting  to  note  that  Glisson  attributed  rickets  to 
disturbed  nutrition  by  arterial  blood,  and  believed  the  changes  in  the  long 
bones  to  be  due  to  excessive  vascularity. 

The  chemical  analysis  of  rickety  bones  shows  a  marked  diminution  in 
the  calcareous  salts,  which  may  be  as  low  as  25  or  35  per  cent. 

The  liver  and  spleen  are  usually  enlarged,  and  sometimes  the  mesenteric 
glands.  As  Gee  suggests,  these  conditions  probably  result  from  the  general 
state  of  the  health  associated  with  rickets.  Beneke  has  described  a  relative 
increase  in  the  size  of  the  arteries  in  rickets. 

Symptoms. — The  disease  comes  on  insidiously  about  the  period  of  denti- 
tion, before  the  child  begins  to  walk.  Mild  grades  of  it  are  often  overlooked 
in  the  families  of  the  well-to-do.  In  many  cases  digestive  disturbances  pre- 
cede the  appearance  of  the  characteristic  lesions,  and  the  nutrition  of  the 
child  is  markedly  impaired.  There  is  usually  slight  fever,  the  child  i« 
irritable  and  restless,  and  sleeps  badly.  If  he  has  already  walked,  he  now 
shows  a  marked  disinclination  to  do  so,  and  seems  feeble  and  unsteady  in 
his  gait.  Sir  William  Jenner  has  called  attention  to  three  general  symptoms 
of  great  importance:  First,  a  diffuse  soreness  of  the  body,  so  that  the  child 
cries  when  an  attempt  is  made  to  move  it,  and  prefers  to  keep  perfectly  still. 
This  is  often  a  marked  and  suggestive  symptom.  Secondly,  slight  fever 
(100°  to  101.5°),  with  nocturnal  restlessness,  and  a  tendency  to  throw  off 
the  bedclothes.  This  may  be  partly  due  to  the  fact  that  the  general  sensi- 
tiveness is  such  that  even  their  weight  may  be  distressing.  And,  thirdly, 
profuse  sweating,  particularly  about  the  head  and  neck,  so  that  in  the  morn- 
ing the  pillow  is  found  soaked  with  perspiration. 

The  tissues  become  soft  and  flabby;  the  skin  is  pale;  and  from  a  healthy, 
plump  condition,  the  child  becomes  puny  and  feeble.  The  muscular  weak- 
ness may  be  marked,  particularly  in  the  legs,  and  paralysis  may  be  suspected. 
This  so-called  pseudo-paresis  of  rickets  results  in  part  from  the  flabby,  weak 
condition  of  the  legs  and  in  part  from  the  pain  associated  with  the  move- 
ments. Coincident  with,  or  following  closely  upon,  the  general  symptoms 
the  characteristic  skeletal  lesions  are  observed.  Among  the  first  of  these  to 
appear  are  the  changes  in  the  ribs,  at  the  junction  of  the  bone  with  the  car- 
tilage, forming  the  so-called  rickety  rosary.  "When  the  child  is  thin  these 
nodules  may  be  distinctly  seen,  and  in  any  case  can  be  easily  made  out  by 
touch.  They  very  rarely  appear  before  the  third  month.  They  may  increase 
in  size  up  to  the  second  year,  and  are  rarely  seen  after  the  fifth  year.  The 
thorax  undergoes  important  changes.  Just  outside  the  junction  of  the  car- 
tilages with  the  ribs  there  is  an  oblique,  shallow  depression  extending  down- 
ward and  outward.  A  transverse  curve,  sometimes  called  Harrison's  groove, 
passes  outward  from  the  level  of  the  ensiform  cartilage  toward  the  axilla,  and 
may  be  deepened  at  each  inspiration.  It  is  rendered  more  prominent  by  the 
eversion  and  prominence  of  the  costal  border.  The  sternum  projects,  par- 
ticularly in  its  lower  half,  forming  the  so-called  pigeon  or  chicken  breast. 
These  changes  in  the  thorax  are  not  peculiar,  however,  to  rickets,  and  are 
much  more  commonly  associated  with  h^-pertrophy  of  the  tonsils,  or  any 
trouble  which  interferes  vsdth  the  free  entrance  of  air  into  the  lungs.  The 
spine  is  often  curved  posteriorly,  the  processes  are  prominent;  lateral  curva- 
ture is  not  so  common. 


RICKETS.  429 

The  head  of  a  rickety  child  usually  looks  large  in  proportion  both  to  the 
body  and  the  face,  and  the  fontanelles  remain  open  for  a  long  time.  There 
are  areas,  particularly  in  the  parieto-occipital  regions,  in  which  ossification  is 
imperfect;  and  the  bone  may  yield  to  the  pressure  of  the  finger,  a  condition 
to  which  the  term  cranio-tahes  has  been  given.  The  relation  of  this  condition 
to  rickets  is  still  somewhat  doubtful,  as  it  is  very  often  associated  with  syphi- 
lis— in  47  of  100  cases  studied  by  George  Carpenter.  Coincidently  with  this, 
hyperplasia  proceeds  in  the  frontal  and  parietal  eminences,  so  that  thes6  por- 
tions of  the  skull  increase  in  thickness,  and  may  form  irregular  bosses.  In 
one  type  the  skull  may  be  large  and  elongated,  with  the  top  considerably 
flattened.  In  another,  and  perhaps  more  common  case,  the  shape  of  the  skull, 
when  seen  from  above,  is  rectangular — the  caput  quadratum.  The  skull  looks 
large  in  proportion  to  the  face.  The  forehead  is  broad  and  square,  and  the 
frontal  eminences  marked.  The  anterior  fontanelle  is  late  in  closing,  and 
may  remain  open  until  the  third  or  fourth  year.  The  skin  is  thin,  the  veins 
are  full  and  prominent,  and  the  hair  is  often  rubbed  from  the  back  of  the 
skull.  In  contradistinction  to  the  cranio-tabes  is  the  condition  of  cranio- 
sclerosis,  which  has  also  been  ascribed  to  rickets. 

On  placing  the  ear  over  the  anterior  fontanelle,  or  in  the  temporal  region, 
a  systolic  murmur  may  frequently  be  heard.  This  condition,  first  described 
by  John  D.  Fisher,  of  Boston,  in  1833,  is  heard  with  the  greatest  frequency 
in  rickets,  but  its  presence  and  persistence  in  perfectly  healthy  infants  have 
been  amply  demonstrated.  The  murmur  is  rarely  heard  after  the  fifth  year, 
A  knowledge  of  the  existence  of  this  systolic  brain  murmur  may  prevent 
errors.     A  case  has  been  reported  as  an  instance  of  tumor  of  the  brain. 

Changes  occur  in  the  bones  of  the  face,  chiefiy  in  the  maxillse,  which  are 
reduced  in  size.  The  normal  process  of  dentition  is  much  disturbed;  indeed, 
late  teething  is  one  of  the  marked  features  in  rickets.  The  teeth  which  appear 
may  be  small  and  badly  formed. 

In  the  upper  limbs  changes  in  the  scapulae  are  not  common.  The  clavicle 
may  be  thickened  at  the  sternal  end,  and  there  may  be  thickening  near  the 
attachment  of  the  sterno-cleido  muscle.  The  most  noticeable  changes  are 
at  the  lower  ends  of  the  radius  and  ulna.  The  enlargement  is  at  the  junction- 
area  of  the  shaft  and  epiphysis.  Less  evident  enlargements  may  occur  at  the 
lower  end  of  the  humerus.  In  severe  cases  the  natural  shape  of  the  bones 
of  the  arm  may  be  much  altered,  since  they  have  had  to  support  the  weight  of 
the  child  in  crawling  on  the  floor.  The  changes  in  the  pelvis  are  of  special 
importance,  particularly  in  female  children,  as  in  extreme  cases  they  lead  to 
great  deformity,  with  narrowing.  In  the  legs,  the  lower  end  of  the  tibia  first 
hecomes  enlarged ;  and  in  slight  cases  it  may  alone  be  affected.  In  the  severe 
forms  the  upper  end  of  the  bone,  the  corresponding  parts  of  the  fibula,  and 
the  lower  end  of  the  femur  become  greatly  thickened.  If  the  child  walks,  slight 
bowing  of  the  tibiae  inevitably  results.  In  more  advanced  cases  the  tibiae,  and 
even  the  femora,  may  be  arched  forward.  In  other  instances  the  condition  of 
knock-knee  occurs.  Unquestionably  the  chief  cause  of  these  deformities  is 
the  weight  of  the  body  in  walking,  but  muscular  action  takes  part  in  it.  The 
green-stick  fracture  is  not  uncommon  in  the  soft  bones  of  rickets. 

These  changes  in  the  skeleton  proceed  slowly,  and  the  general  s3'Tnptoms 
Tary  a  good  deal  with  their  progress.    The  child  becomes  more  or  less  ema- 


430  CONSTITUTIONAL  DISEASES. 

ciated,  though  "  fat  rickets  "  is  by  no  means  uncommon,  and  a  child  may  be 
well  nourished  but  "  pasty  "  and  flabby.  Fever  is  not  constant,  but  in  actively 
progressing  changes  in  the  bone  there  is  usually  a  slight  pyrexia.  The  abdo- 
men is  large,  "  pot-bellied/'  due  partly  to  flatulent  distention,  partly  to  en- 
largement of  the  liver^  and  in  severe  cases  to  diminution  of  the  volume  of  the 
thorax.  The  spleen  is  often  enlarged  and  readily  palpable.  The  urine  is 
stated  to  contain  an  excess  of  lime  salts,  but  Jacobi  and  Barlow  say  this  has 
not  been  proved.  No  special  or  peculiar  changes,  indeed,  have  as  yet  been 
described.  There  is  usually  slight  anaemia,  the  haemoglobin  is  absolutely  and 
relatively  decreased;  a  leucocytosis  may  or  may  not  be  present;  it  is  more 
common  with  enlargement  of  the  spleen  (Morse).  Many  rickety  children 
show  marked  nervous  symptoms;  irritability,  peevishness,  and  sleeplessness 
are  constantly  present.  Jenner  called  attention  to  the  close  relationship  which 
existed  between  rickets  and  infantile  convulsions,  particularly  to  the  fits 
which  occur  after  the  sixth  month.  Tetany  is  by  no  means  uncommon.  It 
involves  most  frequently  the  arms  and  hands;  occasionally  the  legs  as  well. 
Laryngismus  stridulus  is  a  common  complication,  and  though  not,  as  some 
state,  invariably  associated,  yet  it  is  certainly  much  more  frequent  in  rickety 
than  in  other  children.  Severe  rickets  interferes  seriously  with  the  growth 
of  a  child.  Extreme  examples  of  rickety  dwarfs  are  not  uncommon.  Acute 
rickets,  so  called,  is  in  reality  a  manifestation  of  scurvy  and  will  be  described 
with  that  disease. 

Prognosis. — The  disease  is  never  in  itself  fatal,  but  the  condition  of  the 
child  is  such  that  it  is  readily  carried  off  by  intercurrent  affections,  particu- 
larly those  of  the  respiratory  organs.  Spasm  of  the  larynx  and  convulsions 
occasionally  cause  death.  In  females  the  deformity  of  the  pelvis  is  serious, 
as  it  may  lead  to  difficulties  in  parturition. 

Treatment. — The  better  the  condition  of  the  mother  during  pregnancy 
the  less  likelihood  is  there  of  the  development  of  rickets  in  the  child.  Eapidly 
repeated  pregnancies  and  suckling  of  a  child  during  pregnancy  seem  impor- 
tant factors  in  the  production  of  the  disease.  Of  the  general  treatment, 
attention  to  the  feeding  of  the  child  is  the  first  consideration.  If  the  mother 
is  unhealthy,  or  can  not  from  any  cause  nurse  the  child,  a  suitable  wet-nurse 
should  be  provided,  or  the  child  must  be  artificially  fed,  in  which  case  cow's 
milk,  diluted  according  to  the  age  of  the  child,  should  constitute  the  chief  food. 
Care  should  be  taken  to  examine  the  condition  of  the  stools,  and  if  curds  are 
present  the  child  is  taking  too  much,  or  it  is  not  sufficiently  diluted.  Barley- 
water  or  carefully  strained  and  well-boiled  oatmeal  gruel  form  excellent  addi- 
tions to  the  milk. 

The  child  should  be  warmly  clad  and  should  be  in  the  fresh  air  and 
sunshine  the  greater  part  of  the  day.  It  is  a  "  vulgar  error  "  to  suppose  that 
delicate  children  can  not  stand,  when  carefully  wrapped  up,  an  even  low  tem- 
perature. The  child  should  be  bathed  daily  in  warm  water.  Careful  friction 
with  sweet  oil  is  very  advantageous,  and,  if  properly  performed,  allays  rather 
than  aggravates  the  sensitiveness.  Special  care  should  be  taken  to  prevent 
deformity.  The  child  should  not  be  allowed  to  walk,  and  for  this  purpose 
splints  applied  so  as  to  extend  beyond  the  feet  are  very  effective.  Of  medi- 
cines, phosphorus  has  been  warmly  recommended  by  Kassowitz,  and  its  use 
is  also  advised  by  Jacobi.    The  child  may  be  given  gr.  -^  two  or  three  times 


OBESITY.  431 

a  day,  dissolved  in  olive  oil.  The  best  preparation  in  such  cases  is  the  elixir 
phosphori,  six  to  ten  or  twelve  minims  three  times  a  day  (Jacobi).  Cod- 
liver  oil,  in  doses  of  from  a  half  to  one  teaspoonful,  is  very  advantageous. 
The  syrup  of  the  iodide  of  iron  may  be  given  with  the  oil.  The  digestive 
disturbances,  together  with  the  respiratory  and  nervous  complications,  should 
receive  appropriate  treatment. 

VIII.     OBESITY. 

Corpulence,  an  excessive  development  of  the  bodily  fat — an  "oily  dropsy," 
in  the  words  of  Lord  Byron — is  a  condition  for  which  we  are  consulted  in 
three  groups  of  cases.  First,  there  are  persons  of  both  sexes  who  have  an 
hereditary  tendency  to  obesity.  Secondly,  there  is  an  increasing  number  of 
cases  of  obesity  in  children,  particularly  in  the  United  States,  associated  with 
bad  habits  in  eating,  and  usually  carelessness  and  lack  of  control  on  the  part 
of  the  parents.  Thirdly,  and  most  frequently,  we  are  consulted  by  women 
at  the  middle  period  of  life,  who  are  troubled  with  an  over-growth  of  fat. 
While  as  a  rule  fat  is  no  sign  of  health,  and  particularly  in  children  may  be 
associated  with  angemia  and  rickets,  on  the  other  hand  a  great  many  stout 
persons  enjoy  unusual  vigor.  Nor  is  obesity  always  associated  with  over- 
eating. Many  stout  persons  are  light  eaters,  and  chlorotic  girls  with  de- 
praved or  poor  appetites  may  be  very  plump.  After  forty,  as  Sir  James  Paget 
remarks,  we  tend  to  become  either  thin  or  fat,  and  the  former  are  usually 
happier  and  live  longer.  Too  much  food  and  too  little  exercise  are  largely 
responsible  in  about  half  of  the  cases,  but  in  the  hereditary  ones  these  factors 
do  not  prevail,  and  this  is  a  point  to  be  borne  in  mind  very  carefully  in  the 
question  of  treatment.  As  Duckworth  states,  gout  is  an  important  agent  in 
many  instances! 

A  remarkable  form  seen  occasionally  is  acute  obesity  in  which  as  much  as 
seventy  pounds  in  weight  may  be  gained  in  six  or  eight  months.  In  one  case 
it  was  associated  with  marked  cardiac  weakness  and  extreme  dyspnoea  on 
exertion. 

In  obesity  it  is  now  generally  conceded  that  the  carbohydrates,  which  were 
so  long  blamed,  are  not  at  fault,  since  they  are  themselves  converted  into 
water  and  carbon  dioxide.  On  account,  however,  of  the  facility  with  which 
they  are  utilized  for  the  purposes  of  oxidation,  the  albuminous  elements  of 
the  food  are  less  readily  oxidized  and  not  so  fully  decomposed,  and  the  fat 
is  in  reality  separated  from  them.  So,  too,  the  fats  themselves  are  not  so 
prone  to  cause  obesity  as  the  carbohydrates,  being  less  readily  oxidized  and 
interfering  less  with  the  complete  metabolism  of  the  albuminous  elements. 

An  extraordinary  phenomenon  in  excessively  fat  young  persons  is  an  un- 
controllable tendency  to  sleep — like  the  fat  boy  in  Pickwick.  I  have  seen 
one  instance  of  it.  Caton  has  reported  a  case.  Sainton  (Narcolepsie  et 
Ohesite,  Eev.  Neurologique,  1901)  regards  it  as  auto-toxic  in  origin. 

Treatment. — We  must  bear  in  mind  at  the  outset  the  injunction  of  Hip- 
pocrates (Aphorism  III),  speaking  of  a  full  habit  of  body,  that  extreme 
depletions  are  dangerous,  and  that  the  reduction  must  not  be  carried  to  an 
extreme.  The  aphorism  of  the  celebrated  George  Cheyne  (whose  history 
records  one  of  the  most  successful  instances  of  the  treatment  of  obesity  in 


432  CONSTITUTIONAL  DISEASES. 

literature),  quoted  at  page  463,  contains  the  essence  of  good  sense  on  the 
subject.  Put  in  other  words,  it  reads — We  eat  too  much  after  forty  years 
of  age. 

We  are  often  consulted  by  persons  in  whose  family  obesity  prevails  to 
give  rules  for  the  prevention  of  the  condition  in  children  or  in  women  ap- 
proaching the  climacteric.  In  the  case  of  children  very  much  may  be  done 
by  regulating  the  diet,  reducing  the  starches  and  fats  in  the  food,  not  allow- 
ing the  children  to  eat  sweets,  and  encouraging  systematic  exercises.  In  the 
case  of  women  who  tend  to  grow  stout  after  child-bearing  or  at  the  climac- 
teric, in  addition  to  systematic  exercises,  they  should  be  told  to  avoid  taking 
too  much  food,  and  particularly  to  reduce  the  starches  and  sugars.  There 
are  a  number  of  methods  or  systems  in  vogue  at  present.  In  the  celebrated 
one  of  Banting,  the  carbohydrates  and  fats  were  excluded  and  the  amount 
of  food  was  greatly  reduced.     Ebstein  allows  more  fat. 

Oertel's  method  is  given  under  the  treatment  of  fatty  heart.  He  reduces 
the  amount  of  liquid  taken,  and  this  is  practically,  too,  the  so-called  Schwen- 
inger cure,  in  which  liquids  are  allowed  only  two  hours  after  the  food. 

Von  Noorden's  dietar}^  given  in  his  exhaustive  article  in  Nothnagel's 
Handbuch,  is  as  follows:  Eight  o'clock,  80  grammes  of  lean,  cold  meat,  25 
grammes  of  bread,  one  cup  of  tea,  with  a  spoonful  of  milk,  no  sugar.  Ten 
o'clock,  one  egg.  Twelve  o'clock,  a  cup  of  strong  meat  broth.  One  o'clock, 
a  small  plate  of  meat  soup  flavored  with  vegetables,  159  grammes  of  lean 
meat  of  one  or  two  sorts,  partly  fish,  partly  flesh,  100  grammes  of  potatoes 
with  salad,  100  grammes  of  fresh  fruit,  or  compote  without  sugar.  Three 
o'clock,  a  cup  of  black  coffee.  Four  o'clock,  200  grammes  of  fresh  fruit. 
Six  o'clock,  a  quarter  of  a  litre  of  milk,  if  desired,  with  tea.  Eight  o'clock, 
125  grammes  of  cold  meat,  or  180  grammes  of  meat  weighed  raw  and  grilled, 
and  eaten  with  pickles  or  radishes  and  salad,  30  grammes  of  Graham  bread, 
and  two  or  three  spoonfuls  of  cooked  fruit  without  sugar.  He  believes  it 
more  satisfactory  to  give  in  addition  to  the  three  meals  smaller  quantities 
of  food  at  shorter  intervals,  so  as  to  obviate  the  tendency  to  weakness  which 
these  patients  often  experience.  In  addition  he  allows  twice  in  the  day 
a  glass  of  wine.  The  use  of  mineral  water,  weak  tea,  or  lemonade  is  not 
limited  at  the  meal  times  or  in  the  intervals.  An  occasional  "  hunger-day* " 
is  given. 

In  the  treatment  of  extreme  obesity  it  is  very  much  better  that  the  patient 
should  be  in  hospital,  or  under  the  care  of  a  nurse,  who  will  undertake  the 
proper  weighing  and  administration  of  the  food. 

The  thyroid  extract  should  be  used  only  in  a  systematic  "  cure."  Five 
grains  three  times  a  day  is  a  sufficient  dose.  In  conjunction  with  the  diet  and 
exercises,  it  is  useful,  but  it  should  not  be  ordered  indiscriminately  to  fat 
persons. 

Adiposis  Dolorosa  {Dercuras  Disease). — "A  disorder  characterized  by 
irregular,  s}^nmetrical  deposits  of  fatty  masses  in  various  portions  of  the 
body,  preceded  by  or  attended  with  pain."  It  is  an  affection  of  women, 
occurring  at  the  middle  period  of  life.  In  association  with  neuralgic  pains, 
fatty  swellings  occur  in  various  parts  of  the  body.  The  bunches  of  fat  may 
form  huge  masses,  pendulous,  and  of  a  pultaceous  consistence.  They  do  not 
occur  on  the  hands,  feet,  or  face.     It  differs  from  other  forms  of  obesitv  in 


OBESITY.  433 

its  lumpy  distribution,  and  in  the  nervous  disturbances  in  the  form  of  pains 
and  parsesthesias.     The  nature  of  the  trouble  is  unknown. 

In  a  case  of  Burr's,  and  in  one  of  Dercum's,  the  thyroid  gland  showed 
atrophic  changes.  Dercum  tells  me  that  he  has  seen  improvement  from  the 
use  of  the  thyroid  extract,  and  in  one  case  there  was  a  complete  disappear- 
ance of  all  the  neuritic  symptoms,  and  a  great  diminution  in  the  size  of  the 
fatty  deposits. 


29 


SECTION   V. 
DISEASES   OF  THE  DIGESTIVE   SYSTEM. 


A.    DISEASES  OF   THE  MOUTH. 

STOMATITIS. 

(1)  Acute  Stomatitis. — Simple  or  erythematous  stomatitis,  the  common- 
est form,  results  from  the  action  of  irritants  of  various  sorts.  Frequent  at 
all  ages,  in  children  it  is  usually  associated  with  dentition  and  with  gastro- 
intestinal disturbance,  particularly  in  ill-nourished,  unhealthy  subjects;  in 
adults  it  may  follow  the  abuse  of  tobacco,  or  the  use  of  too  hot  or  too  highly 
seasoned  food;  it  is  a  concomitant  of  indigestion,  or  of  the  specific  fevers. 

The  affection  may  be  limited  to  the  gums  and  lips  or  may  extend  over 
the  whole  surface  of  the  mouth  and  include  the  tongue.  There  is  at  first 
superficial  redness  and  dryness  of  the  membrane,  followed  by  increased  secre- 
tion and  swelling  of  the  tongue,  which  is  furred,  and  indented  by  the  teeth. 
There  is  rarely  any  constitutional  disturbance,  but  in  children  there  may  be 
slight  elevation  of  temperature.  The  condition  is  sufficient  to  cause  consid- 
erable discomfort,  sometimes  amounting  to  actual  distress  and  pain,  particu- 
larly in  mastication. 

In  infants  the  mouth  should  be  carefully  sponged  after  each  feeding.  A 
mouth-wash  of  borax  or  the  glycerin  of  borax  may  be  used,  and  in  severe 
cases,  which  tend  to  become  chronic,  a  dilute  solution  of  nitrate  of  silver  (3 
or  4  grains  to  the  ounce)  may  be  applied. 

(2)  Aphthous  Stomatitis. — This  form,  also  known  as  follicular  or  vesicu- 
lar stomatitis,  is  characterized  by  the  presence  of  small,  slightly  raised  spots, 
from  2  to  4  mm.  in  diameter,  surrounded  by  reddened  areolse.  The  spots 
appear  first  as  vesicles,  which  rupture,  leaving  small  ulcers  with  grayish  bases 
and  bright-red  margins.  They  are  seen  most  frequently  on  the  inner  surfaces 
of  the  lips,  the  edges  of  the  tongue,  and  the  cheeks.  They  are  seldom  present 
on  the  mucous  membrane  of  the  pharynx.  This  form  is  met  with  most  often 
in  children  under  three  years.  It  may  occur  either  as  an  independent  affec- 
tion or  in  association  with  any  one  of  the  febrile  diseases  of  childhood  or 
with  an  attack  of  indigestion.  The  crop  of  vesicles  comes  out  with  great 
rapidity  and  the  little  ulcers  may  be  fully  formed  within  twenty-four  hours. 
The  child  complains  of  soreness  of  the  mouth  and  takes  food  with  reluctance. 
The  buccal  secretions  are  increased,  and  the  breath  is  heavy,  but  not  foul. 
The  constitutional  symptoms  are  usually  those  of  the  disease  with  which  the 
aphthae  are  associated.     The  disease  must  not  be  confounded  with  thrush. 

434 


DISEASES  OF  THE  MOUTH.  435 

No  special  parasite  has  been  found  in  connection  with  it.  It  is  not  a  serious 
condition,  and  heals  rapidly  with  the  improvement  of  the  constitutional  state. 
In  severe  cases  it  may  extend  to  the  pillars  of  the  fauces  and  to  the  pharynx, 
and  produce  ulcers  which  are  irritating  and  difficult  to  heal. 

Each  ulcer  should  be  touched  with  nitrate  of  silver  and  the  mouth  should 
be  thoroughly  cleansed  after  taking  food.  A  wash  of  chlorate  of  potassium, 
or  of  borax  and  glycerin,  may  be  used.  The  constitutional  symptoms  should 
receive  careful  attention. 

Here  may  be  mentioned  a  curious  affection  which  has  been  observed  chiefly 
in  southern  Italy,  and  which  is  characterized  by  a  pearly-colored  membrane 
with  induration,  immediately  beneath  the  tongue  on  the  frgenum  (Riga's 
disease).  There  may  be  much  induration  and  ultimately  ulceration.  It 
occurs  in  both  healthy  and  cachetic  children,  usually  about  the  time  of  the 
eruption  of  the  first  teeth.     It  is  sometimes  epidemic. 

(3)  Ulcerative  Stomatitis. — This  form,  which  is  also  known  by  the  names 
of  fetid  stomatitis^  or  putrid  sore  mouthy  occurs  particularly  in  children  after 
the  first  dentition.  It  may  prevail  as  a  wide-spread  epidemic  in  institutions 
in  which  the  sanitary  conditions  are  defective.  It  has  been  met  with  in  jails 
and  camps.  .  Insufficient  and  unwholesome  food,  improper  ventilation,  and 
prolonged  damp,  cold  weather  seem  to  be  special  predisposing  causes.  Lack 
of  cleanliness  of  the  mouth,  the  presence  of  carious  teeth,  and  the  collection 
of  tartar  around  them  favor  the  occurrence  of  the  disease.  The  affection 
spreads  like  a  specific  disease,  but  the  microbe  has  not  yet  been  isolated.  It 
has  been  held  that  the  disease  is  the  same  as  the  foot-and-mouth  disease  of 
cattle,  and  that  it  is  conveyed  by  the  milk,  but  there  is  no  positive  evidence 
on  these  points.  Payne  suggests  that  the  virus  is  identical  with  that  of  con- 
tagious impetigo. 

The  morbid  process  begins  at  the  margin  of  the  gums,  which  become 
swollen  and  red,  and  bleed  readily.  Ulcers  form,  the  bases  of  which  are 
covered  with  a  grayish- white,  firmly  adherent  membrane.  In  severe  cases,  the 
teeth  may  become  loosened  and  necrosis  of  the  alveolar  process  may  occur. 
The  ulcers  extend  along  the  gum-line  of  the  upper  and  lower  jaws ;  the  tongue, 
lips,  and  mucosa  of  the  cheeks  are  usually  swollen,  but  rarely  ulcerated.  There 
is  salivation,  the  breath  is  foul,  and  mastication  is  painful.  The  submaxillary 
lymph-glands  are  enlarged.  An  exanthem  may  break  out  and  be  mistaken 
for  measles.  The  constitutional  sjnnptoms  are  often  severe,  and  in  debilitated 
children  death  sometimes  occurs; 

In  the  treatment  of  this  form  of  stomatitis  chlorate  of  potassium  has  been 
found  to  be  almost  specific.  It  should  be  given  in  doses  of  10  grains,  three 
times  a  day,  to  a  child,  and  to  an  adult  double  that  amount.  Locally  it  may 
be  used  as  a  mouth-wash,  or  the  powdered  salt  may  be  applied  directly  to  the 
ulcerated  surfaces.  When  there  is  much  fetor,  a  solution  of  potassium  per- 
manganate may  be  used  as  a  wash,  and  an  application  of  nitrate  of  silver 
made  to  the  ulcers. 

There  are  several  other  varieties  of  ulcerative  sore  mouth,  which  differ 
entirely  from  this  form.  Ulcers  of  the  mouth  are  common  in  nursing  women, 
and  are  usually  seen  on  the  mucous  membrane  of  the  lips  and  cheeks.  They 
arise  from  the  mucous  follicles,  and  are  from  3  to  5  mm.  in  diameter.  They 
may  cause  little  or  no  inconvenience;  but  in  some  instances  they  are  very 


436  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

painful  and  interfere  seriously  with  the  taking  of  food  and  its  mastication. 
As  a  rule  they  heal  readily  after  the  application  of  nitrate  of  silver,  and  the 
condition  is  an  indication  for  tonics,  fresh  air,  and  a  better  diet. 

Eecurring  outbreaks  of  an  herpetic^  even  pemphigoid,  stomatitis  are  seen 
in  neurotic  individuals  {stomatitis  neurotica  chronica,  Jacobi).  It  may  pre- 
cede or  accompany  the  fatal  form  of  pemphigus  vegetans. 

Parrot  describes  the  occasional  appearance  in  new-born,  debilitated  chil- 
dren of  small  ulcers  symmetrically  placed  on  the  hard  palate  on  either  side 
of  the  middle  line.  They  rarely  heal,  but  tend  to  increase  in  size,  and  may 
involve  the  bone. 

Bednar's  aphthae  consist  of  small  patches  and  ulcers  on  the  hard  palate, 
caused  as  a  rule  in  young  infants  by  the  artificial  nipple  or  the  nurse's 
finger. 

(4)  Parasitic  Stomatitis  {Thrush;  Soor;  Muguet). — This  affection,  most 
commonly  seen  in  children,  is  dependent  upon  a  fungus,  Saccharomyces 
albicans,  called  by  Robin  O'idium  albicans.  It  belongs  to  the  order  of 
yeast  fungi,  and  consists  of  branching  filaments,  from  the  ends  of  which 
ovoid  torula  cells  develop.  The  disease  does  not  arise  apparently  in  a  normal 
mucosa.  The  use  of  an  improper  diet,  uncleanliness  of  the  mouth,  the  acid 
fermentation  of  remnants  of  food,  or  the  occurrence,  from  any  cause,  of  ca- 
tarrhal stomatitis  predispose  to  the  growth.  In  institutions  it  is  frequently 
transmitted  by  unclean  feeding-bottles,  spoons,  etc.  It  is  not  confined  to 
children,  but  is  met  with  in  adults  in  the  final  stages  of  fever,  in  chronic 
tuberculosis,  diabetes,  and  in  cachectic  states.  The  parasite  grows  in  the 
upper  layers  of  the  mucosa,  and  the  filaments  form  a  dense  felt-work  among 
the  epithelial  cells.  The  disease  begins  on  the  tongue  and  is  seen  in  the  form 
of  slightly  raised,  pearly-white  spots,  which  increase  in  size  and  gradually 
coalesce.  The  membrane  thus  formed  can  be  readily  scraped  off,  leaving  an 
intact  mucosa,  or,  if  the  process  extends  deeply,  a  bleeding,  slightly  ulcerated 
surface.  The  disease  spreads  to  the  cheeks,  lips,  and  hard  palate,  and  may 
involve  the  tonsils  and  pharynx.  In  very  severe  cases  the  entire  buccal  mucosa 
is  covered  by  the  grayish-white  membrane.  It  may  even  extend  into  the 
oesophagus  and,  according  to  Parrot,  to  the  stomach  and  caecum.  It  is  occa- 
sionally met  with  on  the  vocal  cords.  Robust,  well-nourished  children  are 
sometimes  affected,  but  it  is  usually  met  with  in  enfeebled,  emaciated  infants 
with  digestive  or  intestinal  troubles.  In  such  cases  the  disease  may  persist 
for  months. 

The  affection  is  readily  recognized,  and  must  not  be  confounded  with 
aphthous  stomatitis,  in  which  the  ulcers,  preceded  by  the  formation  of  vesi- 
cles, are  perfectly  distinctive.  In  thrush  the  microscopical  examination  shows 
the  presence  of  the  characteristic  fungus  throughout  the  membrane.  In  this 
condition,  too,  the  mouth  is  usually  dry — a  striking  contrast  to  the  salivation 
accompanying  aphthse. 

Thrush  is  more  readily  prevented  than  removed.  The  child's  mouth 
should  be  kept  scrupulously  clean,  and,  if  artificially  fed,  the  bottles  should 
be  thoroughly  sterilized.  Lime-water  or  any  other  alkaline  fiuid,  such  as  the 
bicarbonate  of  soda  (a  drachm  to  a  tumbler  of  water),  may  be  employed. 
When  the  patches  are  present  these  alkaline  mouth-washes  may  be  continued 
after  each  feeding.     A  spray  of  borax  or  of  sulphite  of  soda  (a  drachm  to 


DISEASES  OF  THE  MOUTH.  437 

the  ounce)  or  the  black  wash  with  glycerine  may  be  employed.  The  perman- 
ganate of  potassium  is  also  useful.  The  constitutional  treatment  is  of  equal 
importance,  and  it  will  often  be  found  that  the  thrush  persists,  in  spite  of 
all  local  measures,  until  the  general  health  of  the  infant  is  improved  by 
change  of  air  or  the  relief  of  the  diarrhoea,  or,  in  obstinate  cases,  the  substi- 
tution of  a  natural  for  the  artificial  diet. 

(5)  Gangrenous  Stomatitis  (Cancrnm  Oris;  Noma). — An  affection  char- 
acterized by  a  rapidly  progressing  gangrene,  starting  on  the  gums  or  cheeks, 
and  leading  to  extensive  sloughing  and  destruction.  This  terrible,  but  for- 
tunately rare,  disease  is  seen  onl}'^  in  children  under  very  unsanitary  conditions 
or  during  convalescence  from  the  acute  fevers.  It  is  more  common  in  girls 
than  in  boys.  It  is  met  with  between  the  ages  of  two  and  five  years.  In  at 
least  one-half  of  the  cases  the  disease  has  occurred  during  convalescence  from 
measles.  Cases  have  been  seen  also  after  scarlet  fever  and  typhoid.  The 
mucous  membrane  is  first  affected,  usually  of  the  gums  or  of  one  cheek.  The 
process  begins  insidiously,  and  when  first  seen  there  is  a  sloughing  ulcer  of 
the  mucous  membrane,  which  spreads  rapidl}^  and  leads  to  brawny  induration 
of  the  skin  and  adjacent  parts.  The  sloughing  extends,  and  in  severe  cases 
the  cheek  is  perforated.  The  disease  may  spread  to  the  tongue  and  chin; 
it  may  invade  the  bones  of  the  jaws  and  even  involve  the  eyelids  and  ears.  In 
mild  cases  an  ulcer  forms  on  the  inner  surface  of  the  cheek,  which  heals  or 
may  perforate  and  leave  a  fistulous  opening.  Naturally  in  such  a  severe 
affection  the  constitutional  disturbance  is  very  great,  the  pulse  is  rapid,  the 
prostration  extreme,  and  death  usually  takes  place  within  a  week  or  ten  days. 
The  temperature  may  reach  103°  or  104°.  Diarrhoea  is  usually  present,  and 
aspiration  pneumonia  often  develops.  H.  R.  Wharton  has  described  a  case 
in  which  there  was  extensive  colitis.  Bishop  and  Ryan  have  isolated  an  organ- 
ism which'  resembles  in  all  points  the  diphtheria  bacillus  of  reduced  virulence. 

The  treatment  of  the  disease  is  unsatisfactory.  In  many  cases  the  onset 
is  so  insidious  that  there  is  an  extensive  sloughing  sore  when  the  case  first 
comes  under  observation.  Destruction  of  the  sore  by  the  cautery,  either  the 
Paquelin  or  fuming  nitric  acid,  is  the  most  effectual.  Antiseptic  applications 
should  be  made  to  destroy  the  fetor.  The  child  should  be  carefully  nourished 
and  stimulants  given  freely. 

(6)  Mercurial  Stomatitis  (Ptyalism). — It  occurs  chiefly  in  persons  who 
have  a  special  susceptibility,  and  rarely  now  as  a  result  of  the  excessive  iise 
of  the  drug.  It  is  met  with  also  in  persons  whose  occupation  necessitates 
the  constant  handling  of  mercury.  It  often  follows  the  administration  of 
repeated  small  doses.  Thus,  a  patient  with  heart-disease  who  was  ordered 
an  eighth  of  a  grain  of  calomel  every  three  hours  for  diuretic  purposes  had, 
after  taking  eight  or  ten  doses,  a  severe  stomatitis,  which  persisted  for  several 
weeks.  I  have  known  it  to  follow  the  administration  of  small  doses  of  gray 
powder.  The  patient  complains  first  of  a  metallic  taste  in  the  mouth,  the 
gums  become  swollen,  red,  and  sore,  mastication  is  difficult,  the  salivary  glands 
become  enlarged  and  painful,  and  there  is  a  great  increase  in  their  secretion. 
The  tongue  is  swollen,  the  breath  has  a  foul  odor,  and,  if  the  affection  pro- 
gresses, there  may  be  ulceration  of  the  mucosa,  and,  in  rare  instances,  necrosis 
of  the  jaw.  Although  troublesome  and  distressing,  the  disease  is  rarely  seri- 
ous, and  recovery  usually  takes  place  in  a  couple  of  weeks.     Instances  in 


438  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

which  the  teeth  become  loosened  or  detached  or  in  wliich  the  inflammation 
extends  to  the  pharynx  and  Eustachian  tubes  are  rarely  seen  now. 

The  administration  of  mercury  should  be  susj^ended  so  soon  as  the  gums 
are  "  touched.''  Mild  cases  of  the  affection  subside  within  a  few  days  and 
require  only  a  simple  mouth-wash.  In  severer  cases  the  chlorate  of  potassium 
may  be  given  internally,  and  used  to  rinse  the  mouth.  The  bowels  should  be 
freely  opened;  the  patient  should  take  a  hot  bath  every  evening  and  should 
drink  plentifully  of  alkaline  mineral  waters.  Atropine  is  sometimes  service- 
able, and  may  be  given  in  doses  of  ^hr  of  a  grain  twice  a  day.  Iodine  is  also 
recommended.  When  the  salivation  is  severe  and  protracted,  the  patient  be- 
comes much  debilitated  and  anaemic,  so  that  a  supporting  treatment  is  indi- 
cated. The  diet  is  necessarily  liquid,  for  the  patient  finds  the  chief  difficulty 
in  taking  food.  If  the  pain  is  severe  a  Dover  powder  may  be  given  at 
night. 

Here  may  be  appropriately  mentioned  the  influence  of  stomatitis,  particu- 
larly the  mercurial  form,  upon  the  developing  teeth  of  children.  The  con- 
dition known  as  erosion,  in  which  the  teeth  are  honeycombed  or  pitted  owing 
to  defective  formation  of  enamel,  is  indicative,  as  a  rule,  of  infantile  stoma- 
titis. Such  teeth  must  be  distinguished  carefully  from  those  of  congenital 
S3^hilis,  which  may  of  course  coexist,  but  the  two  conditions  are  distinct.  The 
honeycombing  is  frequentty  seen  on  the  incisors ;  but,  according  to  Jonathan 
Hutchinson,  the  test  teeth  of  infantile  stomatitis  are  the  first  permanent 
molars,  then  the  incisors,  "  which  are  almost  as  constantly  pitted,  eroded,  and 
of  bad  color,  often  showing  the  transverse  furrow  which  crosses  all  the  teeth 
at  the  same  level."  Magitot  regards  these  transverse  furrows  as  the  result 
of  infantile  convulsions  or  of  severe  illness  during  early  life.  He  tliinks  they 
are  analogous  to  the  furrows  on  the  nails  which  so  often  follow  a  serious 
disease. 

(7)  Geographical  Tongue  (Eczema  of  the  Tongue). — A  remarkable  des- 
quamation of  the  superficial  epithelium  of  the  tongue  in  circinate  jDatches, 
which  spread  while  the  central  portions  heal.  Fusion  of  patches  leads  to  areas 
with  sinuous  outlines.  When  extensive  the  tongue  may  be  covered  with  these 
areas,  like  a  geographical  map.  The  affection  causes  a  good  deal  of  itching 
and  heat,  and  may  be  a  source  of  much  mental  worry  to  the  patients,  who 
often  dread  lest  it  may  be  a  commencing  cancer. 

The  etiology  of  the  disease  is  unknown.  It  occurs  in  infants  and  chil- 
dren, and  it  is  not  very  infrequent  in  adults.  It  has  been  regarded  as  a  gouty 
manifestation,  and  transient  attacks  may  accompany  indigestion.  It  is  very 
liable  to  relapse.  In  adults  it  may  prove  very  obstinate,  and  I  know  of  one 
instance  in  which  the  disease  persisted  in  spite  of  all  treatment  for  more  than 
two  years.  Solutions  of  nitrate  of  silver  give  the  most  satisfactory  results  in 
relieving  the  intense  burning. 

There  is  a  troublesome  affection,  not  unlike  the  geographical  tongue,  as 
the  patients  have  the  same  sense  of  burning  and  pain  on  eating.  It  is  a 
superficial  glossitis,  limited  usually  to  the  border  and  point  of  the  tongue, 
which  presents  irregular  reddish  spots,  looking  as  if  the  epithelium  was  re- 
moved, and  the  papillie  are  reddened  and  swollen.  The  condition  is  sometimes 
known  as  Moller's  glossitis.  Local  treatment  with  nitrate  of  silver  as  a  rule 
gives  relief. 


DISEASES  OF   THE  MOUTH.  439 

(8)  Leukoplakia  buccalis. — Samuel  Plumbe  described  the  condition  as 
icthyosis  lingualis.  It  has  also  been  called  buccal  psoriasis  and  I euco -keratosis 
mucosa?  oris.  The  following  forms  occur:  (a)  Small  white  spots  upon  the 
tongue,  slightly  raised,  even  papillomatous — ^lingual  corns.  (&)  Diffuse  thick- 
ening of  the  epithelial  coating  of  the  tongue,  either  a  thin,  bluish-white  color 
or  opaque  white,  depending  upon  the  thickness.  It  is  patchy,  and  more  often 
upon  the  dorsum  and  sides,  (c)  Diffuse  oral  leukoplakia,  a  remarkable  con- 
dition in  which  the  roof  of  the  mouth,  the  gums,  lips,  and  cheeks  are  covered 
with  an  opaque  white,  sometimes  smooth,  sometimes  fissured,  rugose  layer. 
In  this  wide-spread  form  the  tongue  may  be  spared.  The  visible  mucosa  of 
the  lips  may  be  involved,  and  occasionally  the  genital  mucosa. 

While  appearing  spontaneously,  the  condition  is  most  common  in  heavy 
smokers,  and  has  been  called  smoker's  tongue.  Epithelioma  occasionally 
starts  from  the  localized  patches.  A  majority  of  the  patients  have  had  syphi- 
lis, but  the  condition  does  not  yield,  as  a  rule,  to  specific  treatment.  There 
is  a  glossy,  fiat  atrophy  of  the  posterior  part  of  the  tongue,  also  believed  to 
be  syphilitic  (Virchow). 

Leukoplakia  is  a  very  obstinate  affection.  All  irritants,  such  as  smoke  and 
very  hot  food,  should  be  avoided.  Local  treatment  with  one-half-per-cent 
corrosive  sublimate  or  a  one-per-cent  chromic-acid  solution  has  been  recom- 
mended. The  propriety  of  active  local  treatment  is  doubtful.  Papillomatous 
outgrowths  should  be  cut  off.  The  X-rays  may  be  tried.  The  most  extensive 
form  may  disappear  spontaneously. 

(9)  Fetor  Oris. — The  practitioner  is  frequently  consulted  for  foul  breath, 
and  is  daily  made  aware  of  its  wide-spread  prevalence.  Too  often  he  is  himself 
the  subject  of  the  condition,  to  the  disgust  of  his  patients,  with  whom  he 
has  to  come  into  such  close  contact.  It  is  impossible  to  give  even  a  list  of  all 
the  causes  which  are  mentioned.  The  following  are  a  few  of  the  more  im- 
portant: (1)  In  connection  with  indigestion  and  the  associated  catarrhal 
disturbances  in  the  mouth,  pharynx,  and  stomach.  The  breath  is  "  heavy," 
as  the  mothers  say.  A  simple  mouth-wash  and  a  mercurial  purge  suffice  to . 
remove  it.  In  a  more  serious  disease  of  the  stomach  the  breath  may  be  foul, 
and  occasionally,  in  sloughing  cancer,  horribly  stinking.  (2)  Local  condi- 
tions in  the  mouth:  (a)  All  the  forms  of  stomatitis.  Smokers  should  re- 
member that,  apart  altogether  from  the  smell  of  tobacco,  their  breath  in  the 
morning  is  usually,  to  say  the  least,  "heavy,"  (&)  Pyorrhoea  alveolaris. 
This  is  the  most  common  cause  of  foul  breath  in  adults,  and  is  almost  con- 
stantly present  after  middle  life,  causing  a  perfectly  distinctive  odor  only  too 
well  known  to  all  of  us.  To  test  for  the  presence  draw  a  bit  of  stout  thread 
or  the  edge  of  a  sheet  of  paper  high  up  between  the  teeth  and  the  gums  and 
then  smell  it.  Scrupulous  treatment  of  the  gums  by  a  dentist  is  needed,  and 
daily  scouring,  etc.  (3)  The  tonsillar  diseases.  In  the  crypts  of  the  tonsils 
the  epithelial  debris  accumulates,  and,  invaded  by  micro-organisms,  gradually 
forms  the  little  round  or  triangular  bodies  which  can  be  squeezed  out  of  the 
lacunge,  and  when  pressed  between  the  fingers  smell  like  Limburger  cheese. 
The  fetor  oris  from  this  cause  is  quite  distinctive.  To  test  the  presence  in 
child  or  adult,  smell  the  finger  after  it  has  been  rubbed  firmly  upon  the  tonsil. 
Local  treatment  is  needed.  (4)  Decayed  teeth,  the  foul  odor  of  which  is 
quite  distinct  from  that  of  pyorrhoea  or  chronic  tonsillitis,     (5)  Eespiratory. 


440  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

Many  diseases  of  the  nose,  larjmx,  bronchi,  and  lungs  are  associated  with  foul 
breath.  (6)  Heemic.  The  halitus — the  expired  air  from  the  lung — ma}^  be 
impregnated  with  odors  from  the  blood.  Of  this  there  are  many  well-known 
instances. 

For  practical  purposes,  it  is  to  be  remembered  that  pyorrhoea  alveolaris 
and  what  is  called  chronic  lacunar  tonsillitis  are  the  two  most  common  causes 
of  foul  breath. 

(10)  Oral  Sepsis. — To  William  Hunter,  of  Charing  Cross  Hospital,  is  due 
the  credit  of  insisting  upon  the  importance  of  the  mouth  as  the  chief  channel 
of  entrance  of  the  pyogenic  organisms,  and  as  itself  the  seat  of  septic  pro- 
cesses. Necrosed  teeth,  pyorrhoea  alveolaris,  gingivitis,  alveolar  abscess,  etc., 
are  present  in  a  great  many  people.  A  systemic  infection  may  follow  or  the 
general  health  may  be  lowered  by  the  continuous  production  of  pus.  In  ex- 
tensive pyorrhoea  alveolaris  the  daily  amount  of  pus  must  be  considerable, 
and  there  can  be  no  question  that  it  has  a  debilitating  influence  on  the  general 
health  and  is  sometimes  associated  with  a  moderate  anemia  and  with  a  pasty 
complexion.  Hunter  describes  septic  gastritis  and  septic  enteritis  as  common 
sequences ;  indeed,  he  regards  appendicular,  pleuritic,  gall-bladder  and  pyelitic 
inflammations  as  forms  of  "  medical  sepsis  "  due  largely  to  infection  from 
the  mouth.  One  form  of  pernicious  ana?mia — infective  hsemolytic  antemia — 
he  believes  to  be  due  to  oral  sepsis,  or  an  infective  glossitis.  Of  the  20  cases 
of  pernicious  anaemia  which  I  had  under  observation  in  1904,  pyorrhoea 
alveolaris  was  present  in  more  than  half,  but  not  one  presented  the  infec- 
tive glossitis.  Certain  types  of  nephritis  are  also  believed  to  be  due  to  oral 
infection. 

There  is  no  question  of  the  importance  of  the  subject,  and  we  should  insist 
upon  scrupulous  cleanliness  of  the  mouth  and  teeth,  particularly  clearing 
away  the  tartar  and  the  pockets  of  pus.  An  adult  should  have  his  teeth 
cleansed  in  this  way  by  a  dentist  once  a  month.  We  should,  too,  have  less 
delicacy  in  telling  our  friends  in  whom  the  odor  of  the  breath  reveals  the 
presence  of  the  pj'orrhcea.     (See  B.  M.  J.,  November  19,  1904.) 

(11)  Affections  of  the  mucous  glands  are  not  very  common.  In  catarrhal 
troubles  in  children  and  in  measles  they  may  be  swollen.  They  are  enlarged 
and  very  prominent  in  Mikulicz's  disease,  with  chronic  symmetrical  enlarge- 
ment of  the  salivary  and  lachrymal  glands.  There  is  a  singular  affection  of 
the  mucous  glands  of  the  lips,  chiefly  of  the  lower,  with  much  swelling  and 
infiltration.  It  was  described  by  Volkmann,  and  has  been  called  Balz's  dis- 
ease. The  mucous  glands  are  enlarged,  the  ducts  much  dilated,  and  on 
pressure  a  mucoid  or  muco-purulent  secretion  may  exude.  The  skin  over  the 
lips  may  be  reddened  and  swollen. 


B,    DISEASES   OE  THE   SALIVARY  GLANDS. 

1.  Supersecretion  (Ptyalism) . — The  normal  amount  of  saliva  varies  from 
2  to  3  pints  in  the  twenty-four  hours.  The  secretion  is  increased  during  the 
taking  of  food  and  in  the  physiological  processes  of  dentition.  A  great  in- 
crease, to  which  the  term  ptyalism  is  applied,  is  met  with  under  many  cir- 
cumstances.    It  occurs  occasionally  in  mental  and  nervous  affections  and  in 


DISEASES  OF  THE  SALIVARY  GLANDS.  441 

rabies.  Occasionally  it  is  seen  in  the  acute  fevers,  particularly  in  small-pox. 
It  occurs  sometimes  with  disease  of  the  pancreas.  It  has  been  met  with 
during  gestation,  usually  early,  though  it  may  persist  throughout  the  entire 
course.  It  has  been  known  to  occur  at  each  menstrual  period;  and,  lastly, 
it  is  a  common  effect  of  certain  drugs.  Mercury,  gold,  copper,  the  iodine 
compounds,  and  (among  vegetable  remedies)  jaborandi,  muscarin,  and  to- 
bacco excite  the  salivary  secretion.  Of  these  we  most  frequently  see  the 
effect  of  mercury  in  producing  ptyalism.  The  salivation  may  be  present  with- 
out any  inflammation  of  the  mouth. 

2.  Xerostomia  (Arrest  of  the  Salivary  and  Buccal  Secretions;  Dry 
Mouth). — In  this  condition,  first  described  by  Jonathan  Hutchinson,  the 
secretions  of  the  mouth  and  salivary  glands  are  suppressed.  The  tongue  is 
red,  sometimes  cracked,  and  quite  dry;  the  mucous  membrane  of  the  cheeks 
and  of  the  palate  is  smooth,  shining,  and  dry;  and  mastication,  deglutition, 
and  articulation  are  very  difficult.  The  condition  is  not  common.  A  majority 
of  the  cases  are  in  women,  and  in  several  instances  have  been  associated  with 
nervous  phenomena.  The  general  health,  as  a  rule,  is  unimpaired.  Hadden 
suggests  that  it  is  due  to  involvement  of  some  centre  which  controls  the 
secretion  of  the  salivary  and  buccal  glands.  In  one  case  a  man  aged  thirty- 
two  had  a  peculiar  growth  in  the  mouth,  which  proved  to  be  the  remnants 
of  food ;  owing  to  the  absence  of  any  salivary  or  buccal  secretions,  it  collected 
along  the  gums,  and  became  hardened  and  adherent. 

3.  Inflammation  of  the  Salivary  Glands. 
(a)   Specific  Parotitis.     (See  Mumps.) 

(h)   Symptomatic  parotitis  or  parotid  huho  occurs: 

( 1 )  In  the  course  of  the  infectious  fevers — typhus,  typhoid,  pneumonia, 
pyasmia,  etc.  In  ordinary  practice  it  occurs  oftenest,  perhaps,  in  typhoid 
fever.  It  is  the  result  either  of  septic  infection  through  the  blood,  or  the 
inflammation,  in  many  cases,  passes  up  the  salivary  duct,  and  so  reaches  the 
gland.  The  process  is  usually  very  intense  and  leads  rapidly  to  suppuration. 
It  is,  as  a  rule,  an  unfavorable  indication  in  the  course  of  a  fever.  Parotitis 
may  occur  in  secondary  syphilis. 

(3)  In  connection  with  injury  or  disease  of  the  abdomen  or  pelvis,  a 
condition  to  which  Stephen  Paget  has  called  special  attention.  Of  101  cases 
of  this  kind,  "  10  followed  injury  or  disease  of  the  urinary  tract,  18  were 
due  to  injury  or  disease  of  the  alimentary  canal,  and  23  were  due  to  injury 
or  disease  of  the  abdominal  wall,  the  peritonseum,  or  the  pelvic  cellular  tissue. 
The  remaining  50  were  due  to  injury,  disease,  or  temporary  derangement  of 
the  genital  organs."  By  temporary  derangement  is  meant  slight  injuries  or 
natural  processes — a  slight  blow  on  the  testis,  the  introduction  of  a  pessary, 
menstruation,  or  pregnancy.  The  etiology  of  this  form  of  parotitis  is  obscure ; 
but  Bucknell  has  brought  forward  strong  evidence  to  show  that  in  all  these 
cases  infection  takes  place  through  the  duct. 

(3)  In  association  with  facial  paralysis,  as  in  a  case  of  fatal  peripheral 
neuritis  described  by  Gowers;  in  diabetes  and  chronic  metallic  poisoning. 

In  the  treatment  of  parotid  bubo  the  application  of  half  a  dozen  leeches 
will  sometimes  reduce  the  inflammation  and  promote  resolution.     When  sup- 
puration seems  inevitable  hot  fomentations  should  be  applied.     A  free  in- 
cision should  be  made  early. 
30 


442  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

(c)  Chronic  parotitis,  a  condition  in  which  the  glands  are  enlarged,  rarely 
painful,  may  follow  inflammation  of  the  throat  or  mumps.  Salivation  may 
be  present.  It  may  be  due  to  lead,  mercury,  or  potassium  iodide.  It  occurs 
also  in  chronic  Bright's  disease  and  in  secondary  syphilis.  S}T.nmetrical  en- 
largement of  the  parotids  of  moderate  extent  is  not  very  uncommon  among 
hospital  patients.  I  have  seen  three  instances  this  year  (1904—^05).  I  saw 
one  case,  with  Halsted,  in  which  for  several  years  the  glands  had  been  greatly 
enlarged,  forming  prominent  painless  tumors. 

(d)  Mikulicz's  Disease. — In  1892  Mikulicz  described  an  enlargement  of 
the  salivary,  laehrjonal,  and  buccal  glands,  persisting  for  years  without  any 
special  cause.  A  good  many  cases  have  now  been  reported.  In  my  patient, 
a  girl  of  eleven,  the  spleen  was  also  enlarged.  She  died  of  chronic  tubercu- 
losis, and  before  death  the  enlargement  of  the  salivary  glands  had  disap- 
peared.    The  lachrymal  glands  were  completely  sclerotic. 

(e)  Gaseous  Tumors  of  Steno's  Duct  and  of  tlie  Parotid  Gland. — In  glass- 
blowers  and  musicians  Steno's  duct  may  become  inflated  with  air  and  form 
a  tumor  the  size  of  a  nut  or  of  an  egg.  Some  have  contained  a  mixture  of 
air,  saliva,  and  pus.  In  rare  cases  there  are  gaseous  tumors  of  the  glands, 
which  give  a  sensation  of  crepitation  on  palpation. 


C.    DISEASES   OE   THE  PHARYNX. 

(1)  Circulatory  Disturbances. —  {a)  Hypermnia  is  common  in  acute  and 
chronic  affections  of  the  throat,  and  is  frequently  seen  as  a  result  of  the  irri- 
tation of  tobacco  smoke,  and  from  the  constant  use  of  the  voice.  Venous 
stasis  is  seen  in  valvular  disease  of  the  heart,  and  in  mechanical  obstruction 
of  the  superior  vena  cava  by  tumor  or  aneurism.  In  aortic  insufficiency  the 
capillary  pulse  may  sometimes  be  seen  and  the  intense  throbbing  of  the  in- 
ternal carotid  may  be  mistaken  for  aneurism. 

(&)  HcBmorrhage  is  found  in  association  with  bleeding  from  other  mucous 
surfaces,  or  it  is  due  to  local  causes — granulations  or  vegetations.  It  may 
be  mistaken  for  hsemorrhage  from  the  hmgs  or  stomach.  Sometimes  the 
patient  finds  the  pillow  stained  in  the  morning  with  bloody  secretion.  The 
condition  is  rarely  serious,  and  requires  only  suitable  local  treatment.  Occa- 
sionally a  haemorrhage  takes  place  into  the  mucosa,  producing  a  pharyngeal 
hsematoma.  I  have  thrice  seen  a  condition  of  the  uvula  resembling  haemor- 
rhagic  infarction.  One  was  in  a  patient  with  acute  rheumatism,  to  whom 
large  doses  of  salicylic  acid  had  been  given;  the  other  two  were  instances  of 
peliosis  rheumatica,  in  both  of  which  partial  sloughing  of  the  uvula  took 
place. 

(c)  (Edema. — An  infiltrated  o?dematous  condition  of  the  uvula  and  adja- 
cent parts  is  not  very  uncommon  in  conditions  of  debility,  in  profound 
anaemia,  and  in  Bright's  disease.  The  uvula  is  sometimes  from  this  cause 
enormously  enlarged,  whence  may  arise  difficulty  in  swallowing  or  in 
breathing. 

(2)  Acute  Pharyngitis  (Sore  Throat;  Angina  Simplex). — The  entire 
pharyngeal  structures,  often  with  the  tonsils,  are  involved.  The  condition 
may  follow  cold  or  exposure.     In  other  instances  it  is  associated  with  con- 


DISEASES  OF  THE  PHARYNX.  443 

stitutional  states,  such  as  rheumatism  or  gout,  or  with  digestive  disorders. 
The  patient  complains  of  uneasiness  and  soreness  in  swallowing,  of  a  feeling 
of  tickling  and  dryness  in  the  throat,  together  with  a  constant  desire  to  hawk 
and  cough.  Frequently  the  inflammation  extends  into  the  larynx  and  pro- 
duces hoarseness.  Not  uncommonly  it  is  only  part  of  a  general  naso-pharyn- 
geal  catarrh.  The  process  ma}^  pass  into  the  Eustachian  tubes  and  cause 
slight  deafness.  There  is  stiffness  of  the  neck,  the  lymph-glands  of  which 
may  be  enlarged  and  painful.  The  constitutional  symptoms  are  rarely  sefere. 
The  disease  sets  in  with  a  chilly  feeling  and  slight  fever;  the  pulse  is  in- 
creased in  frequency.  Occasionally  the  febrile  symptoms  are  more  severe, 
particularly  if  the  tonsils  are  specially  involved.  The  examination  of  the 
throat  shows  general  congestion  of  the  mucous  memlDrane,  which  is  dry  and 
glistening,  and  in  places  covered  with  sticky  secretion.  The  uvula  may  be 
much  swollen. 

Acute  pharyngitis  lasts  only  a  few  days  and  requires  mild  measures.  If 
the  tonsils  are  involved  and  the  fever  is  high,  aconite  or  sodium  salicylate  may 
be  given.  Guaiacum  also  is  beneficial;  but  in  a  majority  of  the  cases  a 
calomel  purge  or  a  saline  aperient  and  inhalations  with  steam  meet  the 
indications. 

(3)  Chronic  Pharyngitis. — This  may  follow  repeated  acute  attacks.  It 
is  very  common  in  persons  who  smoke  or  drink  to  excess,  and  in  those  who 
use  the  voice  very  much,  such  as  clergymen,  hucksters,  and  others.  It  is 
frequently  associated  with  chronic  nasal  catarrh.  The  naso-pharynx  and  the 
posterior  wall  are  the  parts  most  frequently  affected.  The  mucous  membrane 
is  relaxed,  the  venules  are  dilated,  and  roundish  bodies,  from  2  to  4  mm. 
in  diameter,  reddish  in  color,  project  to  a  variable  distance  beyond  the  mucous 
membrane.  These  represent  the  proliferations  of  lymph  tissue  about  the 
mucous  glands.  They  may  be  very  abundant,  forming  elongated  rows  in  the 
lateral  walls  of  the  pharynx.  With  this  there  may  be  a  dry  glistening  state 
of  the  pharyngeal  mucosa,  sometimes  known  as  pharyngitis  sicca.  The  pillars 
of  the  fauces  and  the  uvula  are  often  much  relaxed.  The  secretion  forms 
at  the  back  of  the  pharynx  and  the  patient  may  feel  it  drop  down  from  the 
vault,  or  it  is  tenacious  and  adherent,  and  is  only  removed  by  repeated  efforts 
at  hawking. 

In  the  treatment,  special  attention  must  be  paid  to  the  general  health. 
If  possible,  the  cause  should  be  ascertained.  The  condition  is  almost  con- 
stant in  smokers,  and  can  not  be  cured  without  stopping  the  use  of  tobacco. 
The  use  of  food  either  too  hot  or  too  much  spiced  should  be  forbidden.  When 
it  depends  upon  excessive  exercise  of  the  voice,  rest  should  be  enjoined.  In 
many  of  these  cases  change  of  air  and  tonics  help  very  much.  In  the  local 
treatment  of  the  throat  gargles,  washes,  and  pastilles  of  various  sorts  give 
temporary  relief,  but  when  the  hypertrophic  condition  is  marked  the  spots 
should  be  thoroughly  destroyed  by  the  galvano-cautery.  In  many  instances 
this  affords  great  and  permanent  relief,  but  in  others  the  condition  persists, 
and  as  it  is  not  unbearable,  the  patient  gives  up  all  hope  of  permanent  relief. 

(4)  Ulceration  of  the  Pharynx. — (a)  Follicular.  The  ulcers  are  usually 
small,  superficial,  and  generally  associated  with  chronic  catarrh. 

(&)  Syphilitic.  Most  frequently  painless  and  situated  on  the  posterior 
wall  of  the  pharynx,  they  occur  in  the  secondary  stage  as  small,  shallow  ex- 


444  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

cavations  with  the  mucous  patches.     In  the  tertiary  stage  they  are  due  to 
erosion  of  gummata,  and  in  healing  they  leave  whitish  cicatrices. 

(c)  Tuberculous.  Not  very  uncommon  in  advanced  cases  of  phthisis;  if 
extensive,  they  form  one  of  the  most  distressing  features  of  the  disease.  The 
ulcers  are  irregular,  with  ill-defined  edges  and  grayish-yellow  bases.  The  pos- 
terior wall  of  the  pharyns  may  have  an  eroded,  worm-eaten  appearance.  These 
ulcers  are,  as  a  rule,  intensely  painful.  Occasionally  the  primary  disease  is 
about  the  tonsils  and  the  pillars  of  the  fauces. 

(d)  Ulcers  occur  in  connection  with  pseudo-membranous  inflammation, 
particularly  the  diphtheritic.    In  cancer  and  in  lupus  ulcers  are  also  present. 

(e)  Ulcers  are  met  with  in  certain  of  the  fevers,  particularly  in 
typhoid. 

In  many  instances  the  diagnosis  of  the  nature  of  pharyngeal  ulcers  is 
very  difficult.  The  tuberculous  and  cancerous  varieties  are  readily  recog- 
nized, but  it  happens  not  infrequently  that  a  doubt  arises  as  to  the  syphilitic 
character  of  an  ulcer.  In  many  instances  the  local  conditions  may  be  uncer- 
tain. Then  other  evidences  of  syphilis  should  be  sought  for,  and  the  patient 
should  be  placed  on  mercury  and  iodide  of  potassium,  under  which  remedies 
specific  ulcers  usually  heal  with  great  rapidity. 

(5)  Acute  Infectious  Phlegmon  of  the  Pharynx. — Under  this  term  Sen- 
ator has  described  cases  in  which,  along  with  difficulty  in  swallowing,  soreness 
of  the  throat,  and  sometimes  hoarseness,  the  neck  enlarges,  the  pharyngeal 
mucosa  becomes  swollen  and  injected,  the  fever  is  high,  the  constitutional 
symptoms  are  severe,  and  the  inflammation  passes  on  rapidly  to  suppuration. 
The  symptoms  are  very  intense.  The  swelling  of  the  phar5mgeal  tissues  early 
reaches  such  a  grade  as  to  impede  respiration.  Very  similar  symptoms  may 
be  produced  by  foreign  bodies  in  the  pharynx. 

(6)  Retro-pharyngeal  abscess  occurs:  (1)  In  healthy  children  between 
six  months  and  two  years  of  age.  The  child  becomes  restless,  the  voice 
changes;  it  becomes  nasal  or  metallic  in  tone,  and  there  are  pain  and  diffi- 
culty in  swalloT\dng.  Inspection  of  the  pharynx  reveals  a  projecting  tumor 
in  the  middle  line,  or  if  it  be  not  visible,  it  is  readily  felt,  on  palpation, 
projecting  from  the  posterior  wall.  This  form  has  been  carefully  described 
by  Koplik.  (2)  As  a  not  infrequent  sequel  of  the  fevers,  particularly  of 
scarlet  fever  and  diphtheria.  (3)  In  caries  of  the  bodies  of  the  cervical 
vertebrge. 

The  diagnosis  is  readily  made,  as  the  projecting  tumor  can  be  seen,  or 
felt  with  the  finger  on  the  posterior  wall  of  the  pharynx. 

(7)  Angina  Ludovici  (Ludwig's  Angina;  Cellulitis  of  the  Nech). — In 
medical  practice  this  is  seen  as  a  secondary  inflammation  in  the  specific 
fevers,  particularly  diphtheria  and  scarlet  fever.  It  may,  however,  occur 
idiopathically  or  result  from  trauma.  It  is  probably  always  a  streptococcus 
infection  which  spreads  rapidly  from  the  glands.  The  swelling  at  first  is 
most  marked  in  the  submaxillary  region  of  one  side.  The  symptoms  are, 
as  a  rule,  intense,  and,  unless  early  and .  thorough  surgical  measures  are  em- 
ployed, there  is  great  risk  of  systemic  infection.  Semon  holds  that  the  vari- 
ous acute  septic  inflammations  of  the  throat — acute  oedema  of  the  larynx, 
phlegmon  of  the  pharynx  and  larynx,  and  angina  Ludovici — "  represent 
degrees  varying  in  virulence  of  one  and  the  same  process.'* 


DISEASES  OF  THE  TONSILS.  445 

D.    DISEASES  OF  THE  TONSILS. 
I.     ACUTE    TONSILLITIS. 

I.    FOLLICULAR  OR  LACUNAR  TONSILLITIS. 

For  practical  purposes,  under  this  name  may  be  described  the  various 
forms  which  have  been  called  catarrhal,  erythematous,  ulcero-membranous, 
and  herpetic. 

Etiology. — The  disease  is  met  with  most  frequently  in  young  persons,  but 
in  children  under  ten  it  is  less  common  than  the  chronic  form.  It  is  rare 
in  infants.  Sex  has  no  special  influence.  Exposure  to  wet  and  cold,  and 
bad  hygienic  surroundings  appear  to  have  a  direct  etiological  connection  with 
the  disease.  In  so  many  instances  defective  drainage  has  been  found  asso- 
ciated with  outbreaks  of  follicular  tonsillitis  that  sewer-gas  is  regarded  as  a 
common  exciting  cause.  One  attack  renders  a  patient  more  liable  to  sub- 
sequent infection.  The  tonsils  proper  and  the  adjacent  lymphatic  tissues 
undoubtedly  act  as  portals  of  entry  for  micro-organisms,  not  only  in  acute 
rheumatism  but  probably  in  other  affections.  Packard  has  called  particular  at- 
tention to  acute  tonsillitis  as  a  precursor  of  endocarditis,  erythema  nodosum, 
and  chorea.  Cheadle  describes  it  as  one  of  the  phases  of  rheumatism  in 
childhood,  with  which  articular  attacks  or  chorea  may  alternate.  The  exist- 
ence of  pains  in  the  limbs  upon  which  some  lay  stress  is  no  evidence  of  the 
connection  of  the  affection  with  rheumatism.  A  disease  so  common  and 
wide-spread  as  acute  tonsillitis  necessarily  attacks  many  persons  in  whose 
families  rheumatism  prevails  or  who  may  themselves  have  had  acute  attacks. 

Mackenzie  gives  a  table  showing  that,  in  four  successive  years  more  cases 
occurred  in  September  than  in  any  other  month;  in  October  nearly  as  many, 
with  July,  August,  and  November  next.  In  this  country  it  seems  more  preva- 
lent in  the  spring.  So  many  cases  arise  within  a  short  time  that  the  disease 
may  be  almost  epidemic.  It  spreads  through  a  family  in  such  a  way  that  it 
must  be  regarded  as  contagious. 

An  old  notion  prevails  that  there  is  a  definite  relation  between  the  tonsils 
and  the  testes  and  ovaries.  F.  J.  Shepherd  has  called  attention  to  the  cir- 
cumstance that  acute  tonsillitis  is  a  very  common  affection  in  newly  married 
persons.  The  commonest  organism  found  in  tonsillitis  is  a  streptococcus. 
Staphylococci  also  occur.  In  some  cases  the  bacillus  diplitherice  of  Loeffler 
has  been  found,  but  it  does  not  always  possess  the  full  virulence  (see  Atypical 
Forms  of  Diphtheria). 

Morbid  Anatomy. — The  lacunas  of  the  tonsils  become  filled  with  exuda- 
tion products,  which  form  cheesy-looking  masses,  projecting  from  the  orifices 
of  the  crypts.  Not  infrequently  the  exudations  from  contiguous  lacunae 
coalesce.  The  intervening  mucosa  is  usually  swollen,  deep-red  in  color,  and 
may  present  herpetic  vesicles  or,  in  some  instances,  even  membranous  exuda- 
tion, in  which  case  it  may  be  difficult  to  distinguish  the  condition  from  diph- 
theria. The  creamy  contents  of  the  crypt  are  made  up  of  micrococci  and 
epithelial  debris. 

Symptoms. — Chilly  feelings,  or  even  a  definite  chill,  and  aching  pains  in 
the  back  and  limbs  may  precede  the  onset.    The  fever  rises  rapidly,  and  in  the 


446  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

case  of  a  young  child  may  reach  105°  on  the  evening  of  the  first  day.  The 
patient  complains  of  soreness  of  the  throat  and  difficulty  in  swallowing.  On 
examination,  the  tonsils  are  seen  to  he  swollen  and  the  crypts  present  the 
characteristic  creamy  exudate.  The  tongue  is  furred^  the  hreath  is  heavy 
and  foul,  and  the  urine  is  higlily  colored  and  loaded  with  urates.  In  children 
the  respirations  are  usually  very  hurried,  and  the  pulse  is  greatly  increased 
in  rapidity.  Swallowing  is  painful,  and  the  voice  often  becomes  nasal.  Slight 
swelling  of  the  cervical  glands  is  present.  In  severe  cases  the  symptoms  in- 
crease and  the  tonsils  become  still  more  swollen.  The  inflammation  gradually 
subsides,  and,  as  a  rule,  within  a  week  the  fever  departs  and  the  local  condition 
greatly  improves.  The  tonsils,  however,  remain  somewhat  swollen.  The  pros- 
tration and  constitutional  disturbance  are  often  out  of  proportion  to  the 
intensity  of  the  local  disease. 

Complications. — Febrile  albuminuria  is  not  uncommon,  and  even  acute 
nephritis.  Endocarditis  and  pericarditis  ate  more  rare.  It  is  to  be  borne  in 
mind  that  in  a  child  with  fever  an  apex  systolic  murmur  is  almost  invariably 
present.  The  disease  may  extend  to  the  middle  ear.  A  diffuse  erythema  may 
simulate  the  rash  of  scarlet  fever. 

Diagnosis. — It  may  be  difficult  to  distinguish  follicular  tonsillitis  from 
diphtheria.  It  would  seem,  indeed,  as  if  there  were  intermediate  forms  be- 
tween the  mildest  lacunar  and  the  severer  pseudo-membranous  tonsillitis.  In 
the  follicular  form  the  individual  yellowish-gray  masses,  separated  by  the 
reddish  tonsillar  tissue,  are  very  characteristic;  whereas  in  diphtheria  the 
membrane  is  of  ashy  gray,  and  uniform,  not  patchy.  A  point  of  the  greatest 
importance  in  diphtheria  is  that  the  membrane  is  not  limited  to  the  tonsils, 
but  creeps  up  the  pillars  of  the  fauces  or  appears  on  the  uvula.  The  diph- 
theritic membrane  when  removed  leaves  a  bleeding,  eroded  surface;  whereas 
the  exudation  of  lacunar  tonsillitis  is  easily  separated,  and  there  is  no  erosion 
beneath  it.  In  all  doubtful  cases  cultures  should  be  made  to  determine  the 
presence  or  absence  of  Loeffler's  bacillus. 

II.    SUPPURATIVE  TONSILLITIS. 

Etiology. — This  arises  under  conditions  very  similar  to  those  mentioned 
in  the  lacunar  form.  It  may  follow  exposure  to  cold  or  wet,  and  is  particu- 
larly liable  to  recur.  It  is  most  common  in  adolescence.  The  inflammation 
is  here  more  deeply  seated.  It  involves  the  stroma,  and  tends  to  go  on  to 
suppuration. 

Symptoms. — The  constitutional  disturbance  ■  is  very  great.  The  tempera- 
ture rises  to  104°  or  105°,  and  the  pulse  ranges  from  110  to  130.  Nocturnal 
delirium  is  not  uncommon.  The  prostration  may  be  extreme.  There  is  no 
local  disease  of  similar  extent  which  so  rapidly  exhausts  the  strength  of  a 
patient.  Soreness  and  dr}Tiess  of  the  throat,  with  pain  in  swallowing,  are 
the  symptoms  of  which  the  patient  first  complains.  One  or  both  tonsils  may 
be  involved.  They  are  enlarged,  firm  to  the  touch,  dusky  red  and  oedematous, 
and  the  contiguous  parts  are  also  much  swollen.  The  swelling  of  the  glands 
may  be  so  great  that  they  meet  in  the  middle  line,  or  one  tonsil  may  even 
push  the  uvula  aside  and  almost  touch  the  other  gland.  The  salivary  and 
buccal  secretions  are  increased.    The  glands  of  the  neck  enlarge,  the  lower  jaw 


DISEASES  OF   THE  TONSILS.  447 

is  fixed,  and  tlie  patient  is  unable  to  open  liis  mouth.  In  from  two  to  four 
days  the  enlarged  gland  becomes  softer,  and  fluctuation  can  be  distinctly  felt 
by  placing  one  finger  on  the  tonsil  and  the  other  at  the  angle  of  the  jaw.  The 
abscess  points  usually  toward  the  mouth,  but  in  some  cases  toward  the  phar- 
ynx. It  may  burst  spontaneously,  affording  instant  and  great  relief.  Suffo- 
cation has  followed  the  rupture  of  a  large  abscess  and  the  entrance  of  the  pus 
into  the  larynx.  When  the  suppuration  is  peritonsillar  and  extensive,  the 
internal  carotid  artery  may  be  opened;  but  these  are,  fortunately,  very  ,rare 
accidents. 

Treatment. — In  the  follicular  form  aconite  may  be  given  in  full  doses.  It 
acts  very  beneficially  in  children.  The  salicylates,  given  freely  at  the  outset, 
are  regarded  by  some  as  specific,  but  I  have  seen  no  evidence  of  such  prompt 
and  decisive  action.  At  night,  a  full  dose  of  Dover's  powder  may  be  given. 
The  use  of  guaiacum,  in  the  form  of  2-grain  lozenges,  is  warmly  recom- 
mended. Iron  and  quinine  should  be  reserved  until  the  fever  has  subsided. 
A  pad  of  spongio-piline  or  thick  flannel  dipped  in  ice-cold  water  may  be 
applied  around  the  neck  and  covered  with  oiled  silk.  More  convenient  still 
is  a  small  ice-bag.  Locally  the  tonsils  may  be  treated  with  the  dry  sodium 
bicarbonate.  The  moistened  fingertip  is  dipped  into  the  soda,  which  is  then 
rubbed  gently  on  the  gland  and  repeated  every  hour.  Astringent  preparations, 
such  as  iron  and  glycerin,  alum,  zinc,  and  nitrate  of  silver,  may  be  tried.  To 
cleanse  and  disinfect  the  throat,  solutions  of  borax  or  thymol  in  glycerin  and 
water  may  be  used. 

In  suppurative  tonsillitis  hot  applications  in  the  form  of  poultices  and 
fomentations  are  more  comfortable  and  better  than  the  ice-bag.  The  gland 
should  be  felt-^it  can  not  always  be  seen — from  time  to  time,  and  should  be 
opened  when  fluctuation  is  distinct.  The  progress  of  the  disease  may  be  short- 
ened and  the  patient  spared  several  days  of  great  suffering  if  the  gland  is 
scarified  early.  The  curved  bistoury,  guarded  nearly  to  the  point  with  plaster 
or  cotton,  is  the  most  satisfactory  instrument.  The  incision  should  be  made 
from  above  downward,  parallel  with  the  anterior  pillar.  There  are  cases  in 
which,  before  suppuration  takes  place,  the  parenchymatous  swelling  is  so 
great  that. the  patient  is  threatened  with  suffocation.  In  such  instances  either 
the  tonsil  must  be  excised  or  tracheotomy  performed.  Delavan  refers  to  two 
cases  in  which  he  states  that  tracheotomy  would,  under  these  circumstances, 
have  saved  life.  Patients  with  this  affection  require  a  nourishing  liquid  diet, 
and  during  convalescence  iron  in  full  doses. 

Early  removal  of  the  tonsils  should  be  practised  when  a  child  suffers  with 
recurring  attacks,  and  thorough  local  treatment  should  be  given  to  the  naso- 
pharynx.   Particular  care  should  be  taken  of  the  child's  mouth  and  throat. 

II.     CHRONIC   TONSILLITIS. 

(Chronic  Naso-pharyngeal  Obstruction ;  Mouth-Breathing- ;  Aprosexia.) 

Under  this  heading  will  be  considered  also  hypertrophy  of  the  adenoid 
tissue  in  the  vault  of  the  pharynx,  •  sometimes  known  as  the  pharyngeal  tonsil, 
as  the  affection  usually  involves  both  the  tonsils  proper  and  this  tissue,  and 
the  symptoms  are  not  to  be  differentiated. 


448  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

Chronic  enlargement  of  the  tonsillar  tissues  is  an  affection  of  great  im- 
portance, and  may  influence  in  an  extraordinary  way  the  mental  and  bodily 
development  of  children. 

Etiology. — Hypertrophy  of  the  tonsillar  structures  is  occasionally  congen- 
ital. Cases  are  perhaps  most  frequent  in  children,  during  the  third  hemi- 
decade.  It  may  be  associated  with  a  general  proliferation  of  all  the  lymphoid 
tissues  of  the  body — lymphatism.  The  condition  also  occurs  in  young  adults, 
more  rarely  in  the  middle-aged.  The  enlargement  may  follow  diphtheria  or 
the  eruptive  fevers.  The  frequency  of  the  occurrence  of  adenoid  growths  in 
the  naso-pharynx  has  been  variously  stated.  Meyer,  to  whom  the  profession 
is  indebted  for  calling  attention  to  the  subject,  found  them  in  about  one  per 
cent  of  the  children  in  Copenhagen,  while  Chappell  found  60  cases  in  the 
examination  of  2,000  children  in  New  York.  These  figures  give  a  very 
moderate  estimate  of  the  prevalence  of  the  trouble.  It  occurs  equally 
in  boys  and  girls,  according  to  some  writers  with  greater  prevalence  in  the 
former. 

Morbid  Anatomy. — The  tonsils  proper  present  a  condition  of  chronic 
hypertrophy,  due  to  multiplication  of  all  the  constituents  of  the  glands.  The 
lymphoid  elements  may  be  chiefly  involved  without  much  development  of 
the  stroma.  In  other  instances  the  fibrous  matrix  is  increased,  and  the  organ 
is  then  harder,  smaller,  firmer,  and  is  cut  with  much  greater  difficulty. 

The  adenoid  growths,  which  spring  from  the  vault  of  the  pharynx,  form 
masses  varying  in  size  from  a  small  pea  to  an  almond.  They  may  be  sessile, 
with  broad  bases,  or  pedunculated.  They  are  reddish  in  color,  of  moderate 
firmness,  and  contain  numerous  blood-vessels.  "  Abundant,  as  a  rule,  over 
the  vault,  on  a  line  with  the  fossa  of  the  Eustachian  tube,  the  growths  may 
lie  posterior  to  the  fossa — ^namely,  in  the  depression  known  as  the  fossa  of 
Eosenmiiller,  or  upon  the  parts  which  are  parallel  to  the  posterior  wall  of  the 
pharynx.  The  growths  appear  to  spring  in  the  main  from  the  mucous  mem- 
brane covering  the  localities  where  the  connective  tissue  fills  in  the  inequali- 
ties of  the  base  of  the  skull ^'  (Harrison  Allen),  The  growths  are  most 
frequently  papillomatous  with  a  lymphoid  parenchyma.  Hypertrophy  of  the 
pharyngeal  adenoid  tissue  may  be  present  without  great  enlargement  of  the 
tonsils  proper.     Chronic  catarrh  of  the  nose  usually  coexists. 

Symptoms. — The  direct  effect  of  chronic  tonsillar  hypertrophy  is  the  es- 
tablishment of  mouth-breathing.  The  indirect  effects  are  deformation  of  the 
thorax,  changes  in  the  facial  expression,  sometimes  marked  alteration  in 
the  mental  condition,  and  in  certain  cases  stunting  of  the  growth.  Woods 
Hutchinson  has  suggested  that  the  embryological  relation  of  these  structures 
with  the  pituitary  body  may  account  for  the  interference  with  development. 
The  establishment  of  mouth-breathing  is  the  symptom  which  first  attracts 
the  attention.  It  is  not  so  noticeable  by  day,  although  the  child  may  present 
the  vacant  expression  characteristic  of  this  condition.  At  night  the  child's 
sleep  is  greatly  disturbed;  the  respirations  are  loud  and  snorting,  and  there 
are  sometimes  prolonged  pauses,  followed  by  deep,  noisy  inspirations.  The 
pulse  may  vary  strangely  during  these  attacks,  and  in  the  prolonged  intervals 
may  be  slow,  to  increase  greatly  with  the  forced  inspirations.  The  alee  nasi 
should  be  observed  during  the  sleep  of  the  child  as  they  are  sometimes  much 
retracted  during  inspiration,  due  to  a  laxity  of  the  walls,  a  condition  readily 


DISEASES  OF  THE   TONSILS.  449 

remedied  by  the  use  of  a  soft  wire  dilator.  Night  terrors  are  common.  The 
child  may  wake  up  in  a  paroxysm  of  shortness  of  breath.  Sometimes  these 
attacks  are  of  great  severity  and  the  dyspnoea,  or  rather  orthopnoea,  may  sug- 
gest pressure  of  enlarged  glands  on  the  trachea.  Sometimes  there  is  a  noc- 
turnal paroxysmal  cough  of  a  very  troublesome  character  (Balne's  cough), 
usually  excited  by  lying  down.    The  attacks  may  occur  through  the  day. 

When  the  mouth-breathing  has  persisted  for  a  long  time  definite  changes 
are  brought  about  in  the  face,  mouth,  and  chest.  The  facies  is  so  peculiar 
and  distinctive  that  the  condition  may  be  evident  at  a  glance.  The  expression 
is  dull,  heavy,  and  apathetic,  due  in  part  to  the  fact  that  the  mouth  is  habitu- 
ally left  open.  In  long-standing  cases  the  child  is  very  stupid-looking,  re- 
sponds slowly  to  questions,  and  may  be  sullen  and  cross.  The  lips  are  thick, 
the  nasal  orifices  small  and  pinched-in  looking,  the  superior  dental  arch  is 
narrowed  and  the  roof  of  the  mouth  considerably  raised. 

The  remarkable  alterations  in  the  shape  of  the  chest  in  connection  with 
enlarged  tonsils  were  first  carefully  studied  by  Dupuytren  (1828),  who  evi- 
dently fully  appreciated  the  great  importance  of  the  condition.  He  noted 
"  a  lateral  depression  of  the  parietes  of  the  chest  consisting  of  a  depression, 
more  or  less  great,  of  the  ribs  on  each  side,  and  a  proportionate  protrusion 
of  the  sternum  in  front."  J.  Mason  Warren  (Medical  Examiner,  1839)  gave 
an  admirable  description  of  the  constitutional  symptoms  and  the  thoracic 
deformities  induced  by  enlarged  tonsils.  These,  with  the  memoir  of  Lambron 
(1861),  constitute  the  most  important  contributions  to  our  knowledge  on  the 
subject.     Three  types  of  deformity  may  be  recognized: 

(a)  The  Pigeon  ok  Chicken  Beeast,  by  far  the  most  common  form,  in 
which  the  sternum  is  prominent  and  there  is  a  circular  depression  in  the 
lateral  zone  (Harrison's  groove),  corresponding  to  the  attachment  of  the 
diaphragm.  The  ribs  are  prominent  anteriorly  and  the  sternum  is  angulated 
forward  at  the  manubrio-gladiolar  junction.  As  a  mouth-breather  is  watched 
during  sleep,  one  can  see  the  lower  and  lateral  thoracic  regions  retracted 
during  inspiration  by  the  action  of  the  diaphragm. 

(&)  Baerel  Chest. — Some  children,  the  subject  of  chronic  naso-pharyn- 
geal  obstruction,  have  recurring  attacks  of  asthma,  and  the  chest  may  be 
gradually  deformed,  becoming  rounded  and  barrel-shaped,  the  neck  short, 
and  the  shoulders  and  back  bowed.  A  child  of  ten  or  eleven  may  have  the 
thoracic  conformation  of  an  old  man  with  emphysema. 

(c)  The  Funnel  Bh-east  (Trichterbrnst) . — This  remarkable  deformity, 
in  which  there  is  a  deep  depression  at  the  lower  sternum,  has  excited  much 
controversy  as  to  its  mode  of  origin.  I  believe  that  in  some  instances,  at 
least,  it  is  due  to  the  obstructed  breathing  in  connection  with  adenoid  vegeta- 
tions. I  have  seen  two  cases  in  children,  in  which  the  condition  was  in  proc- 
ess of  formation.  During  inspiration  the  lower  sternum  was  forcibly  re- 
tracted, so  much  so  that  at  the  height  the  depression  corresponded  to  that 
of  a  well-marked  "  TricMerbrust"  While  in  repose,  the  lower  sternal  region 
was  distinctly  excavated. 

The  voice  is  altered  and  acquires  a  nasal  quality.  The  pronunciation  of 
certain  letters  is  changed,  and  there  is  inability  to  pronounce  the  nasal  con- 
sonants n  and  m.  Bloch  lays  great  stress  upon  the  association  of  mouth- 
breathing  with  stuttering. 


450  DISEASES  OF   THE  DIGESTIVE  SYSTEM. 

The  hearing  is  impaired,  usually  owing  to  the  extension  of  inflammation 
along  the  Eustachian  tubes  and  the  obstruction  with  mucus  or  the  narrowing 
of  their  orifices  by  pressure  of  the  adenoid  vegetations.  In  some  instances  it 
may  be  due  to  retraction  of  the  drums,  as  the  upper  pharynx  is  insufficiently 
supplied  with  air.  N'aturally  the  senses  of  taste  and  smell  are  much  impaired. 
With  these  symptoms  there  may  be  little  or  no  nasal  catarrh  or  discharge, 
but  the  phar^Tigeal  secretion  of  mucus  is  always  increased.  Children,  how- 
ever, do  not  notice  this,  as  the  mucus  is  usually  swallowed,  but  older  persons 
expectorate  it  with  difficidty. 

Among  other  symptoms  ma}^  be  mentioned  headache,  which  is  by  no  means 
imcommon,  general  listlessness,  and  an  indisposition  for  physical  or  mental 
exertion.  Habit-spasm  of  the  face  has  been  described  in  connection  with  it. 
I  have  known  several  instances  in  which  permanent  relief  has  been  afforded 
by  the  removal  of  the  adenoid  vegetations.  Enuresis  is  occasionally  an  asso- 
ciated symptom.  The  influence  upon  the  mental  development  is  striking. 
Mouth-breathers  are  usually  dull,  stupid,  and  backward.  It  is  impossible  for 
them  to  fix  the  attention  for  long  at  a  time,  and  to  this  impairment  of  the 
mental  function  Guye,  of  Amsterdam,  has  given  the  name  aprosexia.  Head- 
aches, forgetfulness,  inability  to  study  without  discomfort,  are  frequent  symp- 
toms of  this  condition  in  students.  There  is  more  than  a  grain  of  truth  in 
the  aphorism  shut  your  mouth  and  save  your  life,  which  is  found  on  the  title- 
page  of  Captain  Catlin's  celebrated  pamphlet  on  mouth-breathing  (1861), 
to  which  cause  he  attributed  all  the  ills  of  civilization. 

A  symptom  specially  associated  with  enlarged  tonsils  is  fetor  of  the  breath. 
In  the  tonsillar  crypts  the  inspissated  secretion  undergoes  decomposition  and 
an  odor  not  unlike  that  of  Limburger  cheese  is  produced.  The  little  cheesy 
masses  may  sometimes  be  squeezed  from  the  crypts  of  the  tonsils.  Though 
the  odor  may  not  apparently  be  very  strong,  yet  if  the  mass  be  squeezed  be- 
tween the  fingers  its  intensity  will  at  once  be  appreciated.  In  some  cases  of 
chronic  enlargement  the  cheesy  masses  may  be  deep  in  the  tonsillar  crypts; 
and  if  they  remain  for  a  prolonged  period  lime  salts  are  deposited  and  a 
tonsillar  calculus  is  in  this  way  produced. 

Children  with  enlarged  tonsils  are  especially  prone  to  take  cold  and  to 
recurring  attacks  of  follicular  disease.  They  are  also  more  liable  to  diph- 
theria, and  in  them  the  anginal  features  in  scarlet  fever  are  always  more 
serious.  The  ultimate  results  of  untreated  adenoid  hypertrophy  are  impor- 
tant. In  some  cases  the  vegetations  disappear,  leaving  an  atrophic  condition 
of  the  vault  of  the  phar}Tix.  Neglect  may  also  lead  to  the  so-called  Thorn- 
waldt's  disease,  in  which  there  is  a  cystic  condition  of  the  pharjTigeal  tonsil 
and  constant  secretion  of  muco-pus. 

Dia^osis. — The  facial  aspect  is  usually  distinctive.  Enlarged  tonsils  are 
readily  seen  on  inspection  of  the  pharjmx.  There  may  be  no  great  enlarge- 
ment of  the  tonsils  and  nothing  apparent  at  the  back  of  the  throat  even  when 
the  naso-pharynx  is  completely  blocked  with  adenoid  vegetations.  In  children 
the  rhinoscopic  examination  is  rarely  practicable.  Digital  examination  is  the 
most  satisfactory.  The  growths  can  then  be  felt  either  as  small,  flat  bodies 
or,  if  extensive,  as  velvety,  grape-like  papillomata. 

Treatment. — If  the  tonsils  are  large  and  the  general  state  is  evidently 
influenced  by  them  they  should  be  at  once  removed.     Applications  of  iodine 


DISEASES  OF  THE  (ESOPHAGUS.  451 

and  iron,  or  pencilling  the  crypts  with  nitrate  of  silver,  are  of  service  in  the 
milder  grades,  but  it  is  waste  of  time  to  apply  them  to  very  enlarged  glands. 
There  is  a  condition  in  which  the  tonsils  are  not  much  enlarged,  but  the  crypts 
are  constantly  filled  with  cheesy  secretions  and  cause  a  very  bad  odor  in  the 
breath.  In  such  instances  the  removal  of  the  secretion  and  thorough  pencil- 
ling of  the  crypts  with  chromic  acid  may  be  practised.  The  galvano-eautery 
is  of  great  service  in  many  cases  of  enlarged  tonsils  when  there  is  any  objec- 
tion to  the  more  radical  surgical  procedure. 

The  treatment  of  the  adenoid  growths  in  the  pharynx  is  of  the  greatest 
importance,  and  should  be  thoroughly  carried  out.  Parents  should  be  frankly 
told  that  the  affection  is  serious,  one  which  impairs  the  mental  not  less  than 
the  bodily  development  of  the  child.  In  spite  of  the  thorough  ventilation 
of  this  subject  by  specialists,  practitioners  do  not  appear  to  have  grasped  as 
yet  the  full  importance  of  this  disease.  They  are  far  too  apt  to  temporize  and 
unnecessarily  to  postpone  radical  measures.  The  child  must  be  anaesthetized, 
when  the  growths  can  be  removed.  The  dangers  of  the  operation  are  slight. 
Haemorrhage  occurs  and  may  be  severe.  Death  from  chloroform  has  been 
somewhat  frequent.  Hinckel  (N".  Y.  Med.  Jr.,  Oct.  29,  1898)  has  collected 
18  cases.  They  probably  come  in  the  category  of  the  cases  of  sudden  death  in 
lymphatism.  The  good  effects  of  the  operation  are  often  apparent  within  a 
few  days,  and  the  child  begins  to  breathe  through  the  nose.  In  some  instances 
the  habit  of  mouth-breathing  persists.  As  soon  as  the  child  goes  to  sleep 
the  lower  jaw  drops  and  the  air  is  drawn  into  the  mouth.  In  these  cases  a 
chin  strap  can  be  readily  adjusted,  which  the  child  may  wear  at  night.  In 
severe  cases  it  may  take  months  of  careful  training  before  the  child  can  speak 
properly.  An  all-important  point  in  the  treatment  of  lesions  of  the  naso- 
pharynx (and,  indeed,  in  the  prevention  of  this  unfortunate  condition)  is  to 
increase  the  breathing  capacity  of  the  chest  by  making  the  child  perform 
systematic  exercises,  which  cause  the  air  to  be  driven  freely  and  forcibly  in 
and  out  through  the  naso-pharjnix.  I  can  not  too  strongly  commend  this 
suggestion  of  Mr.  Arbuthnot  Lane. 

Throughout  the  entire  treatment  attention  should  be  paid  to  hygiene  and 
diet,  and  cod-liver  oil  and  the  iodide  of  iron  may  be  administered  with  benefit. 


E.    DISEASES  OF  THE   (ESOPHAGUS. 

I.    ACUTE    OESOPHAGITIS. 

Etiology. — Acute  inflammation  occurs  (a)  in  the  catarrhal  processes  of 
the  specific  fevers;  more  rarely  as  an  extension  from  catarrh  of  the  pharynx. 
(b)  As  a  result  of  intense  mechanical  or  chemical  irritation,  produced  by 
foreign  bodies,  by  very  hot  liquids,  or  by  strong  corrosives,  (c)  In  the  form 
of  pseudo-membranous  inflammation  in  diphtheria,  and  occasionally  in  pneu- 
monia, typhoid  fever,  and  pysemia.  (d)  As  a  pustular  inflammation  in  small- 
pox, and,  according  to  Laennec,  as  a  result  of  a  prolonged  administration  of 
tartar  emetic,  (e)  In  connection  with  local  disease,  particularly  cancer  either 
of  the  tube  itself  or  extension  to  it  from  without.  And,  lastly,  acute  oesopha- 
gitis, occasionally  with  ulceration,  may  occur  spontaneously  in  sucklings. 


452  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

Morbid  Anatomy. — It  is  extremely  rare  to  see  redness  of  the  mucosa, 
except  when  chemical  irritants  have  been  swallowed.  More  commonly  the 
epithelium  is  thickened  and  has  desquamated,  so  that  the  surface  is  covered 
with  a  fine  granular  substance.  The  mucous  follicles  are  swollen  and  occa- 
sionally there  may  be  seen  small  erosions.  In  the  pseudo-membranous  inflam- 
mation there  is  a  grayish  croupous  exudate,  usually  limited  in  extent,  at  the 
upper  portion  of  the  gullet.  This  must  not  be  confounded  with  the  grayish- 
white  deposit  of  thrush  in  children.  The  pustular  disease  is  very  rare  in 
small-pox.  In  the  plilegmonous  inflammation  the  mucous  membrane  is  greatly 
swollen,  and  there  is  purulent  infiltration  in  the  submucosa.  This  may  be 
limited  as  about  a  foreign  body,  or  extremely  diffuse.  It  may  even  extend 
throughout  a  large  part  of  the  gullet.  Gangrene  occasionally  supervenes. 
There  is  a  remarkable  fibrinous  or  membranous  oesophagitis,  most-  frequently 
met  with  in  the  fevers,  sometimes  also  in  hysteria,  in  which  long  casts  of  the 
tube  ma}^  be  vomited. 

Symptoms. — Pain  in  deglutition  is  always  present  in  severe  inflammation 
of  the  oesophagus.  A  dull  pain  beneath  the  sternum  is  also  present.  In  the 
milder  forms  of  catarrhal  inflammation  there  are  usually  no  symptoms.  The 
presence  of  a  foreign  body  is  indicated  by  dysphagia  and  spasm  with  the 
regurgitation  of  portions  of  the  food.  Later,  l3lood  and  pus  may  be  ejected. 
It  is  surprising  how  extensive  the  disease  may  be  in  the  oesophagus  without 
producing  much  pain  or  great  discomfort,  except  in.  swallowing.  The  intense 
inflammation  which  follows  the  swallowing  of  corrosives,  when  not  fatal, 
gradually  subsides,  and  often  leads  to  cicatricial  contraction  and  stricture. 

Treatment. — The  treatment  of  acute  inflammation  of  the  oesophagus  is 
extremely  unsatisfactory,  particularly  in  the  severer  forms.  The  slight  ca- 
tarrhal cases  require  no  special  treatment.  When  the  dysphagia  is  intense 
it  is  best  not  to  give  food  by  the  mouth,  but  to  feed  entirely  by  enemata. 
Fragments  of  ice  may  be  given,  and  as  the  pain  and  distress  subside,  demul- 
cent drinks.     External  applications  of  cold  often  give  relief. 

A  chronic  form  of  oesophagitis  is  described,  but  this  results  usually  from 
the  prolonged  action  of  the  causes  which  produce  the  acute  form. 

Ulceration,  Catarrhal. — Follicular  ulcers  are  not  uncommon.  Tuberculous 
and  sj'philitic  ulcers  are  rare.  Very  prominent  varicose  veins  and  small  ero- 
sions are  not  uncommon.  The  other  forms  are  the  carcinomatous,  the  erosion 
due  to  aneurism,  and  the  ulcerative  action  of  corrosive  substances.  There  are 
two  other  important  varieties — the  ulcers  in  acute  infectious  diseases,  diph- 
theria, scarlet  fever,  and  pneumonia ;  and  the  peptic  ulcer  of  the  stomach,  first 
described  by  Albers  in  1839.  Tileston  has  collected  forty  cases  of  peptic 
ulcer  in  the  oesophagus.  The  pain,  dysphagia,  vomiting,  and  haemorrhage 
have  been  the  most  important  symptoms.  Perforation  occurred  in  six  cases, 
in  one  instance  into  the  aorta. 

(Esophageal  Varices. — Associated  with  chronic  heart-disease  and  more  fre- 
quently with  the  senile  and  the  cirrhotic  liver,  the  oesophageal  veins  may  be- 
come distended  and  varicose.  The  mucous  membrane  is  in  a  state  of  chronic 
catarrh,  and  the  patient  has  frequent  eructations  of  mucus.  Eupture  of  these 
varices  is  one  of  the  commonest  causes  of  hsematemesis  in  cirrhosis  of  the 
liver  and  in  enlarged  spleen.  The  blood  may  pass  per  rectum  alone,  as  in  a 
case  reported  by  Power,  of  Baltimore,  in  1839. 


DISEASES  OF  THE  (ESOPHAGUS.  453 


II.     SPASM    OF    THE    (ESOPHAGUS    (CEsophagismus). 

This  so-called  spasmodic  stricture  of  the  gullet  is  met  with  in  hysterical 
patients  and  hypochondriacs,  also  in  chorea,  epilepsy,  and  especially  hydro- 
phobia. It  is  sometimes  associated  also  with  the  lodgment  of  foreign  bodies. 
The  idiopathic  form  is  found  in  females  of  a  marked  neurotic  habit,  but  may 
also  occur  in  elderly  men.  It  may  be  present  only  during  pregnancy.  Among 
the  cases  which  have  come  under  my  observation,  one  was  a  hypochondriac 
over  sixty  years  of  age  who  for  many  months  had  taken  only  liquid  food,  and 
with  great  difficulty,  owing  to  a  spasm  which  accompanied  every  attempt  to 
swallow.  The  readiness  with  which  the  bougie  passed  and  the  subsequent 
history  showed  the  true  nature  of  the  case.  The  patient  complains  of  inability 
to  swallow  solid  food,  and  in  extreme  instances  even  liquids  are  rejected. 
The  attack  may  come  on  abruptly,  and  be  associated  with  emotional  disturb- 
ances and  with  substernal  pain.  The  bougie,  when  passed,  may  be  arrested 
temporarily  at  the  seat  of  the  spasm,  which  gradually  yields,  or  it  may  slip 
through  without  the  slightest  ejffiort.  The  condition  is  rarely  serious,  though 
it  may  persist  for  years.  Spasm  of  the  lower  end  of  the  gullet,  associated 
with  cardio-spasm,  may  be  the  cause  of  a  remarkable  fusiform  dilatation  of 
the  oesophagus.    Death  has,  however,  followed  it. 

The  diagnosis  is  not  difficult,  particularly  in  young  persons  with  marked 
nervous  manifestations.  In  elderly  persons  oesophagismus  is  almost  always 
connected  with  hypochondriasis,  but  great  care  must  be  taken  to  exclude 
cancer. 

In  some  cases  a  cure  is  at  once  effected  by  the  passage  of  a  bougie.  The 
general  neurotic  condition  also  requires  special  attention. 

Paralysis  of  the  oesophagus  scarcely  demands  separate  consideration.  It 
is  a  very  rare  condition,  due  most  often  to  central  disease,  particularly  bulbar 
paralysis.  It  may  be  peripheral  in  origin,  as  in  diphtheritic  paralysis.  Occa- 
sionally, it  occurs  also  in  hysteria.     The  essential  symptom  is  dysphagia. 

III.     STRICTURE    OF    THE    CESOPHAGUS. 

This  results  from;  (a)  Congenital  stenosis  of  the  oesophagus. — There  are 
two  groups  of  cases,  one  in  which  there  is  complete  occlusion,  and  the  middle 
of  the  tube  is  converted  into  a  fibrous  cord;  the  other,  the  more  common,  in 
which  the  lower  part  opens  into  the  trachea  or  one  of  the  bronchi.  There  are 
some  19  cases  on  record  (William  Thomas).  (&)  The  cicatricial  contraction 
of  healed  ulcers,  usually  due  to  corrosive  poisons,  occasionally  to  syphilis,  and 
in  rare  instances  after  the  fevers,  (c)  The  growth  of  tumors  in  the  walls, 
as  in  the  so-called  cancerous  stricture.  Eighty-five  per  cent  of  the  cases  are 
of  this  nature  (Kelynack  and  Anderson),  (d)  External  pressure  by  aneu- 
rism, enlarged  lymph-glands,  enlarged  thyroid,  other  tumors,  and  sometimes 
by  pericardial  effusion. 

The  cicatricial  stricture  may  occur  anywhere  in  the  gullet,  and  in  ex- 
treme cases  may,  indeed,  involve  the  whole  tube,  but  in  a  majority  of  in- 
stances it  is  found  either  high  up  near  the  pharjrnx  or  low  down  toward  the 
stomach.     The  narrowing  may  be  extreme,  so  that  only  small  quantities  of 


454  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

food  can  trickle  through,  or  the  obstruction  may  be  quite  slight.  There  is 
usually  no  difficulty  in  making  a  diagnosis  of  the  cicatricial  stricture,  as  the 
history  of  mechanical  injury  or  the  swallowing  of  a  corrosive  fluid  makes 
clear  the  nature  of  the  case.  When  the  stricture  is  low  down  the  oesophagus 
is  dilated  and  the  walls  are  usually  much  hypertrophied.  When  the  obstruc- 
tion is  high  in  the  gullet,  the  food  is  usually  rejected  at  once,  whereas,  if  it  is 
low,  it  may  be  retained  and  a  considerable  quantity  collects  before  it  is  re- 
gurgitated. Any  doubt  as  to  its  having  reached  the  stomach  is  removed  by 
the  alkalinity  of  the  material  ejected  and  the  absence  of  the  characteristic 
gastric  odor.  Auscultation  of  the  oesophagus  may  be  practised  and  is  some- 
times of  service.  The  patient  takes  a  mouthful  of  water  and  the  auscultator 
listens  along  the  left  of  the  spine.  The  normal  oesophageal  hruit  may  be 
heard  later  than  seven  seconds,  the  normal  time,  or  there  may  be  heard  a  loud 
splashing,  gurgling  sound.  The  secondary  murmur,  heard  as  the  fluid  enters 
the  stomach,  may  be  absent.  The  passage  of  the  oesophageal  bougie  will  deter- 
mine more  accurately  the  locality.  Conical  bougies  attached  to  a  flexible 
whalebone  stem  are  the  most  satisfactory,  but  the  gum-elastic  stomach  tube 
may  be  used;  a  large  one  should  be  tried  first.  The  patient  should  be  placed 
on  a  low  chair  with  the  head  well  thrown  back.  The  index  finger  of  the 
left  hand  is  passed  far  into  the  pharynx,  and  in  some  instances  this  procedure 
alone  may  determine  the  presence  of  a  new  growth.  The  bougie  is  passed 
beside  the  finger  until  it  touches  the  posterior  wall  of  the  pharynx,  then  along 
it,  more  to  one  side  than  in  the  middle  line,  and  so  gradually  pushed  into 
the  gullet.  It  is  to  be  borne  in  mind  that  in  passing  the  cricoid  cartilage  there 
is  often  a  slight  obstruction.  Great  gentleness  should  be  used,  as  it  has  hap- 
pened more  than  once  that  the  bougie  has  been  passed  through  a  cancerous 
ulcer  into  the  mediastinum  or  through  a  diverticulum.  I  have  known  this 
accident  to  happen  several  times — once  in  the  case  of  a  distinguished  surgeon, 
who  performed  oesophagotomy  and  passed  the  tube,  as  he  thought,  into  the 
stomach.  The  post  mortem  on  the  next  day  showed  that  the  tube  had  entered 
a  diverticulum  and  through  it  the  left  pleura,  in  which  the  milk  injected 
through  the  tube  was  found.  In  another  instance  the  tube  passed  through  a 
cancerous  ulcer  into  the  lung,  which  was  adherent  and  inflamed.  In  a  recent 
instance  the  passage  of  the  tube  was  the  cause  of  an  acute  pleurisy.  Fortu- 
nately these  accidents^  sometimes  unavoidable,  are  extremely  rare.  It  is  well 
always,  as  a  precautionary  measure  before  passing  the  bougie,  to  examine 
carefully  for  aneurism,  which  may  produce  all  the  symptoms  of  organic  stric- 
ture. In  cases  in  which  the  narrowing  is  extreme  there  is  always  emaciation. 
For  treatment,  surgical  works  must  be  consulted. 

IV.     CANCER    OF    THE    CESOPHAGXJS. 

This  is  usually  epithelioma.  It  is  not  a  common  disease;  there  have  been 
only  20  cases  in  the  medical  wards  of  the  Johns  Hopkins  Hospital  in  sixteen 
years.  It  may  occur  in  quite  young  persons;  I  saw  a  case  with  Julius  Fried- 
enwald  in  a  woman  under  thirty  years  of  age.  It  is  more  frequent  in  males 
than  in  females.  The  middle  and  lower  thirds  are  most  often  affected.  At 
first  confined  to  the  mucous  membrane,  the  cancer  gradually  increases  and 
soon  "ulcerates.     The  lumen  of  the  tube  is  narrowed,  but  when  ulceration  is 


DISEASES  OF  THE  (ESOPHAGUS.  455 

extensive  in  the  later  stages  the  stricture  may  be  less  marked.  Dilatation  of 
the  tube  and  hypertrophy  of  the  walls  usually  take  place  above  the  cancer. 
The  ulcer  may  perforate  the  trachea  or  a  bronchus,  the  lung,  the  pleura,  the 
mediastinum,  the  aorta  or  one  of  its  larger  branches,  the  pericardium,  or  it 
may  erode  the  vertebral  column.  The  recurrent  laryngeal  nerves  are  not 
infrequently  implicated.  Perforation  of  the  lung  produces,  as  a  rule,  local 
gangrene. 

Symptoms. — The  earliest  symptom  is  dysphagia,  which  is  progressive'  and 
may  become  extreme,  so  that  the  patient  emaciates  rapidly.  Regurgitation 
may  take  place  at  once;  or,  if  the  cancer  is  situated  near  the  stomach,  it  may 
be  deferred  for  ten  or  fifteen  minutes,  or  even  longer  if  the  tube  is  much 
dilated.  The  rejected  materials  may  be  mixed  with  blood  and  may  contain 
cancerous  fragments.  In  persons  over  fifty  years  of  age  persistent  difficulty 
in  swallowing  accompanied  by  rapid  emaciation  usually  indicates  oesophageal 
cancer.  The  cervical  lymph-glands  are  frequently  enlarged  and  may  give 
early  indication  of  the  nature  of  the  trouble.  Pain  may  be  persistent  or  be 
present  only  when  food  is  taken.  In  certain  instances  the  pain  is  very  great. 
The  latent  cases  are  very  rare.  Bronchitis  and  broncho-pneumonia  are  com- 
mon terminal  events. 

Prognosis. — The  prognosis  is  hopeless;  the  patients  usually  become  pro- 
gressively emaciated,  and  die  either  of  asthenia  or  sudden  perforation  of  the 
ulcer. 

Diagnosis. — In  the  diagnosis  of  the  condition  it  is  important,  in  the  first 
place,  to  exclude  pressure  from  without,  as  by  aneurism  or  other  tumor.  The 
history  enables  us  to  exclude  cicatricial  stricture  and  foreign  bodies.  The 
sound  may  be  passed  and  the  presence  of  the  stricture  determined.  As  men- 
tioned above,  great  care  should  be  exercised.  Fragments  of  carcinomatous 
tissue  may  in  some  instances  be  removed  with  the  tube.'  On  auscultation 
along  the  left  side  of  the  spine  the  primary  oesophageal  murmur  may  be  much 
altered  in  quality. 

Treatment. — In  most  cases  milk  and  liquids  can  be  swallowed,  but  supple- 
mentary nourishment  should  be  given  by  the  rectum.  It  may  be  advisable 
in  some  instances  to  pass  a  tube  into  the  stomach  and  introduce  food  in  this 
way.  When  there  is  difficulty  in  feeding  the  patient  it  is  very  much  better 
to  have  gastrostomy  performed  at  once,  as  it  gives  the  greatest  comfort  and 
ease,  and  prolongs  the  patient's  life. 

V.     RUPTURE    OF    THE    CESOPHAGUS. 

(1)  Rupture  may  occur  in  a  healthy  organ  as  a  result  of  prolonged  vomit- 
ing after  a  full  meal,  or  when  intoxicated.  Eight  cases  are  on  record  (Vir- 
chow's  Archiv,  vol.  162).  Boerhaave  described  the  first  case  in  Baron  Wassen- 
nar,  who  "  broke  asunder  the  tube  of  the  oesophagus  near  the  diaphragm,  so 
that,  after  the  most  excruciating  pain,  the  elements  which  he  swallowed  passed, 
together  with  the  air,  into  the  cavity  of  the  thorax,  and  he  expired  in  twenty- 
four  hours." 

(2)  In  a  few  cases  the  rupture  has  occurred  in  a  diseased  and  weakened 
tube,  near  the  scar  of  an  ulcer,  for  example. 

(3)  Post-mortem   softening — oesophago-malacia — a  not   very  uncommon 


456  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

condition,  must  not  be  mistaken  for  it.  In  spontaneous  rupture  the  rent 
is  clean-cut  and  circumferential;  in  malacia  it  is  rounded  and  often  cribri- 
form^ and  the  margins  are  softened.  The  contents  of  the  stomach  may  be 
in  the  left  pleura. 

VI.    DILATATIONS    AND    DIVERTICULA. 

Stenosis  of  the  gullet  is  followed  by  secondary  dilatation  of  the  tube  above 
the  constriction  and  great  hypertrophy  of  the  walls.  Primary  dilatation, 
which  is  extremel}^  rare,  appears  to  be  associated  with  spasm  of  the  lower 
end  of  the  gullet  and  of  the  cardiac  orifice.  The  tube  may  attain  extraor- 
dinary dimensions,  as  in  the  specimen  presented  in  1904  to  the  Association 
of  American  Physicians  by  Kinnicutt  (see  Transactions).  Eegurgitation  of 
food  is  the  most  common  symptom.  There  may  also  be  difficulty  in  breathing 
from  pressure. 

Diverticula  are  of  two  forms:  (a)  Pressure  diverticula,  which  are  most 
common  at  the  junction  of  the  pharynx  and  gullet,  on  the  posterior  wall. 
Owing  to  weakness  of  the  muscles  at  this  spot,  local  bulging  occurs,  which  is 
gradually  increased  by  the  pressure  of  food,  and  finally  forms  a  saccular 
pouch.  (&)  The  traction  diverticula  situated  on  the  anterior  wall  near  the 
bifurcation  of  the  trachea,  result,  as  a  rule,  from  the  extension  of  inflam- 
mation from  the  lymph-glands  with  adhesion  and  subsequent  cicatricial  con- 
traction, by  which  the  wall  of  the  gullet  is  drawn  out.  Diverticula  have  been 
successfully  extirpated. 

A  rare  and  remarkable  condition,  of  which  a  case  has  been  recorded  by 
MacLachlan,  and  of  which  a  second  is  still  (1904)  in  attendance  at  my  clinic, 
is  the  cesophago-pleuro-cutaneous  fistula.  In  my  patient  fluids  are  discharged 
at  intervals  through  a  fistula  in  the  right  infra-clavicular  region,  which 
appears  to  communicate  with  a  cavity  in  the  upper  part  of  the  pleura  or 
lung.     The  condition  has  persisted  for  more  than  twenty-five  years. 


F.    DISEASES  OE  THE   STOMACH. 

I.    ACUTE    GASTRITIS. 

(Simple  Gastritis ;  Acute  Gastric  Catarrh ;  Acute  Dyspepsia.) 

Etiology. — Acute  gastric  catarrh,  one  of  the  most  common  of  complaints, 
occurs  at  all  ages,  and  is  usually  traceable  to  errors  in  diet.  It  may  follow 
the  ingestion  of  more  food  than  the  stomach  can  digest,  or  it  may  result  from 
taking  unsuitable  articles,  which  either  themselves  irritate  the  mucosa  or, 
remaining  undigested,  decompose,  and  so  excite  an  acute  dyspepsia.  A  fre- 
quent cause  is  the  taking  of  food  which  has  begun  to  decompose,  particularly 
in  hot  weather.  In  children  these  fermentative  processes  are  very  apt  to 
excite  acute  catarrh  of  the  bowels  as  well.  Another  very  common  cause  is  the 
abuse  of  alcohol,  and  the  acute  gastritis  which  follows  a  drinking-bout  is 
one  of  the  most  typical  forms  of  the  disease.  The  tendency  to  acute  indi- 
gestion varies  very  much  in  difEerent  individuals,  and  indeed  in  families. 


DISEASES  OF   THE  STOMACH.  457 

We  recognize  this  in  using  the  expressions  a  "  delicate  stomach "  and  a 
"  strong  stomach."  Gouty  persons  are  generally  thought  to  be  more  disposed 
to  acute  dyspepsia  than  others.  Acute  catarrh  of  the  stomach  occurs  at  the 
outset  of  many  of  the  infectious  fevers. 

Lebert  described  a  special  infectious  form  of  gastric  catarrh,  occurring 
in  epidemic  form,  and  only  to  be  distinguished  from  mild  typhoid  fever  by 
the  absence  of  rose  spots  and  swelling  of  the  spleen.  Many  practitioners  still 
adhere  to  the  belief  that  there  is  a  form  of  gastric  fever,  but  the  evidence 
of  its  existence  is  by  no  means  satisfactory,  and  certainly  a  great  majority 
of  all  cases  are  examples  of  mild  typhoid. 

Morbid  Anatomy. — Beaumont's  study  of  St.  Martin's  stomach  showed 
that  in  acute  catarrh  the  mucous  membrane  is  reddened  and  swollen,  less 
gastric  juice  is  secreted,  and  mucus  covers  the  surface.  Slight  haemorrhages 
may  occur  or  even  small  erosions.  The  submucosa  may  be  somewhat  oedema- 
tous.  Microscopically  the  changes  are  chiefly  noticeable  in  the  mucous  and 
peptic  cells,  which  are  swollen  and  more  granular,  and  there  is  an  infiltration 
of  the  intertubular  tissue  with  leucocytes. 

Symptoms. — In  mild  cases  the  symptoms  are  those  of  slight  "  indigestion  " 
— an  uncomfortable  feeling  in  the  abdomen,  headache,  depression,  nausea, 
eructations,  and  vomiting,  which  usually  gives  relief.  The  tongue  is  heavily 
coated  and  the  saliva  is  increased.  In  children  there  are  intestinal  symptoms 
— diarrhoea  and  colicky  pains.  There  is  usually  no  fever.  The  duration  is 
rarely  more  than  twenty-four  hours.  In  the  severer  forms  the  attack  may 
set  in  with  a  chill  and  febrile  reaction,  in  which  the  temperature  rises  to 
103°  or  103°.  The  tongue  is  furred,  the  breath  heavy,  and  vomiting  is  fre- 
quent. The  ejected  substances,  at  first  mixed  with  food,  subsequently  con- 
tain much  mucus  and  bile-stained  fluids.  There  may  be  constipation,  but 
very  often  there  is  diarrhoea.  The  urine  presents  the  usual  febrile  charac- 
teristics, and  there  is  a  heavy  deposit  of  urates.  The  abdomen  may  be  some- 
what distended  and  slightly  tender  in  the  epigastric  region.  Herpes  may 
appear  on  the  lips.  The  attack  may  last  from  one  to  three  days,  and  occa- 
sionally longer.  The  examination  of  the  vomitus  shows,  as  a  rule,  absence 
of  the  hydrochloric  acid,  presence  of  lactic  and  fatty  acids,  and  marked 
increase  in  the  mucus. 

Diagnosis. — The  ordinary  afebrile  gastric  catarrh  is  readily  recognized. 
The  acute  febrile  form  is  so  similar  to  the  initial  symptoms  of  many  of  the 
infectious  diseases  that  it  is  impossible  for  a  day  or  two  to  make  a  diagnosis, 
particularly  in  the  cases  which  have  come  on,  so  to  speak,  spontaneously  and 
independently  of  an  error  in  diet.  Some  of  these  resemble  closely  an  acute 
infection;  the  symptoms  may  be  very  intense,  and  if,  as  sometimes  happens, 
the  attack  sets  in  with  severe  headache  and  delirium  the  case  may  be  mistaken 
for  meningitis.  When  the  abdominal  pains  are  intense  the  attack  may  be 
confounded  with  gallstone  colic.  In  discriminating  between  acute  febrile  gas- 
tritis and  the  abortive  forms  of  typhoid  fever  it  is  to  be  borne  in  mind  that 
in  the  former  the  temperature  rises  abruptly,  the  remissions  are  slighter,  and 
the  drop  is  more  sudden.  The  initial  bronchitis,  the  well-marked  splenic 
enlargement,  and  the  rose  spots  are  not  present.  It  is  a  very  common  error 
to  class  under  gastric  fever  the  mild  forms  of  the  various  infectious  disorders. 
The  gastric  crises  in  locomotor  ataxia  have  in  many  instances  been  confounded 


458  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

with  a  simple  acute  gastritis,  and  it  is  always  wise  in  adults  to  test  the  knee- 
jerks  and  pupillary  reactions. 

Treatment. — Mild  cases  recover  spontaneously  in  twenty-four  hours,  and 
require  no  treatment  other  than  a  dose  of  castor  oil  in  children  or  of  blue 
mass  in  adults.  In  the  severer  forms,  if  there  is  much  distress  in  the  region 
of  the  stomach,  the  vomiting  should  be  promoted  b}^  warm  water  or  the  simple 
emetics.  A  full  dose  of  calomel,  8  to  10  grains,  should  be  given,  and  followed 
the  next  morning  by  a  dose  of  Hunyadi-Janos  or  Carlsbad  water.  If  there 
is  eructation  of  acid  fluid,  bicarbonate  of  soda  and  bismuth  may  be  given. 
The  stomach  should  have,  if  possible,  absolute  rest,  and  it  is  a  good  plan  in 
the  case  of  strong  persons,  particularly  in  those  addicted  to  alcohol,  to  cut 
off  all  food  for  a  day  or  two.  The  patient  may  be  allowed  soda  water  and 
ice  freely.  It  is  well  not  to  attempt  to  check  the  vomiting  unless  it  is 
excessive  and  protracted.  Eecovery  is  usually  complete,  though  repeated 
attacks  may  lead  to  subacute  gastritis  or  to  the  establishment  of  chronic 
dyspepsia. 

Phleg-monoTis  Gastritis;  Acute  Suppurative  Gastritis. — This  is  an  ex- 
cessively rare  disease,  characterized  by  the  occurrence  of  suppurative  processes 
in  the  sub  mucosa.  The  affection  is  more  common  in  men  than  in  women. 
Leith  has  collected  85  cases,  and  has  given  the  best  account  in  the  literature 
(Edinburgh  Hospital  Reports,  vol.  iv).  The  cause  is  seldom  obvious.  It 
has  been  met  with  as  an  idiopathic  affection,  but  it  has  occurred  also  in 
puerperal  fever  and  other  septic  processes,  and  has  occasionally  followed 
trauma.  Anatomically  there  appear  to  be  two  forms,  a  diffuse  purulent 
infiltration  and  a  localized  abscess  formation,  in  which  case  the  tumor  may 
reach  the  size  of  an  egg,  and  may  burst  into  the  stomach  or  into  the  peri- 
toneal cavity.  In  two  of  the  cases  I  have  seen,  the  abscess  was  in  connection 
with  cancer  of  the  stomach,  and  it  is  interesting  to  note  that  in  both  there 
were  recurring  chills.  In  a  third  case,  in  a  diffuse  carcinoma,  there  was  ex- 
tensive phlegmonous  inflammation  with  vomiting  of  a  horribly  foetid  material. 

Symptoms. — The  symptoms  are  variable.  There  are  usually  pain  in  the 
abdomen,  fever,  dry  tongue,  and  symptoms  of  a  severe  infective  process,  de- 
lirium and  coma  preceding  death.  Jaundice  has  been  met  with,  and  a  pur- 
puric rash.  Occasionally,  when  the  abscess  tumor  is  large,  it  has  been  felt 
externally,  in  one  case  forming  a  mass  as  large  as  two  fists.  There  are  in- 
stances which  run  a  more  chronic  course,  with  pains  in  the  abdomen,  fever, 
and  chills. 

Diagnosis. — The  diagnosis  is  rarely  possible,  even  when  with  abscess  rup- 
ture occurs,  and  the  pus  is  vomited,  as  it  is  not  possible  to  differentiate  the 
condition  from  an  abscess  perforating  into  the  stomach  from  without.  It  is 
stated,  however,  that  Chvostek  made  the  diagnosis  in  one  of  his  cases. 

Toxic  Gastritis. — This  most  intense  form  of  inflammation  of  the  stomach 
is  excited  by  the  swallowing  of  concentrated  mineral  acids  or  strong  alkalies, 
or  by  such  poisons  as  phosphorus,  corrosive  sublimate,  ammonia,  arsenic,  etc. 
In  the  non-corrosive  poisons,  such  as  phosphorus,  arsenic,  and  antimony,  the 
process  consists  of  an  acute  degeneration  of  the  glandular  elements,  and  haem- 
orrhage. In  the  powerful  concentrated  poisons  the  mucous  membrane  is  exten- 
sively destroyed,  and  may  be  converted  into  a  brownish-black  eschar.  In 
the  less  severe  grades  there  may  be  areas  of  necrosis  surrounded  by  inflam- 


DISEASES  OF  THE  STOMACH.  459 

matory  reaction,  while  the  submucosa  is  hsemorrhagic  and  infiltrated.  The 
process  is  of  course  more  intense  at  the  fundus,  but  the  active  peristalsis  may 
drive  the  poison  through  the  pylorus  into  the  intestine. 

Symptoms. — Tlie  symptoms  are  intense  pain  in  the  mouth,  throat,  and 
stomach,  salivation,  great  difficulty  in  swallowing,  and  constant  vomiting,  the 
vomited  materials  being  bloody  and  sometimes  containing  portions  of  the 
mucous  membrane.  The  abdomen  is  tender,  distended,  and  painful  on  pres- 
sure. In  the  most  acute  cases  symptoms  of  collapse  supervene;  the  pulse  is 
weak,  the  skin  pale  and  covered  with  sweat;  there  is  restlessness,  and  some- 
times convulsions.  There  may  be  albumin  or  blood  in  the  urine,  and  petechise 
may  occur  on  the  skin.  When  the  poison  is  less  intense,  the  sloughs  may 
separate,  leaving  ulcers,  which  too  often  lead,  in  the  oesophagus  to  stricture, 
in  the  stomach  to  chronic  atrophy,  and  finally  to  death  from  exhaustion. 

Diagnosis. — The  diagnosis  of  toxic  gastritis  is  usually  easy,  as  inspection 
of  the  mouth  and  pharynx  shows,  in  man}^  instances,  corrosive  effects,  while 
the  examination  of  the  vomit  may  indicate  the  nature  of  the  poison. 

In  poisoning  by  acids,  magnesia  should  be  administered  in  milk  or  with 
egg  albumen.  When  strong  alkalies  have  been  taken,  the  dilute  acids  should 
be  administered.  If  the  case  is  seen  early,  lavage  should  be  used.  For  the 
severe  inflammation  which  follows  the  swallowing  of  the  stronger  poisons 
palliative  treatment  is  alone  available,  and  morphia  may  be  freely  employed 
to  allay  the  pain. 

Diphtheritic  or  Membranous  Gastritis. — This  condition  is  met  with  occa- 
sionally in  diphtheria,  but  more  commonly  as  a  secondary  process  in  typhus 
or  typhoid  fever,  pneumonia,  pyaemia,  small-pox,  and  occasionally  in  debili- 
tated children.  The  exudation  may  be  extensive  and  uniform  or  in  patches. 
The  condition  is  not  recognizable  during  life,  unless,  as  in  a  case  of  John 
Thomson's,  the  membranes  are  vomited. 

Mycotic  and  Parasitic  Gastritis. — It  occasionally  happens  that  fungi  grow 
in  the  stomach  and  excite  inflammation.  One  of  the  most  remarkable  cases 
of  the  kind  is  that  reported  by  Kundrat,  in  which  the  favus  fungus  occurred 
in  the  stomach  and  intestine. 

In  cancer  and  in  dilatation  of  the  stomach  the  sarcin^  and  yeast  fungi 
probably  aid  in  maintaining  the  chronic  gastritis.  As  a  rule,  the  gastric 
juice  is  capable  of  killing  the  ordinary  bacteria.  Orth  states  that  the  anthrax 
bacilli,  in  certain  cases,  produce  swelling  of  the  mucosa  and  ulceration. 
Eug.  Fraenkel  has  reported  a  case  of  acute  emphysematous  gastritis  probably 
of  mycotic  origin.  The  larvae, of  certain  insects  may  excite  gastritis,  as  in  the 
cases  reported  by  Gerhardt,  Meschede,  and  others.  In  rare  instances  tuber- 
culosis and  syphilis  attack  the  gastric  mucosa. 

II.     CHRONIC    GASTRITIS. 

(Chronic  Catarrh  of  the  Stomach ;   Chronic  Dyspepsia.) 

Definition. — A  condition  of  disturbed  digestion  associated  with  increased 
mucous  formation,  qualitative  or  quantitative  changes  in  the  gastric  juice, 
enfeeblement  of  the  muscular  coats,  so  that  the  food  is  retained  for  an  ab- 
normal time  in  the  stomach;  and,  finally,  with  alterations  in  the  structure 
of  the  mucosa. 


460  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

Etiology. — The  causes  of  chronic  gastritis  may  be  classified  as  follows: 
(1)  Dietetic.  Unsuitable  or  improperly  prepared,  food,  and  the  persistent 
use  of  certain  articles  of  diet,  such  as  very  fat  substances  or  foods  containing 
too  much  of  the  carbohydrates.  The  use  in  excessive  quantit}^  of  hot  bread, 
hot  cakes,  and  pie  is  a  fruitful  cause,  particular!}-  in  the  United  States.  The 
use  in  excess  of  tea  or  coffee,  and,  above  all,  of  alcohol  in  its  various  forms. 
Under  this  heading,  too,  may  be  mentioned  the  habits  of  eating  at  irregular 
hours  or  too  rapidly  and  imperfectly  chewing  the  food.  Excess  in  eating 
does  more  damage  than  excess  in  drinking.  The  platter  kills  more  than  the 
sword.  A  common  cause  of  chronic  catarrh  is  drinking  too  freely  of  ice- 
water  during  meals,  a  practice  which  plays  no  small  part  in  the  prevalence 
of  dyspepsia  in  America.  Another  frequent  cause  is  the  abuse  of  tobacco, 
particularly  chewing.  (2)  Constitutional  causes.  Ana?mia,  chlorosis,  chronic 
tuberculosis,  gout,  diabetes,  and  Bright's  disease  are  often  associated  with 
chronic  gastric  catarrh.  (3)  Local  conditions:  (a)  of  the  stomach,  as  in 
cancer,  ulcer,  and  dilatation,  which  are  invariably  accompanied  by  catarrh; 
(&)  conditions  of  the  portal  circulation,  causing  chronic  engorgement  of  the 
mucous  membrane,  as  in  cirrhosis,  chronic  heart-disease,  and  certain  chronic 
lung  affections. 

Morbid  Anatomy. — Anatomically  two  forms  of  chronic  gastritis  may  be 
recognized,  the  simple  and  the  sclerotic. 

(a)  Simple  Chroxic  Gastritis. — The  organ  is  usually  enlarged,  the 
mucous  membrane  pale  gray  in  color,  and  covered  with  closely  adherent, 
tenacious  mucus.  The  veins  are  large,  patches  of  ecchymosis  are  not  infre- 
quently seen,  and  in  the  chronic  catarrh  of  portal  obstruction  and  of  chronic 
heart-disease  small  hgemorrhagic  erosions.  Toward  the  pylorus  the  mucosa 
is  not  infrequently  irregularly  pigmented,  and  presents  a  rough,  wrinkled, 
mammillated  surface,  the  etat  mamelone  of  the  French,  a  condition  which 
may  sometimes  be  so  prominent  that  writers  have  described  it  as  gastritis 
polyposa.  The  membrane  may  be  thinner  than  normal,  and  much  firmer, 
tearing  less  readily  with  the  finger-nail.  Ewald  thus  describes  the  histolog- 
ical changes:  The  minute  anatomy  shows  the  picture  of  a  parenchymatous 
and  an  interstitial  inflammation.  The  gland  cells  are  in  part  eroded  or  show 
cloudy  granular  swelling  or  atrophy.  The  distinction  between  the  principal 
and  marginal  cells  can  not  be  recognized,  and  in  many  places,  particularly  in 
the  pyloric  region,  the  tubes  have  lost  their  regular  form  and  show  in  many 
places  an  atypical  branching,  like  the  fingers  of  a  glove.  Individual  glands 
are  cut  off  toward  the  fundus,  but  appear  at  the  border  of  the  submucosa  as 
cysts,  partly  empty,  with  a  smooth  membrane,  partly  filled  with  remnants 
of  hyaline  and  retractile  epithelium.  An  abundant  small-celled  infiltration 
presses  apart  the  tubules,  being  particularly  marked  toward  the  surface  of 
the  mucosa,  and  from  the  submucosa  extensions  of  the  connective  tissue  may 
be  seen  passing  between  the  glands.  The  mucoid  transformation  of  the  cells 
of  the  tubules  is  a  striking  feature  in  the  process  and  may  extend  to  the 
very  fundus  of  the  glands. 

(&)  Sclerotic  Gastritis. — As  a  final  result  of  the  parench}Tnatous  and 
interstitial  changes  the  mucous  membrane  may  undergo  complete  atrophy, 
so  that  but  few  traces  of  secreting  substance  remain.  There  appear  to  be 
two  forms  of  this  sclerotic  atrophy — one  with  thiiming  of  the  coats  of  the 


DISEASES  OF   THE  STOMACH.  461 

stomachy  phthisis  ventriculi,  and  a  retention  or  even  increase  of  the  size  of 
the  organ;  the  other  with  enormous  thickening  of  the  coats  and  great  reduc- 
tion in  the  volume  of  the  organ,  the  condition  which  is  usually  described  as 
cirrJwsis  ventriculi.  Extreme  atrophy  of  the  mucous  membrane  of  the  stom- 
ach has  been  carefully  studied  by  Fenwick,  Ewald,  and  others,  and  we  now 
recognize  the  fact  that  there  may  be  such  destruction  and  degeneration  of  the 
glandular  elements  by  a  progressive  growth  of  interstitial  tissue  that  ulti- 
mately scarcely  a  trace  of  secreting  tissue  remains.  In  a  characteristic  dase, 
studied  by  Henry  and  myself,  the  greater  portion  of  the  lining  membrane 
of  the  stomach  was  converted  into  a  perfectly  smooth,  cuticular  structure, 
showing  no  trace  whatever  of  glandular  elements,  with  enormous  hypertrophy 
of  the  muscularis  mucosaB,  and  here  and  there  formation  of  cysts.  In  the 
other  form,  with  identical  atrophy  and  cyst  formation,  there  is  enormous 
increase  in  the  connective  tissue,  and  the  stomach  may  be  so  contracted  that 
it  does  not  hold  more  than  a  couple  of  ounces.  The  walls  may  measure  from 
2  to  3  cm.;  the  greatest  increase  in  thickness  is  in  the  submucosa,  but  the 
hypertrophy  also  extends  to  the  muscular  layers.  A  similar  affection  may 
coexist  in  the  caecum  and  colon.  The  condition  may  be  difficult  to  distinguish 
from  diffuse  carcinoma.  There  may  be  also  proliferative  peritonitis,  with 
perihepatitis,  perisplenitis,  and  ascites.  While  one  is  not  justified  in  saying 
that  all  cases  of  cirrhosis  of  the  stomach  represent  a  final  stage  in  the  history 
of  a  chronic  catarrh,  it  is  true  that  in  most  cases  the  process  is  associated 
with  atrophy  of  the  gastric  mucosa,  while  the  history  indicates  the  existence 
of  chronic  dyspepsia. 

Symptoms. — The  affection  persists  for  an  indefinite  period,  and,  as  is  the 
case  with  most  chronic  diseases,  changes  from  time  to  time.  The  appetite 
is  variable,  sometimes  greatly  impaired,  at  others  very  good.  Among  early 
symptoms  are  feelings  of  distress  or  oppression  after  eating,  which  may  be- 
come aggravated  and  amount  to  actual  pain.  When  the  stomach  is  empty 
there  may  also  be  a  painful  feeling.  The  pain  differs  in  different  cases,  and 
may  be  trifling  or  of  extreme  severity.  When  localized  and  felt  beneath  the 
sternum  or  in  the  precordial  region  it  is  known  as  heart-burn  or  sometimes 
cardialgia.  There  is  pain  on  pressure  over  the  stomach,  usually  diffuse  and 
not  severe.  The  tongue  is  coated,  and  the  patient  complains  of  a  bad  taste  in 
the  mouth.  The  tip  and  margin  of  the  tongue  are  very  often  red.  Associated 
with  this  catarrhal  stomatitis  there  may  be  an  increase  in  the  salivary  and 
pharyngeal  secretions.  Nausea  is  an  early  symptom,  and  is  particularly  apt 
to  occur  in  the  morning  hours.  It  is  not,  however,  nearly  so  constant  a  symp- 
tom in  chronic  gastritis  as  in  cancer  of  the  stomach,  and  in  mild  grades  of  the 
affection  it  may  not  occur  at  all.  Eructation  of  gas,  which  may  continue  for 
some  hours  after  taking  food,  is  a  very  prominent  feature  in  cases  of  so-called 
flatulent  dyspepsia,  and  there  may  be  marked  distention  of  the  intestines. 
With  the  gas,  bitter  fluids  may  be  brought  up.  Vomiting,  which  is  not  very 
frequent,  occurs  either  immediately  after  eating  or  an  hour  or  two  later. 
In  the  chronic  catarrh  of  old  topers  a  bout  of  morning  vomiting  is  common, 
in  which  a  slimy  mucus  is  brought  up.  The  vomitus  consists  of  food  in 
various  stages  of  digestion  and  slimy  mucus,  and  the  chemical  examination 
shows  the  presence  of  abnormal  acids,  such  as  butyric,  or  even  acetic,  in 
addition  to  lactic  acid,  while  the  hydrochloric  acid,  if  indeed  it  be  present. 


462  DISEASES  OF   THE  DIGESTIVE  SYSTEM. 

is  ranch  reduced  in  quantity.  The  digestion  may  be  much  delayed,  and  on 
washing  out  the  stomach  as  late  as  seven  hours  after  eating,  portions  of  food 
are  still  present.  The  prolonged  retention  favors  decomposition,  the  stomach 
becomes  distended  with  gas,  and  this,  with  the  chronic  catarrh,  may  induce 
gradually  an  atony  of  the  muscular  walls.  The  absorption  is  slow,  and 
iodide  of  potassium,  given  in  capsules,  which  should  normally  reach  the  saliva 
within  fifteen  minutes,  may  not  be  evident  for  more  than  half  an  hour. 

Constipation  is  usually  present,  but  in  some  instances  there  is  diarrhoea, 
and  undigested  food  passes  rapidly  through  the  bowels.  The  urine  is  often 
scanty,  high-colored,  and  deposits  a  heavy  sediment  of  urates. 

Of  other  symptoms  headache  is  common,  and  the  patient  feels  constantly 
out  of  sorts,  indisposed  for  exertion,  and  low-spirited.  In  aggravated  cases 
melancholia  may  occur.  Trousseau  called  attention  to  the  occurrence  of 
vertigo,  a  marked  feature  in  certain  cases.  The  j)ulse  is  small,  sometimes 
slow,  and  there  may  be  palpitation  of  the  heart.  Fever  does  not  occur. 
Cough  is  sometimes  present,  but  the  so-called  stomach  cough  of  chronic 
dyspeptics  is  in  all  probability'  dependent  upon  pharvngeal  irritation. 

The  Gastric  Contents. — The  fasting  stomach  may  be  empty  or  it  may 
contain  much  mucus — gastritis  mucipara  of  Boas.  In  the  test  breakfast, 
withdrawn  in  an  hour,  the  HCl  is  usually  diminished,  though  it  may  be  nor- 
mal— gastritis  acida.  In  other  cases  the  free  HCl  may  be  absent — gastritis 
anacida.  While  in  the  advanced  forms  of  atrophy  of  the  mucosa  there  may 
be  neither  acids  nor  ferments — gastritis  atrophicans. 

The  motor  function  of  the  stomach  is  not  usually  much  impaired. 

The  s}Tnptoms  of  atrophy  of  the  mucous  membrane  of  the  stomach,  with 
or  without  contraction  of  the  organ,  are  very  complex,  and  can  not  be  said 
to  present  a  uniform  picture.  The  majority  of  the  cases  present  the  S}Tnp- 
toms  of  an  aggravated  chronic  dyspepsia,  often  of  suc"h  severity  that  cancer 
is  suspected.  In  one  of  the  cases  which  I  examined,  the  persistent  distress 
after  eating,  the  vomiting,  and  the  gradual  loss  of  flesh  and  strength,  very 
naturally  led  to  this  diagnosis,  but  the  duration  of  the  disease  far  exceeded 
that  of  ordinary  carcinoma.  In  the  cirrhotic  form  the  tumor  mass  may  some- 
times be  felt.  In  atrophy  of  the  stomach,  whether  associated  with  cirrhosis 
or  not,  the  clinical  picture  may  be  that  of  a  severe  anaemia.  As  early  as 
1860,  Flint  called  attention  to  this  connection  between  atrophy  of  the  gastric 
tubules  and  anaemia,  an  observation  which  Fenwick  and  others  have  amply 
confirmed. 

Diagnosis. — Ewald  distinguishes  three  forms  of  chronic  gastritis:  (1) 
Simple  gastritis ;  (2)  mucous  (sclileimige)  gastritis;  (3)  atrophic  gastritis. 

In  (1)  the  fasting  stomach  contains  only  a  small  quantity  of  a  slimy 
fluid,  while  after  the  test  breakfast  the  HCl  is  diminished  in  quantity  or 
may  be  absent.  Lactic  acid  and  the  fatty  acids  may  be  present.  After  Boas's 
more  rigid  test  meal  the  organic  acids  are  rarely  found.  The  pepsin  and 
rennet  are  always  present. 

In  (2)  the  acidit}'  is  always  slight  and  the  condition  is  distinguished  from 
(1)  chiefly  by  the  large  amount  of  mucus  present. 

In  (3)  the  fasting  stomach  is  generally  empty,  while  after  the  test  break- 
fast HCl,  pepsin,  and  the  curdling  ferment  are  wholly  wanting. 

The  diagnosis  of  cancer  of  the  stomach  from  chronic  gastritis  may  be  very 


DISEASES  OF  THE  STOMACH.  463 

difficult  when  a  tumor  is  not  present.  The  cases  require  most  careful  study, 
and  it  may  take  several  months  before  a  decision  can  be  reached. 

Treatment. — When  possible  the  cause  in  each  case  should  be  ascertained 
and  an  attempt  made  to  determine  the  special  form  of  indigestion.  Usually 
there  is  no  difficulty  in  differentiating  the  ordinary  catarrhal  and  the  nervous 
varieties,  A  careful  study  of  the  phenomena  of  digestion  in  the  way  already 
laid  down,  though  not  essential  in  every  instance,  should  certainly  be  carried 
out  in  the  more  obstinate  and  obscure  forms.  Two  important  questions  should 
be  asked  of  every  dyspeptic — first,  as  to- the  time  taken  at  his  meals;  and, 
second,  as  to  the  quantity  he  eats.  Practically  a  large  majority  of  all  cases 
of  disturbed  digestion  come  from  hasty  and  imperfect  mastication  of  the  food 
and  from  overeating.  Especial  stress  should  be  laid  upon  the  former  point. 
In  some  instances  it  will  alone  suffice  to  cure  dyspepsia  if  the  patient  will 
count  a  certain  nmnber  before  swallowing  each  mouthful.  The  second  point 
is  of  even  greater  importance.  People  habitually  eat  too  much,  and  it  is 
probably  true  that  a  greater  number  of  maladies  arise  from  excess  in  eating 
than  from  excess  in  drinking.  Chittenden's  researches  have  shown  that  we 
require  much  less  nitrogenous  food  to  maintain  a  standard  of  perfect  health 
— a  lesson  that  the  Hindoos  and  Japanese  have  also  taught  us.  George 
Cheyne's  thirteenth  aphorism  contains  a  volume  of  dietetic  wisdom :  "  Every 
wise  man,  after  Fifty,  ought  to  begin  to  lessen  at  least  the  quantity  of  his 
Aliment,  and  if  he  would  continue  free  of  great  and  dangerous  Distempers 
and  preserve  his  Senses  and  Faculties  clear  to  the  last  he  ought  every  seven 
years  go  on  abateing  gradually  and  sensibly,  and  at  last  descend  out  of  Life 
as  he  ascended  into  it,  even  into  the  Child's  Diet." 

(a)  General  and  Dietetic. — A  careful  and  systematically  arjanged  diet- 
ary is  the  first,  sometimes  the  only,  essential  in  the  treatment  of  a  case  of 
chronic  dyspepsia.  It  is  impossible  to  lay  down  rules  applicable  to  all  cases. 
Individuals  differ  extraordinarily  in  their  capability  of  digesting  different 
articles  of  food,  and  there  is  much  truth  in  the  old  adage,  "  One  man's  food 
is  another  man's  poison."  The  individual  preferences  for  different  articles 
of  food  should  be  permitted  in  the  milder  forms.  Physicians  have  probably 
been  too  arbitrary  in  this  direction,  and  have  not  yielded  sufficiently  to  the 
intimations  given  by  the  appetite  and  desires  of  the  patient. 

A  rigid  milk  diet  may  be  tried.  "  Milk  and  sweet  sound  Blood  differ  in 
nothing  but  in  Color:  MilTc  is  Blood"  (George  Che3me).  In  the  forms  asso- 
ciated with  Bright's  disease  and  chronic  portal  congestion,  as  well  as  in  many 
instances  in  which  the  d3^spepsia  is  part  of  a  neurasthenic  or  hysterical  trouble, 
this  plan  in  conjunction  with  rest  is  most  efficacious.  If  milk  is  not  digested 
well  it  may  be  diluted  one-third  with  soda  water  or  Vichy,  or  5  to  10  grains 
of  carbonate  of  soda,  or  a  pinch  of  salt  may  be  added  to  each  tumblerful.  In 
many  cases  the  milk  from  which  the  cream  has  been  taken  is  better  borne. 
Buttermilk  is  particularly  suitable,  but  can  rarely  be  taken  for  so  long  a  time 
alone,  as  patients  tire  of  it  much  more  readily  than  they  do  of  ordinary  milk. 
ISTot  only  can  the  general  nutrition  be  maintained  on  this  diet,  but  patients 
sometimes  increase  in  weight,  and  the  unpleasant  gastric  symptoms  disappear 
entirely.  It  should  be  given  at  fixed  hours  and  in  definite  quantities.  A  pa- 
tient may  take  6  or  8  ounces  every  three  hours.  The  amount  necessary  varies 
a  good  deal,  but  at  least  3  to  5  pints  should  be  given  in  the  twenty-four  hours. 


464  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

This  form  of  diet  is  not,  as  a  rule,  well  borne  when  there  is  a  tendency  to 
dilatation  of  the  stomach.  The  milk  may  be  previously  peptonized,  Imt  it  is 
impossible  to  feed  a  chronic  dyspeptic  in  this  way.  The  stools  should  be 
carefully  watched,  and  if  more  milk  is  taken  than  can  be  digested  it  is  well 
to  supplement  the  diet  with  eggs  and  dry  toast  or  biscuits. 

In  a  large  proportion  of  the  cases  of  chronic  indigestion  it  is  not  necessary 
to  annoy  the  patient  with  such  strict  dietaries.  It  may  be  quite  sufficient  to 
cut  off  certain  articles  of  food.  Thus,  if  there  are  acid  eructations  or  flatu- 
lency, the  farinaceous  foods  should  be  restricted,  particularly  potatoes  and 
the  coarser  vegetables.  A  fruitful  source  of  indigestion  is  the  hot  bread  which, 
in  different  forms,  is  regarded  as  an  essential  part  of  an  American  breakfast. 
This,  as  well  as  the  various  forms  of  pancakes,  pies  and  tarts,  with  heavy 
pastry,  and  fried  articles  of  all  sorts,  should  be  strictly  forbidden.  As  a  rule, 
white  bread,  toasted,  is  more  readily  digested  than  bread  made  from  the  whole 
meal.  Persons,  however,  differ  very  much  in  this  respect,  and  the  Graham 
or  brown  bread  is  for  many  people  most  digestible.  Sugar  and  very  sweet 
articles  of  food  should  be  taken  in  great  moderation  or  avoided  altogether 
by  persons  with  chronic  dyspepsia.  Many  instances  of  aggravated  indigestion 
have  come  to  my  notice  due  to  the  prevalent  practice  of  eating  largely  of 
ice-cream.  One  of  the  most  powerful  enemies  of  the  American  stomach  in 
the  present  day  is  the  soda-water  fountain,  which  has  usurped  so  important 
a  place  in  the  apothecary  shop. 

Fats,  with  the  exception  of  a  moderate  amount  of  good  butter,  very  fat 
meats,  and  thick,  greasy  soups  should  be  avoided.  Ripe  fruit  in  moderation 
is  often  advantageous,  particularly  when  cooked.  Bananas  are  not,  as  a  rule, 
well  borne.  ■  Strawberries  are  to  many  persons  a  cause  of  an  annual  attack  of 
indigestion  and  sore  throat  in  the  spring  months. 

As  stated,  in  the  matter  of  special  articles  of  food  it  is  impossible  to  lay 
do"v\Ti  rigid  rules,  and  it  is  the  common  experience  that  one  patient  with 
indigestion  will  take  with  impunity  the  very  articles  which  cause  the  greatest 
distress  to  another. 

Another  detail  of  importance  which  may  be  mentioned  in  this  connection 
is  the  general  hygienic  management  of  dyspeptics.  These  patients  are  often 
introspective,  dwelling  in  a  morbid  manner  on  their  symptoms,  and  much 
inclined  to  take  a  despondent  view  of  their  condition.  Very  little  progress 
can  be  made  unless  the  physician  gains  their  confidence  from  the  outset. 
Their  fears  and  whims  should  not  be  made  too  light  of  or  ridiculed.  Sys- 
tematic exercise,  carefully  regulated,  particularly  when,  as  at  watering  places, 
it  is  combined  with  a  restricted  diet,  is  of  special  service.  Change  of  air  and 
occupation,  a  prolonged  sea  voyage,  or  a  summer  in  the  mountains  will  some- 
times cure  the  most  obstinate  dyspepsia. 

(&)  Medicinal. — The  special  therapeutic  measures  may  be  divided  into 
those  which  attempt  to  replace  in  the  digestive  juices  important  elements 
which  are  lacking  and  those  which  stimulate  the  weakened  action  of  the  organ. 
In  the  first  group  come  the  hydrochloric  acid  and  ferments,  which  are  so 
freely  employed  in  dyspepsia.  The  former  is  the  most  important.  It  is  the 
ingredient  in  the  gastric  juice  most  commonly  deficient.  It  is  not  only  neces- 
sary for  its  own  important  actions,  but  its  presence  is  intimately  associated 
with  that  of  the  pepsin,  as  it  is  only  in  the  presence  of  a  sufficient  quantity 


DISEASES  OF  THE  STOMACH.  465 

that  the  pepsinogen  is  converted  into  the  active  digestive  ferment.  It  is  best 
given. as  the  dilute  acid  taken  in  somewhat  larger  quantities  than  are  usually 
advised.  Ewald  recommends  large  doses — of  from  90  to  100  drops — at  in- 
tervals of  fifteen  minutes  after  the  meals.  Leube  and  Kiegel  advise  smaller 
doses.  Probably  from  15  to  20  drops  is  sufficient.  The  prolonged  use  of  it 
does  not  appear  to  be  in  any  way  hurtful.  The  use,  however,  should  be  re- 
stricted to  cases  of  neurosis  and  atrophy  of  the  mucous  membrane.  In  actual 
gastritis  its  value  is  doubtful. 

Nitrate  of  silver  is  a  good  remedy  in  some  cases,  used  in  solution  in  the 
lavage  (1  to  1,500  or  1  to  2,000),  or  in  pill  form,  one-eighth  to  one- fourth 
of  a  grain  three  times  a  day.  For  many  years  Pepper  advocated  the  more 
extended  use  of  this  drug  in  chronic  gastritis.  I  have  seen  an  instance  of 
argyria  after  its  protracted  use. 

The  digestive  ferments :  These  are  extensively  employed  to  strengthen  the 
weakened  gastric  and  intestinal  secretions.  The  use  of  pepsin,  according  to 
Ewald,  may  be  limited  to  the  cases  of  advanced  mucous  catarrh  and  the  in- 
stances of  atrophy  of  the  stomach,  in  which  it  should  be  given,  in  doses  of 
from  10  to  15  grains,  with  dilute  hydrochloric  acid  a  quarter  of  an  hour  after 
meals.  It  may  be  used  in  various  different  forms,  either  as  a  powder  or  in 
solution  or  given  with  the  acid.     The  powder  is  much  more  certain. 

Pancreatin  is  of  equal  or  even  greater  value  than  the  pepsin.  Pains 
should  be  taken  to  use  a  good  article,  such  as  that  prepared  by  Merck.  It 
should  be  given  in  doses  of  from  15  to  20  grains,  in  combination  with  bicar- 
bonate of  soda.  It  is  conveniently  administered  in  tablets,  each  of  which 
contains  5  grains  of  the  pancreatin  and  the  soda,  and  of  these  two  or  three 
may  be  taken  fifteen  or  twenty  minutes  after  each  meal.  Ptyalin  and  diastase 
are  particularly  indicated  when  the  acid  is  excessive.  The  action  of  the 
former  continues  in  the  stomach  during  normal  digestion.  The  malt  diastase 
is  often  very  serviceable  given  with  alkalies. 

Of  measures  which  stimulate  the  glandular  activity  in  chronic  dyspepsia 
lavage  is  by  far  the  most  important,  particularly  in  the  forms  characterizied 
by  the  secretion  of  a  large  quantity  of  mucus.  Lukewarm  water  should  be 
used,  or,  if  there  is  much  mucus,  a  1-per-cent  salt  solution,  or  a  S-  to  5-per- 
cent solution  of  bicarbonate  of  soda.  If  there  is  much  fermentation  the 
3-per-cent  solution  of  boric  acid  may  be  used,  or  a  dilute  solution  of  carbolic 
acid.  It  is  best  employed  in  the  morning  on  an  empty  stomach,  or  in  the 
evening  some  hours  after  the  last  meal.  It  is  perhaps  preferable  in  the  morn- 
ing, except  in  those  cases  in  which  there  is  much  nocturnal  distress  and  flatu- 
lency. Once  a  day  is,  as  a  rule,  sufficient,  or,  in  the  ease  of  delicate  persons, 
every  second  day.  The  irrigation  may  be  continued  until  the  water  which 
comes  away  is  quite  clear.  It  is  not  necessary  to  remove  all  the  fluid  after 
the  irrigation. 

While  perhaps  in  some  hands  this  measure  has  been  carried  to  extremes, 
it  is  one  of  such  extraordinary  value  in  certain  cases  that  it  should  be  more 
widely  employed  by  practitioners.  When  there  is  an  insuperable  objection  to 
lavage  a  substitute  may  be  used  in  the  form  of  warm  alkaline  drinks,  taken 
slowly  in  the  early  morning  or  the  last  thing  at  night. 

Of  medicines  which  stimulate  the  gastric  secretion  the  most  important  are 
the  bitter  tonics,  such  as  quassia,  gentian,  calumba,  cundurango,  ipecacuanha, 
81 


466  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

strychnia,  and  cardamoms.  These  are  probably  of  more  value  in  chronic  gas- 
tritis than  the  hydrochloric  acid.  Of  these  stryclmia  is  the  most  powerful, 
though  none  of  them  have  probably  any  very  great  stimulating  action  on  the 
secretion,  and  influence  rather  the  appetite  than  the  digestion.  Of  stomachics 
which  are  believed  to  favorably  influence  digestion  the  most  important  are 
alcohol  and  common  salt.  The  former  would  appear  to  act  in  moderate  quan- 
tities by  increasing  the  acid  in  the  gastric  juice,  and  with  it  probably  the 
pepsin  formation.  Others  hold  that  it  is  not  so  much  the  secretory  as  the 
motor  function  of  the  stomach  which  the  alcohol  stimulates.  In  moderate 
quantities  it  has  certainly  no  directly  injurious  influence  on  the  digestive 
processes.  Special  care  should  be  taken,  however,  in  ordering  alcohol  to  dys- 
peptics. If  a  patient  has  been  in  the  habit  of  taking  beer  or  light  wines  or 
stimulants  with  his  meals,  the  practice  may  be  continued  if  moderate  quanti- 
ties are  taken.  Beer,  as  a  rule,  is  not  well  borne.  A  dry  sherry  or  a  glass 
of  claret  is  preferable.  In  the  case  of  women  with  any  form  of  dyspepsia 
stimulants  should  be  employed  with  the  greatest  caution,  and  the  practitioner 
should  know  his  patient  well  before  ordering  alcohol. 

The  importance  of  salt  in  gastric  digestion  rests  upon  the  fact  that  its 
presence  is  essential  in  the  formation  of  the  hydrochloric  acid.  An  increase 
in  its  use  may  be  advised  in  all  cases  of  chronic  dyspepsia  in  which  the  acid 
is  defective. 

Treatment  of  Special  Conditions. — Fermentation  and  Flatulency. — When 
the  digestion  is  slow  or  imperfect,  fermentation  goes  on  in  the  contents,  with 
the  formation  of  gas  and  the  production  of  lactic,  butyric,  and  acetic  acids. 
For  the  treatment  of  this  condition  careful  dieting  may  suffice,  particularly 
forbidding  such  articles  as  tea,  pastry,  and  the  coarser  vegetables.  It  is  usually 
combined  with  pyrosis,  in  which  the  acid  fluids  are  brought  into  the  mouth. 
Bismuth  and  carbonate  of  soda  sometimes  suffice  to  relieve  the  condition. 
Thymol,  creasote,  and  carbolic  acid  may  be  employed.  For  acid  dyspepsia 
Sir  William  Eoberts  recommends  the  bismuth  lozenge  of  the  British  Pharma- 
copoeia, the  antacid  properties  of  which  depend  on  chalk  and  bicarbonate  of 
soda.  It  should  be  taken  an  hour  or  two  after  meals,  and  only  when  the  pain 
and  uneasiness  are  present.  The  burnt  magnesia  is  also  a  good  remedy. 
Grlycerin  in  from  20-  to  60-minim  doses,  the  essential  oils,  animal  charcoal 
alone  or  in  combination  with  compound  cinnamon  powder,  may  be  tried. 
If  there  is  much  pain,  chloroform  in  20-minim  doses  or  a  teaspoonful 
of  Hoffman's  anodyne  may  be  used.  In  obstinate  cases  lavage  is 
indicated  and  is  sometimes  striking  in  its  effects.  Alkaline  solutions  may 
be  used. 

Vomiting  is  not  a  feature  which  often  calls  for  treatment  in  chronic  dys- 
pepsia; sometimes  in  children  it  is  a  persistent  symptom.  Creasote  and 
carbolic  acid  in  drop  doses,  a  few  drops  of  chloroform  or  of  dilute  hydro- 
cyanic acid,  cocaine,  bismuth,  and  oxalate  of  cerium  may  be  used.  If  obsti- 
nate, the  stomach  should  be  washed  out  daily. 

Constipation  is  a  frequent  and  troublesome  feature  of  most  forms  of  indi- 
gestion. Occasionally  small  doses  of  mercury,  podophyllin,  the  laxative  min- 
eral waters,  sulphur,  and  cascara  may  be  employed.  Glycerin  suppositories 
or  the  injection  of  from  half  a  teaspoonful  to  a  teaspoonful  of  glycerin  is 
very  efficacious. 


DISEASES  OF  THE  STOMACH.  467 

Many  cases  of  chronic  dyspepsia  are  greatly  benefited  by  the  use  of  mineral 
waters,  particularly  a  residence  at  the  springs  with  a  careful  supervision  of 
the  diet  and  systematic  exercise. 

III.    DILATATION    OF    THE    STOMACH    (Gastrectasis). 

Etiology. — Acute  dilatation  is  a  rare  condition,  described  by  Hilton 
Fagge,  characterized  by  sudden  onset,  vomiting  of  enormous  quantities  of  fluid, 
and  symptoms  of  collapse.  Of  102  cases  collected  by  Lewis  A.  Conner  42  fol- 
lowed operation  with  general  anesthesia.  The  next  largest  group  occurs  in  the 
course  of  severe  diseases,  or  during  convalescence.  Cases  have  followed  in- 
juries, particularly  of  the  head  and  spine.  In  9  cases  the  symptoms  came 
on  after  a  single  large  meal;  6  cases  were  associated  with  spinal  disease,  in  3 
while  the  patients  were  in  a  plaster  of  Paris  jacket,  and  in  a  few  cases  it  has 
come  on  in  persons  in  good  health.  There  were  74  deaths.  In  69  autopsies 
the  duodenum  was  found  dilated  in  38  cases.  In  a  majority  of  cases  it  is  due 
to  a  constriction  of  the  lower  end  of  the  duodenum  by  traction  on  the  mesen- 
teric root,  which  is  particvilarly  apt  to  occur  when  there  is  a  long  mesentery 
and  when  the  coil  of  small  bowel  is  empty  and  falls  into  the  true  pelvis.  The 
diagnosis  is  usually  easy — repeated  vomiting  of  large  quantities  of  bilious  non- 
faecal  fluid,  with  subnormal  temperature,  pain,  collapse  symptoms,  and  dis- 
tended abdomen  are  the  common  features.  The  treatment  consists  in  repeated 
emptying  of  the  stomach  with  the  tube;  change  in  posture  from  the  dorsal  to 
the  belly  position  or  the  knee-elbow  position  has  been  followed  by  prompt  relief. 
Operation  has  not  proved  very  satisfactory. 

Cheonic  dilatation  results  from :  (a)  Pyloric  obstruction  due  to  nar- 
rowing of  the  orifice  or  of  the  duodenum  by  the  cicatrization  of  an  ulcer, 
hypertrophic  stenosis  of  the  pylorus  (whether  cancerous  or  simple),  congeni- 
tal stricture,  or  occasionally  by  pressure  from  without  of  a  tumor  or  of  a 
floating  kidney.  The  pylorus  may  be  tilted  up  by  adhesion  to  the  liver  or 
gall-bladder,  or  the  stomach  may  be  so  dilated  that  the  pylorus  is  dragged 
down  and  kinked.  Adhesions  about  the  gall-bladder  may  extend  along  the 
adjacent  parts  of  the  stomach  and  hitch  up  the  pylorus  into  the  hilus  of  the 
liver,  forming  a  very  acute  kink.  (&)  Relative  or  absolute  insufficiency  of  the 
muscular  power  of  the  stomach,  due  on  the  one  hand  to  repeated  overfilling  of 
the  organ  with  food  and  drink,  and  on  the  other  to  atony  of  the  coats  induced 
by  chronic  inflammation  or  the  degeneration  of  impaired  nutrition,  the  result 
of  constitutional  affections. 

The  most  extreme  forms  are  met  with  as  a  sequence  of  the  cicatricial  con- 
traction of  an  ulcer.  There  may  be  considerable  stenosis  without  much  dila- 
tation, the  obstruction  being  compensated  by  hypertrophy  of  the  muscular  coats. 

In  the  second  group,  due  to  atony  of  the  muscular  coats,  we  must  distin- 
guish between  instances  in  which  the  stomach  is  simply  enlarged  and  those 
with  actual  dilatation,  conditions  characterized  by  Ewald  as  megalogastria 
and  gastrectasis  respectively.  The  size  of  the  stomach  varies  greatly  in  differ- 
ent individuals,  and  the  maximum  capacity  of  a  normal  organ  Ewald  places 
at  about  1,600  cc.    Measurements  above  this  point  indicate  absolute  dilatation. 

Atonic  dilatation  of  the  stomach  may  result  from  weakness  of  the  coats, 
due  to  repeated  overdistention  or  to  chronic  catarrh  of  the  mucous  membrane. 


468  DISEASES  OF  THE  DIGESTIVE   SYSTEM. 

or  to  the  general  muscular  debility  which  is  associated  with  chronic  wasting 
disorders  of  all  sorts.  The  combination  of  chronic  gastric  catarrh  with  over- 
feeding and  excessive  drinking  is  one  of  the  most  fruitful  sources  of  atonic 
dilatation,  as  pointed  out  by  Xaun}Ti.  The  condition  is  frequently  seen  in 
diabetics,  in  the  insane,  and  in  beer-drinkers.  In  Germany  this  form  is  very 
common  in  men  employed  in  the  breweries.  Possibly  muscular  weakness  of 
the  coats  may  result  in  some  cases  from  disturbed  innervation.  Dilatation 
of  the  stomach  is  most  frequent  in  middle-aged  or  elderly  persons,  but  the 
condition  is  not  uncommon  in  children,  especially  in  association  with  rickets. 

Symptoms. — In  atonic  dilatation  there  may  be  no  symptoms  whatever, 
even  with  a  very  greatly  enlarged  organ;  more  frequently  there  are  the  asso- 
ciated features  of  neurasthenia,  enteroptosis,  and  nervous  dyspepsia;  while  in 
a  third  group  there  may  be  all  the  symptoms  of  pyloric  obstruction — vomiting 
of  enormous  quantities,  etc.  There  is  no  limit  to  the  capacity  of  the  organ 
in  this  condition.  Gould  and  Pyle  mention  an  instance  in  which  the  stomach 
held  70  pints ! 

The  features  of  pyloric  ohstruction_,  from  whatever  cause,  are  usualh'  very 
evident.  Dyspepsia  is  present  in  nearly  all  cases,  and  there  are  feelings  of 
distress  and  uneasiness  in  the  region  of  the  stomach.  The  patient  may  com- 
plain much  of  hunger  and  thirst  and  eat  and  drink  freely.  The  most  charac- 
teristic symptom  is  the  vomiting  at  intervals  of  enormous  quantities  of  liquid 
and  of  food,  amounting  sometimes  to  four  or  more  litres.  The  material  is 
often  of  a  dark-grayish  color,  with  a  characteristic  sour  odor  due  to  the 
organic  acids  present,  and  contains  mucus  and  remnants  of  food.  On  stand- 
ing it  separates  into  three  layers,  the  lowest  consisting  of  food,  the  middle 
of  a  turbid,  dark-gray  fluid,  and  the  uppermost  of  a  brownish  froth.  The 
microscopical  examination  shows  a  large  variety  of  bacteria,  yeast  fungi,  and 
the  sarcina  ventriculi.  There  may  also  be  cherry  stones,  plum  stones,  and 
grape  seeds. 

The  hydrochloric  acid  may  be  absent,  diminished,  normal,  or  in  excess, 
depending  upon  the  cause  of  the  dilatation.  The  fermentation  produces  lactic, 
butyric,  and,  possibly,  acetic  acid  and  various  gases. 

In  consequence  of  the  small  amount  of  fluid  which  passes  from  the  stom- 
ach or  is  absorbed  there  are  constipation,  scanty  urine,  and  extreme  drjmess 
of  the  skin.  The  general  nutrition  of  the  patient  suffers  greatly;  there  is  loss 
of  flesh  and  strength,  and  in  some  cases  the  most  extreme  emaciation.  The 
gastric  tetany  will  be  considered  in  the  section  on  that  disease. 

Physical  Sigxs. — Inspection. — The  abdomen  may  be  large  and  promi- 
nent, the  greatest  projection  occurring  below  the  navel  in  the  standing  posture. 
In  some  instances  the  outline  of  the  distended  stomach  can  be  plainly  seen, 
the  small  curvature  a  couple  of  inches  below  the  ensiform  cartilage,  and  the 
greater  curvature  passing  obliquely  from  the  tip  of  the  tenth  rib  on  the  left 
side,  toward  the  pubes,  and  then  curving  upward  to  the  right  costal  margin. 
Too  much  stress  can  not  be  laid  on  the  importance  of  inspection.  Yerj  often 
the  diagnosis  may  be  made  de  visu.  Active  peristalsis  may  be  seen  in  the 
dilated  organ,  the  waves  passing  from  left  to  right.  Occasionally  anti-peri- 
stalsis may  be  seen.  In  cases  of  stricture,  particularly  of  MqDertrophic  stenosis, 
as  the  peristaltic  wave  reaches  the  pylorus,  the  tumor-like  thickening  can 
sometimes  be  distinctlv  seen  through  the  thin  abdominal  wall.     To  stimulate 


DISEASES  OF  THE  STOMACH.  469 

the  peristalsis  the  abdomen  may  be  flipped  with  a  wet  towel.  Inflation  may 
be  practised  with  carbonic-acid  gas,  A  small  teaspoonful  of  tartaric  acid 
dissolved  in  an  ounce  of  water  is  first  given^  then  a  rather  larger  quantity  of 
bicarbonate  of  soda.  In  many  cases,  particularly  in  thin  persons,  the  outline 
of  the  dilated  stomach  stands  out  with  great  distinctness,  and  waves  of  peri- 
stalsis are  seen  in  it. 

Palpation. — The  peristalsis  may  be  felt,  and  usually  in  stenosis  the  tumor 
is  evident  at  the  pylorus.  The  resistance  of  a  dilated  stomach  is  peculiar, 
and  has  been  aptly  compared  to  that  of  an  air  cushion.  Bimanual  palpation 
elicits  a  splashing  sound — dapotage — which  is,  of  course,  not  distinctive,  as 
it  can  be  obtained  whenever  there  is  much  liquid  and  air  in  the  organ.  The 
splashing  may  be  very  loud,  and  the  patient  may  produce  it  himself  by  sud- 
denly depressing  the  diaphragm,  or  it  may  be  readily  obtained  by  shaking 
him.     The  gurgling  of  gas  through  the  pylorus  may  be  felt. 

Percussion. — The  note  is  tympanitic  over  the  greater  portion  of  a  dilated 
stomach;  in  the  dependent  part  the  note  is  flat.  In  the  upright  position  the 
percussion  should  be  made  from  above  downward,  in  the  left  parasternal  line, 
until  a  change  in  resonance  is  reached.  The  line  of  this  should  be  marked, 
and  the  patient  examined  in  the  recumbent  position,  when  it  will  be  found 
to  have  altered  its  level.  When  this  is  on  a  line  with  the  navel  or  below  it, 
dilatation  of  the  stomach  may  generally  be  assumed  to  exist.  The  fluid  may 
be  withdrawn  from  the  stomach  with  a  tube,  and  the  dulness  so  made  to 
disappear,  or  it  may  be  increased  by  pouring  in  more  fluid.  In  cases  of  doubt 
the  organ  should  be  artificially  distended  with  carbonic-acid  gas  in  the  manner 
described  above.  The  most  accurate  method  of  determining  the  size  of  the 
stomach  is  by  inflation  through  a  stomach-tube  with  a  Davidson's  syringe. 
Pacanowski  has  shown  that  the  greatest  vertical  diameter  of  gastric  resonance 
in  the  normal  stomach  varies  from  10  to  14  cm,  in  the  male  and  is  about  10 
cm.  in  the  female. 

Auscultation. — The  dapotage  or  succussion  can  be  obtained  readily.  Fre- 
quently a  curious  sizzling  sound  is  present,  not  unlike  that  heard  when 
the  ear  is  placed  over  a  soda-water  bottle  when  first  opened.  It  can  be  heard 
naturally,  and  is  usually  evident  when  the  artificial  gas  is  being  generated. 
The  heart  sounds  may  sometimes  be  transmitted  with  great  clearness  and 
with  a  metallic  quality. 

Mensuration  may  be  used  by  passing  a  hard  sound  into  the  stomach  until 
the  greater  curvature  is  reached.  Normally  it  rarely  passes  more  than  60  cm., 
measured  from  the  teeth,  but  in  cases  of  dilatation  it  may  pass  as  much 
as  70  cm. 

Diagnosis. — The  diagnosis  can  usually  be  made  without  much  difficulty. 
I  would  like  to  emphasize  again  the  great  value  of  inspection,  particularly 
in  combination  with  inflation  of  the  stomach  with  carbonic-acid  gas.  Curious 
errors,  however,  are  on  record,  one  of  the  most  remarkable  of  which  was  the 
confounding  of  dilated  stomach  with  an  ovarian  cyst;  even  after  tapping  and 
the  removal  of  portions  of  food  and  fruit  seeds,  abdominal  section  was  per- 
formed and  the  dilated  stomach  opened.  The  diagnosis  of  ascites  has  been 
made  and  the  abdomen  opened.  The  prognosis  depends  upon  the  cause;  it 
is  good  in  simple  atony,  bad  in  cancerous  stricture,  fairly  good  in  simple 
stricture,  from  whatever  cause. 


470  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

Treatment. — In  the  cases  due  to  atom-  careful  regulation  of  the  diet  and 
proper  treatment  of  the  associated  catarrh  will  suffice  to  effect  a  cure.  Strych- 
nine, ergot,  and  iron  are  recommended.  Washing  out  the  stomach  is  of  great 
service,  though  we  do  not  see  such  striking  and  immediate  results  in  this 
form.  In  cases  of  mechanical  obstruction  the  stomach  should  be  emptied  and 
thoroughly  washed,  either  with  warm  water  or  with  an  antiseptic  solution. 
We  accomplish  in  this  way  three  important  things:  We  remove  the  weight, 
which  helps  to  distend  the  organ;  we  remove  the  mucus  and  the  stagnating 
and  fermenting  material  which  irritates  and  inflames  the  stomach  and  im- 
pedes digestion;  and  we  cleanse  the  inner  surface  of  the  organ  by  the  appli- 
cation of  water  and  medicinal  substances.  The  patient  can  usually  be  taught 
to  wash  out  his  own  stomach,  and  in  a  case  of  dilatation  from  simple  stricture 
I  have  known  the  practice  to  be  followed  daily  for  three  years  with  great 
benefit.  The  rapid  reduction  in  the  size  of  the  stomach  is  often  remarkable, 
the  vomiting  ceases,  the  food  is  taken  readily,  and  in  many  cases  the  general 
nutrition  improves  rapidly.  As  a  rule,  once  a  day  is  sufficient,  and  it  may 
be  practised  either  the  first  thing  in  the  morning  or  before  going  to  bed.  So 
soon  as  the  fermentative  processes  have  been  checked  lukewarm  water  alone 
should  be  used. 

The  food  should  be  taken  in  small  quantities  at  frequent  intervals,  and 
should  consist  of  scraped  beef,  Leube's  beef  solution,  and  tender  meats  of  all 
sorts.  Fatty  and  starchy  articles  of  diet  are  to  be  avoided.  Liquids  should 
be  taken  sparingly. 

Surgery  should  be  resorted  to  early  in  cases  of  organic  stricture ;  in  atonic 
dilatation,  after  all  other  measures  have  been  given  a  thorough  trial,  gastro- 
enterostomy may  be  advised. 

IV.    THE   PEPTIC    ULCER,  GASTRIC   AND    DUODENAL. 

The  round,  perforating,  simple  or  peptic  ulcer  is  usually  single,  and 
occurs  in  the  stomach  and  in  the  duodenum  as  far  as  the  papilla.  All  post- 
mortem statistics  show  a  great  preponderance  of  the  gastric  ulcer,  but  the 
enormous  experience  of  surgeons  has  taught  us  that  in  more  than  fifty  per 
cent  of  the  clinical  cases  the  ulcer  is  outside  the  pyloric  ring. 

Erosions. — Small  abrasions  of  the  mucosa — 2  to  4  mm. — ^usually  multiple, 
are  common,  extending  half-way  or  quite  through  the  laj-er.-  They  are  often 
called  hgemorrhagic  erosions  from  their  blood-stained  appearance.  They  are 
met  with  in  the  new-born,  in  cachectic  states  in  children,  in  chronic  heart  and 
arterial  disease,  in  cirrhosis  of  the  liver,  etc.  Of  no  clinical  importance,  as  a 
rule,  occasionally  an  acute  hemorrhagic  erosion  of  quite  small  size  opens  a 
large  arter}^  and  the  patient  bleeds  to  death.  There  is  no  difference  between 
this  condition  and  the  acute  form  of  the  gastric  ulcer. 

In  many  cases  of  chronic  dyspepsia  small  fragments  of  the  mucosa  are 
washed  out  by  the  stomach  tube,  and  Einhorn  thinks  that  this  may  be  a  special 
form  characterized  by  pains,  dyspepsia,  and  weakness. 

In  certain  acute  infections  with  the  pneumococcus  (Dieulafoy)  and  septic 
organisms  there  may  be  hsemorrhagic  erosions,  which  occasionally  prove  fatal 
by  hsematemesis. 

And,  lastly,  it  is  probable  that  the  post-operative  hsematemesis,  slight  or 


DISEASES  OF  THE  STOMACH.  471 

grave,  may  be  due  to  these  erosions.  The  French  have  described  them  as  if 
peculiar  to  operations  for  appendicitis  (vomito-negro  appendiculaire) ,  but 
we  have  had  many  cases  after  all  sorts  of  abdominal  operations.  It  is  prob- 
able that  the  slight  gastric  haemorrhages  which  occur  in  connection  with  the 
throbbing  aorta  in  neurotic  women  are  due  to  these  erosions. 

Etiology  of  Peptic  Ulcer. — Incidence. — It  is  more  common  in  Great  Brit- 
ain and  on  the  Continent  than  in  America.  There  were  2.3  per  cent  in  Edin- 
burgh (Bramwell),  0.74  per  cent  in  London  (Fenwick),  1.33  per  cent  in 
Berlin,  and  0.57  per  cent  among  161,589  medical  admissions  in  America 
(Campbell  Howard).  It  is  more  common  in  the  northeastern  section  of  the 
United  States — :1.74  per  cent,  Massachusetts  General  Hospital  (Greenough 
and  Joslin),  0.18  per  cent  in  fifteen  years  at  the  Johns  Hopkins  Hospital  in 
all  services  among  a  total  admission  of  44,378  (Campbell  Howard).  Among 
10,841  post  mortems  in  the  United  States  and  Canada  there  were  only  144 
cases  of  ulcer — 1.33  per  cent,  against  5  per  cent  on  the  Continent  and  4.3 
per  cent  in  London. 

8ex. — Of  1,699  cases  collected  from  hospital  statistics  by  W.  H.  Welch 
and  examined  post  mortem,  40  per  cent  were  in  males  and  60  per  cent  were 
in  females.  In  83  cases  (J.  H.  H.)  there  were  48  males  and  38  females — in 
striking  contrast  to  the  Massachusetts  General  Hospital  figures,  5  females  to 
1  male.  Eecent  surgical  statistics  show  a  preponderance  of  males. 
•  Age. — In  females  the  largest  number  of  cases  occurred  between  fifteen  and 
twenty-five;  in  males  between  forty  and  fifty,  in  our  series.  It  may  occur  in 
old  people.  E.  G.  Cutler  has  studied  a  series  of  39  cases  in  children.  In  6 
the  symptoms  came  on  immediately  after  birth.  There  were  8  cases  under 
seven  years  of  age,  and  9  between  eight  and  thirteen. 

Heredity  appears  to  play  a  part  in  some  cases  (Dreschfeld). 

Occupation. — It  was  impossible  in  our  series  to  say  that  occupation  had 
any  influence.  Among  women,  chlorotic,  dyspeptic  servant  girls  seem  very 
prone.  Shoemakers  are  thought  to  be  specially  liable.  It  appears  relatively 
more  common  in  the  hospital  classes. 

Trauma. — Ulcers  have  been  known  to  follow  a  blow  in  the  region  of  the 
stomach.    There  was  a  history  of  injury  in  7  cases  in  our  series. 

Associated  Diseases. — Anaemia  and  chlorosis  predispose  strongly  to  gastric 
ulcer,  particularly  in  women  and  in  association  with  menstrual  disorders.  A 
very  considerable  number  of  all  cases  of  gastric  ulcer  occur  in  chlorotic  girls. 
It  has  been  found  also  in  connection  with  disease  of  the  heart,  arterio-sclerosis, 
and  disease  of  the  liver.  The  tuberculous  and  syphilitic  ulcers  of  the  stomach 
have  already  been  considered. 

Burns. — The  duodenal  ulcer  may  follow  large  superficial  burns.  Perry 
and  Shaw  found  it  in  five  of  one  hundred  and  forty-nine  autopsies  in  cases  of 
burns  of  the  skin. 

Morbid  Anatomy  and  Pathology. — Ninety  per  cent  of  gastric  ulcers  are  to 
be  found  at  the  pyloric  end;  nearly  all  duodenal  ulcers  are  in  the  first  or 
ascending  portion,  and  more  than  one-half  extend  up  to  or  within  three- 
fourths  of  an  inch  of  the  pylorus,  while  twenty  per  cent  involve  the  margin 
of  the  pyloric  ring  (Mayo).  It  may  not  be  easy  on  the  operating  table  to 
distinguish  between  an  ulcer  of  the  duodenum  and  that  of  the  stomach,  but 
Mayo  says  that  the  position  of  the  pyloric  vein  gives  the  exact  location.    Mul- 


472  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

tiple  ulcers  ma}"  occur,  8.2  per  cent  in  Mayo's  series.  From  5  to  3-1  liave 
been  found.  In  the  stomach  post-mortem  statistics  (Welch)  give  in  793 
cases,  288  on  the  lesser  curvature,  235  on  the  posterior  -wall,  69  on  the  ante- 
rior wall,  95  at  the  pylorus,  50  at  the  cardia,  29  at  the  fundus,  and  27  on 
the  greater  curvature. 

The  acute  ulcer  is  usually  small,  punched  out,  the  edges  clean-cut,  the  floor 
smooth,  and  the  peritoneal  surface  not  thickened.  The  chronic  ulcer  is  of 
larger  size,  the  margins  are  no  longer  sharp,  the  edges  are  indurated,  and  the 
border  is  sinuous.  It  may  reach  an  enormous  size,  as  in  the  one  reported  by 
Peabody,  which  measured  19  by  10  cm.  and  -involved  all  of  the  lesser  curva- 
ture and  spread  over  a  large  part  of  the  anterior  and  posterior  walls.  The 
sides  are  often  terraced.  The  floor  is  formed  either  by  the  submucosa,  by  the 
muscular  layers,  or,  not  infrequently,  by  the  neighboring  organs,  to  which  the 
stomach  has  become  attached.  In  the  healing  of  the  ulcer,  if  the  mucosa  is 
alone  involved,  the  granulation  tissue  grows  from  the  edges  and  the  floor  and 
the  newly  formed  tissue  gradually  contracts  and  unites  the  margins,  leaving 
a  smooth  scar.  In  larger  ulcers  which  have  become  deep  and  involved  the 
muscular  coat,  the  cicatricial  contraction  may  cause  serious  changes,  the  most 
important  of  which  is  narrowing  of  the  pyloric  orifice  and  consequent  dila- 
tation of  the  stomach.  In  the  case  of  a  girdle  ulcer,  hour-glass  contraction 
of  the  stomach  may  be  produced.  Large  ulcers  persist  for  years  without  any 
attempt  at  healing. 

Among  the  more  serious  changes  which  may  proceed  in  an  ulcer  are  the 
following : 

Pekfoeatiox. — This  occurred  in  28.1  per  cent  of  1,871  cases  collected  by 
Musser.  In  some  series  (Mayo's)  duodenal  perforation  is  the  more  common. 
Of  272  cases  of  duodenal  ulcer  in  Mayo's  series  (to  June  1,  1908),  perforation 
was  found  sixty-six  times,  16  acute,  13  subacute  with  abscess,  and  37  chronic 
and  protected.  Perforation  of  the  anterior  wall  of  the  stomach  usually  excites 
an  acute  peritonitis.  On  the  posterior  wall  the  ulcer  penetrates  directly  into  the 
lesser  peritoneal  cavity,  in  which  case  it  may  produce  an  air-containing  abscess 
with  the  s}Tnptoms  of  the  condition  known  as  subphrenic  pyopneumothorax. 
In  rare  instances  adhesions  and  a  gastrocutaneous  fistula  form,  usually  in  the 
umbilical  region.  Fistulous  communication  with  the  colon  may  also  occur, 
or  a  gastroduodenal  fistula.  The  pericardium  may  be  perforated,  and  even 
the  left  ventricle.  Perforation  into  the  pleura  may  also  occur.  It  is  to  be 
noted  that  general  emphysema  of  the  subcutaneous  tissues  occasionally  follows 
perforation  of  a  gastric  ulcer. 

Erosiox  of  Blood-vessels. — In  both  forms  of  ulcer  haemorrhage  occurs,  in 
8.1  per  cent  of  Musser's  series  of  1,871  cases.  In  Mojuihan's  11-i  cases  of 
duodenal  ulcer,  hsemorrhage  occurred  in  41.  It  is  more  common  in  the  chronic 
form.  Ulcers  on  the  posterior  wall  may  erode  the  splenic  artery,  but  perhaps 
more  frequently  the  bleeding  proceeds  from  the  artery  of  the  lesser  curvature. 
In  the  case  of  duodenal  ulcer  the  pancreaticoduodenal  artery  may  be  eroded  or 
(as  in  one  of  my  cases)  fatal  hemorrhage  may  result  from  the  opening  of  the 
hepatic  artery,  or  more  rarely  the  portal  vein.  Interesting  changes  occur  in  the 
vessels.  Embolism  of  the  artery  supph'ing  the  ulcerated  region  has  been  met 
with  in  several  cases;  in  others  diffuse  endarteritis.  Small  aneurisms  have 
been  found  in  the  floor  of  the  ulcers  by  Douglas  Powell,  Welch,  and  others. 


DISEASES  OF  THE  STOMACH.  473 

A  rare  event  is  emphysema  of  the  siib-pcritoneal  tissue,  which  may  be  very 
extensive  and  even  pass  on  to  the  posterior  mediastinum.  Jurgensen  ascribes 
it  to  entrance  of  air  into  the  veins,  but  Welch  thinks  it  represents  an  invasion 
with  the  gas  bacillus. 

CiCATEizATiON. — Superficial  ulcers  often  heal  without  leaving  any  serious 
damage.  Stenosis  of  the  pyloric  orifice  not  infrequently  follows  the  healing 
of  an  ulcer  in  its  neighborhood.  In  other  instances  the  large  annular  ulcer 
may  cause  in  its  cicatrization  an  hour-glass  contraction  of  the  stomach.  The 
adhesion  of  the  ulcer  to  neighboring  parts  may  subsequently  be  the  cause 
of  much  pain.  The  parts  of  the  mucosa  in  the  neighborhood  of  the  ulcer 
frequently  show  signs  of  chronic  gastritis. 

Perigastric  Adhesions. — The  condition  is  common,  as  high  as  5  per 
cent  of  post-mortem  records.  It  follows  ulcer,  lesions  of  the  gall-bladder, 
pancreatic  disease,  syphilitic  disease  of  the  liver,  and  chronic  tuberculosis. 
In  some  instances  the  lesions  are  quite  extensive,  and  the  condition  has  been 
called  plastic  perigastritis.  It  may  be  associated,  too,  with  hypertrophic  thick- 
ening of  the  coats  of  the  stomach  and  with  chronic  plastic  peritonitis.  In 
some  instances  the  pylorus  may  be  narrowed  as  a  result  of  the  adhesions,  or 
a  sort  of  hour-glass  stomach  may  be  produced,  or  the  motility  of  the  organ 
is  interfered  with.  Mayo  Eobson  in  1893  called  attention  to  this  condition. 
As  Hale  White  has  pointed  out,  pain  is  the  most  constant  feature  in  this  con- 
dition, and  it  may  simulate  that  of  gastric  ulcer  or  of  hyperacidity,  and  may 
be  present  constantly  or  at  intervals.  It  is  much  influenced  by  posture  and 
usually  relieved  by  pressure.  Local  tenderness  is  present  in  a  majority  of 
instances.  The  cases  are  chronic,  the  general  health  is  but  slightly  interfered 
with,  and  there  are  not,  as  a  rule,  signs  of  gastric  dilatation.  A  definite  tumor 
may  be  present  about  the  region  of  the  pylorus.  E.  P.  Paton  has  collected 
42  cases  on  which  operation  has  been  performed,  apparently  in  a  majority  of 
the  cases  with  benefit. 

Mode  of  Origin. — The  mode  of  origin  is  unknown.  The  anatomical  basis 
is  an  interference  with  the  blood  supply  in  a  limited  area  of  the  mucosa,  at- 
tributed to  embolism,  thrombosis,  or  spasm  of  the  vessels.  As  the  arteries  of 
the  stomach  are  not  end  vessels,  simple  obstruction  can  not  account  for  it. 
Trophic  influences,  bacterial  necrosis  of  the  mucosa,  spasm  of  the  muscular 
coat  in  limited  areas,  etc.,  are  among  the  hypotheses  which  have  been  ad- 
vanced. The  erosion  is  effected  by  the  gastric  juice,  and  the  healing  is  prob- 
ably retarded  by  its  high  grade  of  acidity. 

The  duodenal  ulcer  has  an  identical  origin.  A  few  cases  of  acute  ulcer 
have  a  curious  relation  with  superficial  burns.  Bardeen's  researches  upon 
the  necroses  in  the  viscera  following  extensive  burns  throw  an  important  light 
upon  these  cases,  showing  especially  how  the  gastro-intestinal  mucous  mem- 
brane is  implicated  in  the  toxic  effects. 

The  jejunal  peptic  ulcer,  of  which  more  than  30  cases  have  been  recorded, 
is  a  very  serious  sequel  of  gastro-enterostomy. 

Symptoms. — The  condition  may  be  latent  and  only  met  with  accidentally, 
post  mortem.  The  first  symptoms  may  be  those  of  perforation.  In  other 
cases  again,  for  months  and  years,  the  patient  has  had  dyspepsia,  and  the 
ulcer  may  not  have  been  suspected  until  the  occurrence  of  a  sudden  haemor- 
rhage. 

32 


474  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

Dyspepsia  may  be  slight  and  trifling  or  of  a  most  aggravated  character. 
In  a  considerable  proportion  of  all  cases  nausea  and  vomiting  occur,  the 
latter  not  for  two  or  more  hours  after  eating.  The  vomitus  usually  contains 
a  large  amount  of  hydrochloric  acid. 

HEMORRHAGE  is  present  in  at  least  one-third  of  all  cases.  It  may  be 
latent  (occult).  A  patient  may  feel  faint  and  turn  pale  and  sweat;  the  next 
day  the  stools  may  be  tarry  from  the  blood  that  has  passed  into  the  small 
bowel.  These  concealed  hsemorrhages  are  more  often  small,  and  the  blood 
is  not  readily  seen  in  the  vomitus  or  stools.  Weber's  test  may  be  tried;  the 
fluid  to  be  examined  is  mixed  with  2  or  3  cc.  of  glacial  acetic  acid,  and  then 
shaken  with  sulphuric  ether.  If  blood  be  present  the  ethereal  extract  has  a 
Tokay  wine-like  color.  Meat  should  not  be  eaten  for  a  few  days  before  the  test 
is  made.  These  small,  latent  haemorrhages  may  cause  a  slowly  progressive 
anaemia.  More  commonly  the  bleeding  is  profuse,  and  the  blood  may  be  in 
such  quantities  and  brought  up  so  quickly  that  it  is  fluid,  bright  red  in  color, 
and  quite  unaltered.  When  it  remains  for  some  time  in  the  stomach  and  is 
mixed  with  food  it  may  be  greatly  changed,  but  the  vomiting  of  a  large  quan- 
tity of  unaltered  blood  is  very  characteristic  of  ulcer.  As  a  rule,  there  are 
only  one  or  two  attacks;  in  our  series  7  cases  had  one  haemorrhage,  7  two,  11 
three,  1  four,  and  15  many  (Howard).  Profuse  bleedings  may  occur  at  inter- 
vals for  many  years.  Death  may  follow  directly.  From  16  to  18  per  cent  of 
the  fatal  cases  are  due  to  it  (S.  and  W,  Fenwick). 

The  immediate  effect  of  the  haemorrhage  is  a  severe  ansemia,  from  which 
it  may  take  months  to  rally;  slight  fever  is  common.  Eare  and  untoward 
effects  are  convulsions,  sometimes  only  the  usual  convulsions  of  extreme  cere- 
bral anaemia  from  which  recovery  takes  place,  or  they  may  precede  a  hemi- 
plegia, due  probably  to  thrombosis. 

Amaurosis  may  follow  the  haemorrhage,  and  unfortunately  may  be  perma- 
nent, and  is  due  to  degeneration  of  the  retinal  ganglion  cells,  or  to  a  throm- 
bosis of  the  cerebral  arteries  or  veins. 

Pain  is  perhaps  the  most  constant  and  distinctive  feature  of  ulcer.  It 
varies  greatly  in  character;  it  may  be  only  a  gnawing  or  burning  sensation, 
which  is  particularly  felt  when  the  stomach  is  empty,  and  is  relieved  by  taking 
food,  but  the  more  characteristic  form  comes  on  in  paroxysms  of  the  most 
intense  gastralgia,  in  which  the  pain  is  not  only  felt  in  the  epigastrium,  but 
radiates  to  the  back  and  to  the  sides.  In  many  cases  the  two  points  of  epi- 
gastric pain  and  dorsal  pain,  about  the  level  of  the  tenth  dorsal  vertebra,  are 
very  well  marked.  These  attacks  are  most  frequently  induced  by  taking  food, 
and  they  may  recur  at  a  variable  period  after  eating,  sometimes  within  fifteen 
or  twenty  minutes,  at  others  as  late  as  two  or  three  hours.  It  is  usually  stated 
that  when  the  ulcer  is  near  the  cardia  the  pain  is  apt  to  set  in  earlier,  but 
there  is  no  certainty  on  this  point.  In  some  cases  it  comes  on  in  the  early 
morning  hours.  The  attacks  may  occur  at  intervals  with  great  intensity  for 
weeks  or  months  at  a  time,  so  that  the  patient  constantly  requires  morphia, 
then  again  they  may  disappear  entirely  for  a  prolonged  period.  In  the  attack 
the  patient  is  usually  bent  forward,  and  finds  relief  from  pressure  over  the 
epigastric  region;  one  patient  during  the  attack  would  lean  over  the  back  of 
a  chair;  another  would  lie  flat  on  the  floor,  with  a  hard  pillow  under  the 
abdomen.     Pressure  is,  as  a  rule,  grateful.     It  has  been  thought  that  the 


DISEASES  OF  THE  STOMACH.  475 

posture  assumed  during  the  attack  would  indicate  the  site  of  the  ulcer,  but 
this  is  very  doubtful. 

Tenderness  on  pressure  is  a  common  symptom  in  ulcer,  and  patients 
wear  the  waist-band  very  low.  Pressure  should  be  made  with  great  care,  as 
rupture  of  an  ulcer  is  said  to  have  been  induced  by  careless  manipulation. 

In  old  ulcers  with  thickened  bases  an  indurated  mass  can  usually  be  felt 
in  the  neighborhood  of  the  pylorus. 

Of  general  symptoms,  loss  of  weight  results  from  the  prolonged  dyspepsia, 
but  it  rarely,  except  in  association  with  cicatricial  stenosis  of  the  pylorus, 
reaches  the  high  grade  met  with  in  cancer.  The  ancemia  may  be  extreme,  and 
in  one  case  of  duodenal  ulcer,  which  I  examined,  the  blood-count  was  as  low 
as  700,000  per  c.  mm.  Of  44  cases  in  my  wards  in  which  blood-counts  were 
made,  the  lowest  was  1,902,000  per  c.  mm.  There  are  instances,  such  as  the 
one  reported  by  Pepper  and  Griffith,  in  which  the  extreme  anaemia  can  not 
be  explained  by  the  occurrence  of  hgemorrhage.  In  a  few  instances  polycythse- 
mia  is  present,  even  after  a  hgemorrhage,  due  to  concentration  of  the  blood 
and  possibly  associated  dilatation  of  the  stomach.  In  a  few  cases  parotitis 
occurs,  with  the  perforation  sometimes,  or  after  a  haemorrhage.  In  one  of 
my  cases  there  was  a  remarkable  pigmentation  of  the  face  and  of  the  axillary 
folds. 

Perforation. — This  occurred  in  28.1  per  cent  of  Musser's  series.  The 
acute,  perforating  form  is  much  more  common  in  women  than  in  men.  The 
symptoms  are  those  of  perforative  peritonitis.  Particular  attention  must  be 
given  to  this  accident  since  it  has  come  so  successfully  within  the  sphere  of  the 
surgeon.  As  already  mentioned,  perforation  may  take  place  either  into  the 
lesser  peritoneum  or  into  the  general  peritoneal  cavity,  in  both  of  which  cases 
operation  is  indicated;  in  rare  instances  the  ulcer  may  perforate  the  peri- 
cardium. This  was  the  case  in  10  of  28  cases  in  which  the  diaphragm  was 
perforated  (Pick). 

Localized,  more  frequently  subphrenic,  abscess  may  follow  perforation. 

Urine. — Albumin  is  occasionally  present;  in  14  of  our  series  with  dilata- 
tion of  the  stomach.  Indican  may  be  present.  Acetone  and  diacetic  acid 
(with  syncopal  attacks)  have  been  described  by  Dreschfeld. 

Hour-glass  stomach  most  frequently  results  from  the  cicatrization  of 
an  ulcer.  In  a  few  cases  it  is  congenital.  The  symptoms,  fairly  character- 
istic, are  thus  given  by  Moynihan: 

(1)  In  washing  out  the  stomach  part  of  the  fluid  is  lost.  (2)  If  the  stom- 
ach is  washed  clean,  a  sudden  reappearance  of  stomach  contents  may  take 
place.  (3)  "Paradoxical  dilatation"  when  the  stomach  has  apparently  been 
emptied,  a  splashing  sound  may  be  elicited  by  palpation  of  the  pyloric  seg- 
ment. (4)  After  distending  the  stomach,  a  change  in  the  position  of  the 
distention  tumor  may  be  seen  in  some  cases.  (5)  Gushing,  bubbling,  or 
sizzling  sounds  are  heard  on  dilatation  with  carbon  dioxide  at  a  point  distinct 
from  the  pylorus.  ( 6 )  In  some  cases,  when  both  parts  are  dilated,  two  tumors 
with  a  notch  or  sulcus  between  are  apparent  to  sight  or  touch. 

Prognosis. — In  all  statistics  the  acute  and  chronic  ulcer  have  been  consid- 
ered together.  The  former  is  more  amenable  to  medical  treatment,  but  grave 
complications  may  occur  even  before  the  digestive  symptoms  have  been  very 
pronounced.    The  chronic  ulcer  may  last  for  years — twelve,  eighteen,  or  even 


476  DISEASES  OF   THE  DIGESTIVE  SYSTEM. 

t-sveiity — with  intervals  of  good  health.  The  all-important  point  in  the  prog- 
nosis relates  to  the  question  of  medical  or  surgical  treatment — which  gives  the 
best  results  ?  So  far  as  figures  count,  the  exhaustive  study  of  Musser  favors  the 
former,  12.4  per  cent  mortality  against  20  per  cent  for  the  latter.  This  for 
simple  cases  including  complications.  In  private  practice  many  series  of  cases 
have  not  a  mortality  above  6  per  cent.  The  mortality  of  the  chronic  peptic 
ulcer  in  the  hands  of  such  experts  as  the  Mayos  and  Moynihan  is  very  low. 
In  311  gastrojejunostomies  for  ulcer  of  the  stomach  and  duodenum  the  mor- 
tality was  less  than  1  per  cent,  and  only  three  patients  required  a  secondary 
operation  (Mayo's).  Of  Mo}Tiihan's  cases  of  duodenal  ulcer,  ll-l  in  number 
(exclusive  of  perforation),  there  were  only  two  deaths.  The  end  results  of 
gastro-enterostomy  for  the  chronic  ulcer  appear  to  be  excellent. 

Diagnosis. — The  acute  non-indurated  ulcer  may  cause  very  few  symptoms 
— nothing  beyond  ordinar}"-  dyspepsia  with  pain.  Examination  of  the  stomach 
contents  shows  an  increase  in  the  free  HCl.  Hsematemesis  may  be  the  first 
s}-mptom  of  moment.  This  group  of  cases  is  seen  chiefly  in  young  girls,  and 
appears  to  be  much  more  common  in  England  than  in  the  United  States.  A 
condition  which  may  be  confounded  with  it  is  gasirorrli  exis,  described  hj  Hale 
White.  The  stomach  s}Tnptoms  are  marked,  the  bleeding  may  be  profuse,  but 
post  mortem  or  at  operation  no  ulcer  is  found.  Of  course  very  careful  inspec- 
tion must  be  made,  as  fatal  bleeding  may  come  from  a  very  small  erosion. 
The  symptoms  of  non-indurated  mucous  ulcer  yield  to  a  few  months'  medical 
treatment. 

From  gastralgia,  dyspepsia,  and  hyperchlorhydria  the  diagnosis  of  the 
chronic,  indurated  peptic  ulcer  is  very  difficult;  in  many  of  those  conditions, 
indeed,  surgeons  have  shown  clearly  that  the  symptoms  are  due  to  an  ulcer. 
That  the  brothers  Mayo  should  have  operated  (to  June  1,  1908)  on  272  cases  of 
duodenal  ulcer  (as  many  almost  as  have  been  reported  in  the  whole  literature) 
and  that  Mo}-nihan  should  have  had  to  June,  1908,  174  cases,  indicates  that  we 
physicians  have  been  napping,  and  that  what  the  modern  "  gastro-enterolo- 
gist "  needs  is  a  prolonged  course  of  study  at  such  surgical  clinics  as  Eochester 
(Minnesota)  or  Leeds.  It  is  not  as  if  there  were  any  possibility  of  mistake,  as 
these  are  men  whose  ways  and  work  are  known  to  all.  More  particularly  is 
the  diagnosis  of  duodenal  ulcer  important  since  its  relative  frequency  has  been 
demonstrated.  The  following  account  condensed  from  Moynihan  is  a  picture  of 
hyperchlorhydria  plus  in  the  severe  cases  the  hsematemesis  or  melaena.  After, 
food  the  patient  is  free  from  pain  and  the  hour  or  two  following  a  meal  is  the 
best  time  in  the  day.  Varying  from  one  and  a  half  to  four  hours  after  the 
meal,  a  sense  of  uneasiness  is  noticed  in  the  upper  part  of  the  abdomen.  A 
burning,  gnawing  sensation  develops  with  a  bitter  taste  in  the  mouth  and  eruc- 
tations of  food  or  gas.  The  pain,  which  gradually  increases,  may  be  relieved 
by  belching,  or  by  pressure.  As  it  increases  in  severity,  it  strikes  through  to 
the  back,  to  the  right  of  the  middle  line,  and  it  may  radiate  round  the  right 
side  of  the  chest.  Patients  discover  for  themselves  that  food  relieves  the  pain, 
and  many  carry  a  biscuit  in  their  pockets,  or  take  milk,  a  dose  of  an  alkaline 
medicine,  or  some  form  of  food  as  soon  as  the  uneasiness  develops.  It  will 
often  be  found  that  a  patient  names  certain  hours  as  those  at  which  the  pain 
is  noticed,  11  a.m.,  4  p.m.,  or  2  a.m.  These  are  all  a  few  hours  after  food. 
Many  patients  wake  up,  after  a  short  sleep,  with  an  intense  gnawing  pain  in 


DISEASES  OF  THE  STOMACH.  477 

the  pit  of  the  stomach;  and  they  may  keep  a  few  biscuits,  or  some  bread  and 
butter,  or  a  glass  of  milk  at  the  bedside,  so  that,  on  waking,  the  food  is  taken  to 
relieve  the  pain.  The  pain  may  be  more  severe,  in  fact,  indistinguishable  from 
a  mild  form  of  hepatic  colic,  coming  on  two  or  three  hours  after  food,  as  a 
"  colic  "  or  a  "  spasm."  As  the  pain  comes  on  at  a  time  when  the  patient  begins 
to  feel  hungry  for  his  next  meal,  the  term  "  hunger-pain  "  seems  appropriate. 
A  feeling  of  flatulent  distention  in  the  epigastrium  is  often  very  distressing; 
some  patients  describe  it  as  the  most  intolerable  of  all  their  symptoms.  The 
appetite  is  generally  good,  if  stenosis  has  not  developed.  It  is  not  unusual  for 
a  patient  to  say :  "  I've  a  good  appetite,  I  can  take  anything,  and  I  never 
vomit."  After  a  time,  a  few  weeks,  a  month  or  two,  the  symptoms  may  gradu- 
ally improve,  and  even  disappear,  to  reassert  themselves  after  a  longer  or 
shorter  interval.  In  the  intervals  of  these  attacks,  he  may  be  perfectly  well, 
enjoy  food,  and  gain  weight.  Vomiting  is  an  infrequent  symptom  of  duodenal 
ulceration,  it  comes  as  a  constant  symptom  only  when  stenosis  is  present.  Ex- 
amination of  the  surface  of  the  abdomen  will  generally  reveal  a  tender  area 
a  little  above  and  slightly  to  the  right  of  the  umbilicus.  The  most  serious  of 
the  symptoms,  which  result  from  duodenal  ulceration,  is  haemorrhage,  which 
may  be  manifest  as  hsematemesis  or  melsena  alone.  In  nearly  40  per  cent  of 
the  cases  ulcer  of  the  stomach  also  is  present,  and  in  such  the  pain  comes 
earlier  after  food  and  the  tenderness  on  pressure  is  higher  and  to  the  left. 

The  experience  of  surgeons  has  taught  us  that  a  number  of  cases  in  which 
the  pains  were  regarded  as  gastralgia  have  in  reality  been  due  to  gall-stones, 
with  which,  as  is  now  well  known,  jaundice  is  not  necessarily  connected. 

Treatment. — Post-mortem  observations  show  that  a  very  large  number  of 
ulcers  heal  completely,  but  the  process  is  slow  and  tedious,  often  requiring 
months,  or,  in  severe  cases,  years.  The  following  are  the  important  points 
in  treatment: 

(a)  Absolute  rest  in  bed. 

(&)  A  carefully  and  systematically  regulated  diet.  While  theoretically 
it  is  better  to  give  the  stomach  complete  rest  by  rectal  feeding,  yet  in  prac- 
tice this  strict  limitation  is  not  found  satisfactory.  The  food  should  be 
bland,  easily  digested,  and  given  at  stated  intervals.  The  following  dietary 
will  be  found  useful :  At  8  a.  m.  give  200  cc.  of  Leube's  beef  solution ;  at 
12  M.,  300  cc.  of  milk  gruel  or  peptonized  milk.  The  gruel  should  be  made 
with  ordinary  flour  or  arrowroot,  and  is  mixed  with  an  equal  quantity  of 
milk.  If  necessary  it  may  be  peptonized.  Buttermilk  is  very  well  borne 
by  these  patients.  At  4  p.  m.  the  beef  solution  again,  and  at  8  p.  m.  the  milk 
gruel  or  the  buttermilk. 

The  stomach  in  some  cases  is  so  irritable  that  the  smallest  amount  of 
food  is  not  well  borne.  In  such  cases  lavage  may  be  practised,  if  necessary, 
every  morning,  with  mildly  alkaline  water,  after  which  the  beef  solution  is 
given  and  the  feeding  supplemented  by  the  rectal  injections.  Ill  effects  rarely 
follow  the  careful  use  of  the  stomach  tube  in  gastric  ulcer.  There  are  some 
cases  which  do  well  from  the  outset  on  a  milk  diet,  given  at  regular  intervals, 
3  or  4  ounces  every  two  hours.  When  milk  is  not  well  borne  egg  albumen 
may  be  substituted,  or  the  whites  of  eight  eggs  may  be  alternated  with  Leube's 
beef  solution.  At  the  end  of  a  month,  if  the  condition  has  improved,  the 
patient  may  be  allowed  scraped  beef  or  young  chicken,  perfectly  fresh  sweet- 


478  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

bread,  and  farinaceous  puddings  made  with  milk  and  eggs.  Local  applica- 
tions, such  as  warm  fomentations,  over  the  abdomen  are  very  useful.  The 
patient  should  be  told  that  the  treatment  will  take  at  least  three  months,  and 
for  the  greater  portion  of  the  time  he  should  be  in  bed. 

(c)  Medicinal  measures  are  of  very  little  value  in  gastric  ulcer,  and  the 
remedies  employed  probably  do  not  benefit  the  ulcer,  but  the  gastric  catarrh. 
The  Carlsbad  salts  are  warmly  recommended  by  von  Ziemssen.  The  artificial 
preparation  (sulphate  of  sodium,  50  parts;  bicarbonate  of  sodium,  6;  chloride 
of  sodium,  3)  may  be  substituted,  of  which  a  teaspoonful  is  taken  every  morn- 
ing. Bismuth,  in  doses  of  30  to  60  grains  three  times  a  day,  and  nitrate  of 
silver  may  be  given,  but  they  influence  the  associated  conditions  rather  than 
the  ulcer. 

The  pain,  if  severe,  requires  opium.  Unless  the  gastralgia  is  intense  mor- 
phia should  not  be  given  hypodermically,  as  there  is  a  very  serious  danger 
in  these  cases  of  establishing  the  morphia  habit.  Doses  of  an  eighth  of  a 
grain,  with  the  bicarbonate  of  soda  and  bismuth,  will  allay  the  mild  attacks, 
but  the  very  severe  ones  require  the  hypodermic  injection  of  a  quarter  or  often 
half  a  grain.  Antipyrin  and  antifebrin  may  be  tried,  but,  as  a  rule,  are  quite 
ineffectual.  In  the  milder  attacks  Hoffman's  anodyne,  or  20  or  30  drops  of 
spirits  of  chloroform,  or  the  spirits  of  camphor  will  give  relief.  Counter- 
irritation  over  the  stomach  with  mustard  or  cantharides  is  often  useful. 

When  the  stomach  is  irritable,  the  patient  should  be  fed  per  rectum. 
He  will  sometimes  retain  food  which  is  passed  into  the  stomach  through  the 
tube,  and  Leube's  beef  solution  or  milk  may  be  given  in  this  way.  Cracked 
ice,  chloroform,  oxalate  of  cerium,  bismuth,  hydrocyanic  acid,  and  ingluvin 
may  be  tried.  When  hsemorrhage  occurs  the  patient  should  be  put  under 
the  influence  of  opium  as  rapidly  as  possible.  No  attempt  should  be  made 
to  check  the  haemorrhage  by  administering  medicines  by  the  mouth;  as  the 
profuse  bleeding  is  always  from  an  eroded  artery,  frequently  from  one  of 
considerable  size,  it  is  doubtful  if  acetate  of  lead,  tannic  and  gallic  acids,  and 
the  usual  remedies  have  the  slightest  influence.  The  essential  point  is  to 
give  rest,  which  is  best  obtained  by  opium.  Ergotin  may  be  administered 
hypodermically  in  two-grain  doses.  Nothing  should  be  given  by  the  mouth 
except  small  quantities  of  ice.  In  profuse  bleeding  a  ligature  may  be  applied 
around  a  leg,  or  a  leg  and  arm.  Not  infrequently  the  loss  of  blood  is  so  great 
that  the  patient  faints.  A  fatal  result  is  not,  however,  very  common  from 
haemorrhage.  Transfusion,  direct  from  artery  to  vein  by  Crile's  method,  may 
be  necessary,  or  the  subcutaneous  infusion  of  saline  solution. 

The  patients  usually  recover  rapidly  from  the  haemorrhage  and  require 
iron  in  full  doses,  which  may,  if  necessary,  be  given  hypodermically. 

Surgical  interference  is  indicated :  ( 1 )  In  the  chronic  indurated  ulcer. 
Experience  has  shown  that  after  gastro-enterostomy  the  ulcer  heals  rapidly, 
and  in  some  cases  the  ulcer  itself  may  be  located;  (3)  in  all  cases  when  the 
ulcer  has  caused  mechanical  interferences  with  'the  passage  of  the  gastric  con- 
tents; (3)  in  all  cases  associated  with  recurring  haemorrhages.  In  young  girls 
the  single  severe  attack  of  haematemesis  may  be  a  simple  gastrorrhexis,  or  from 
a  simple  ulcer  that  heals  readily,  but  in  men  severe  haematemesis  is  almost 
always  from  the  chronic  ulcer.  (4)  In  the  perigastric  adhesions  after  chronic 
ulcer  operation  is  sometimes  helpful. 


DISEASES  OF  THE  STOMACH.  479 

In  the  present  state  of  our  knowledge  it  is  not  easy  to  determine  the  limits 
of  medical  and  surgical  practice  in  the  treatment  of  peptic  ulcer.  The  old 
statistics  are  not  of  much  avail,  since  it  is  quite  clear  that  scores  of  cases  have 
been  masquerading  under  the  names  of  hyperchlorhydria,  acid  dyspepsia,  and 
so  forth.  The  simple  non-indurated  ulcer  is,  in  the  majority  of  cases,  a  medi- 
cal disease.  A  chronic  indurated  form  is  best  treated  surgically.  It  is  not 
always  easy  to  say  when  a  given  case  ceases  to  be  medical.  Much  will  depend 
on  the  technical  skill  available.  Gastro-enterostomy  is  not  in  all  hands  a  sim- 
ple affair,  and  while  the  chronic  ulcer  is  slow  and  hard  to  heal,  and  has  many 
possibilities  for  evil,  it  is  not  a  killing  disease. 

V.     CANCER    OF   THE    STOMACH. 

Etiology. — Incidence. — In  an  analysis  of  30,000  cases  of  cancer,  W.  H.. 
Welch  found  the  stomach  involved  in  21.4  per  cent,  this  organ  thus  standing 
next  to  the  uterus  in  order  of  frequency.  Among  8,464  cases  admitted  to  my 
wards,  there  were  150  cases  of  cancer  of  the  stomach.  There  were  39  cases 
among  the  first  1,000  autopsies  in  the  post-mortem  room  of  the  Johns  Hopkins 
Hospital.  The  disease  is  more  common  in  some  countries.  Figures  indicate 
that  cancer  of  the  stomach,  as  of  other  organs,  is  increasing  in  frequency. 

Sex. — T.  McCrae  has  analyzed  150  cases  from  my  wards  and  found  that 
there  were  126  males  and  24  females.    Welch  gives  the  ratio  as  5  to  4. 

Age. — Of  our  150  cases  the  ages  were  as  follows :  Between  twenty  and 
thirty,  6;  from  thirty  to  forty,  17;  forty  to  fifty,  38;  fifty  to  sixty,  49;  sixty 
to  seventy,  36;  seventy  to  eighty,  4.  Fifty-eight  per  cent  occurred  between 
the  ages  of  forty  and  sixty.  Of  the  6  cases  occurring  under  the  thirtieth 
year,  the  youngest  was  twenty-two.  Of  the  large  number  of  cases  analyzed 
by  Welch,  three-fourths  occurred  between  the  fortieth  and  seventieth  years. 
Congenital  cancer  of  the  stomach  has  been  described,  and  cases  have  been  met 
witli  in  children. 

Race. — Among  our  150  cases,  131  were  white;  19  were  negroes. 

Heredity. — Of  the  150  cases  in  only  11  was  there  a  positive  history  of 
cancer  in  the  family.  In  some  families,  as  the  Bonapartes,  the  disease  seems 
to  prevail.  In  our  series  a  very  much  larger  number — 38 — ^had  a  family 
history  of  tuberculosis. 

Previous  Diseases,  Habits,  etc. — A  history  of  dyspepsia  was  present  in 
only  33  cases;  of  these,  17  had  had  attacks  at  intervals,  11  had  had  chronic 
stomach  trouble,  and  5  had  had  dyspepsia  for  one  or  two  years  before  the 
symptoms  of  cancer  developed.  Napoleon,  discussing  this  interesting  point 
with  his  physician  Autommarchi,  said  that  he  had  always  had  a  stomach  of 
iron  and  felt  no  inconvenience  until  the  onset  of  what  proved  to  be  his 
fatal  illness. 

Alcohol. — Seventy-seven  of  our  patients  had  used  it  regularly,  65  of  these 
moderately  (?),  8  excessively.  Trauma. — Only  one  case  gave  a  positive  his- 
tory. In  one  case  the  cancer  followed  rapidly  upon  a  blow  on  the  stomach, 
and  the  patient  lost  sixty  pounds  in  weight  in  three  months.  Gastric  Ulcer. 
— Four  cases  gave  a  history  pointing  to  ulcer,  but  there  was  no  instance  of 
ulcus  carcinomatosum  among  the  autopsies. 

Mental  worry  and  strain  were  given  occasionally  as  causes  of  the  illness. 


480  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

Morbid  Anatomy. — The  most  common  varieties  of  gastric  cancer  are  the 
cylindrical-celled  adeno-carcinoma  and  the  encephaloid  or  medullary  car- 
cinoma; next  in  frequency  is  scirrhous,  and  then  colloid  cancer.  With 
reference  to  the  situation  of  the  tumor,  Welch  analyzed  1,300  cases,  in 
which  the  distribution  was  as  follows:  Pyloric  region,  791;  lesser  curvature^ 
148;  cardia,  104;  posterior  wall,  68;  the  whole  or  greater  part  of  the 
stomach,  61;  multiple  tumors,  45;  greater  curvature,  34;  anterior  wall,  30; 
fundus,  19. 

The  medullary  cancer  occurs  in  soft  masses,  which  involve  all  the  coats 
of  the  stomach  and  usually  ulcerate  early.  The  tumor  may  form  villous 
projections  or  cauliflower-like  outgroT\i:hs.  It  is  soft,  grajdsh  white  in  color, 
and  contains  much  blood.  Microscopically  it  shows  a  scanty  stroma,  enclosing 
alveoli  which  contain  irregular  polyhedral  and  cylindrical  cells.  The  cylin- 
drical-celled epithelioma  may  also  form  large  irregular  masses,  but  the  con- 
sistence is  usually  firmer,  particularly  at  the  edges  of  the  cancerous  ulcers. 
Microscopically  the  section  shows  elongated  tubular  spaces  filled  with  col- 
umnar epithelium,  and  the  intervening  stroma  is  abundant.  Cysts  are  not 
uncommon  in  this  form.  The  scirrhous  variety  is  characterized  by  great  hard- 
ness, due  to  the  abundance  of  the  stroma  and  the  limited  amount  of  alveolar 
structures.  It  is  seen  most  frequently  at  the  pylorus,  where  it  is  a  common 
cause  of  stenosis.  It  may  be  combined  with  the  medullary  form.  It  may 
be  diffuse,  involving  all  parts  of  the  organ,  and  leading  to  a  condition  which 
can  not  be  recognized  macroscopically  from  cirrhosis.  This  form  has  also 
been  seen  in  the  stomach  secondary  to  cancer  of  the  ovaries.  In  connection 
with  the  diffuse  carcinomatosis  there  may  be  simultaneous  involvement  of  the 
small  and  large  intestines,  as  in  the  three  remarkable  cases  reported  by  Kut- 
tall  and  Emanuel.  The  colloid  cancer  is  peculiar  in  its  wide-spread  invasion 
of  all  the  coats.  It  also  spreads  with  greater  frequency  to  the  neighboring 
parts,  and  it  occasionally  causes  extensive  secondary  growths  of  the  same 
nature  in  other  organs.  The  appearance  on  section  is  very  distinctive,  and 
even  with  the  naked  eye  large  alveoli  can  be  seen  filled  with  the  translucent 
colloid  material.  The  term  alveolar  cancer  is  often  applied  to  this  form. 
Ulceration  is  not  constantly  present,  and  there  are  instances  in  which,  with 
most  extensive  disease,  digestion  has  been  but  slightly  disturbed.  There  is  a 
specimen  in  the  Warren  Museum,  at  the  Harvard  Medical  School,  of  the  most 
wide-spread  colloid  cancer,  in  which  the  stomach  contained  after  death  large 
pieces  of  undigested  beef-steak. 

Secoxdary  Caxcer  of  the  Stomach, — Of  37  cases  collected  by  Welch, 
17  were  secondary  to  cancer  of  the  breast.  Among  the  first  1,000  autopsies  at 
the  Johns  Hopkins  Hospital  there  were  3  cases  of  secondary  cancer. 

Changes  in  the  Stomach. — Cancer  at  the  cardia  is  usually  associated 
with  wasting  of  the  organ  and  reduction  in  its  size.  The  oesophagus  above  the 
obstruction  may  be  greatly  dilated.  On  the  other  hand,  annular  cancer  at 
the  pylorus  causes  stenosis  with  great  dilatation  of  the  organ.  In  a  few  rare 
instances  the  pylorus  has  been  extremely  narrowed  without  any  increase  in 
the  size  of  the  stomach.  In  diffuse  scirrhous  cancer  the  stomach  may  be  very 
greatly  thickened  and  contracted.  It  may  be  displaced  or  altered  in  shape 
by  the  weight  of  the  tumor,  particularly  in  cancer  of  the  pylorus;  in  such 
cases  it  has  been  found  in  every  region  of  the  abdomen,  and  even  in  the  true 


DISEASES  OF  THE  STOMACH.  481 

pelvis.  The  mobility  of  the  tumors  is  at  times  extraordinary  and  very  de- 
ceptive, and  they  may  be  pushed  into  the  right  hypochondrium  or  into  the 
splenic  region,  entirely  beneath  the  ribs.  Adhesions  very  frequently  occur, 
particularly  to  the  colon,  the  liver,  and  the  anterior  abdominal  wall. 

Secondary  cancerous  growths  in  other  organs  are  very  frequent,  as  shown  ' 
by  the  following  analysis  by  Welch  of  1,574  cases:  Metastasis  occurred  in  the 
lymphatic  glands  in  551 ;  in  the  liver  in  475 ;  in  the  peritonaeum,  omentum, 
and  intestine  in  357;  in  the  pancreas  in  123;  in  the  pleura  and  lung  in  98; 
in  the  spleen  in  26 ;  in  the  brain  and  meninges  in  9 ;  in  other  parts  in  92. 
The  lymph-glands  affected  are  usually  those  of  the  abdomen,  but  the  cervical 
and  inguinal  glands  are  not  infrequently  attacked,  and  give  an  important  clue 
in  diagnosis.  Secondary  metastatic  growths  occur  subcutaneously,  either  at 
the  navel  or  beneath  the  skin  in  the  vicinity,  and  are  of  great  value  in  diagnosis. 
In  one  instance  a  patient  with  jaundice,  which  had  developed  somewhat  sud- 
denly and  was  believed  to  be  catarrhal,  presented  no  signs  of  enlargement  of 
the  liver  or  tumor  of  the  stomach,  but  a  nodular  body  appeared  at  the  navel, 
which  on  removal  proved  to  be  typical  scirrhus.  A  second  case  in  the  ward 
at  the  same  time,  with,  an  obscure  doubtful  tumor  in  the  left  hypochondrium, 
developed  a  painful  nodular  subcutaneous  growth  midway  between  the  navel 
and  the  left  margin  of  the  ribs, 

Perfokation. — In  the  extensive  ulceration  which  occurs  perforation  of  the 
stomach  is  not  uncommon.  It  occurred  into  the  peritongeum  in  17  of  the  507 
cases  of  cancer  of  the  stomach  collected  by  Brinton.  In  our  series  perforation 
is  recorded  in  4  cases.  When  adhesions  form,  the  most  extensive  destruction 
of  the  walls  may  take  place  without  perforation  into  the  peritoneal  cavity. 
In  one  instance  which  came  under  my  observation  a  large  portion  of  the  left 
lobe  of  the  liver  lay  within  the  stomach.  Occasionally  a  gastro-cutaneous 
fistula  is  established.  Perforation  may  occur  into  the  colon,  the  small  bowel, 
the  pleura,  the  lung,  or  into  the  pericardium. 

Symptoms. — Latent  Carcinoma. — The  cases  are  not  very  infrequent.  There 
may  be  no  symptoms  pointing  to  the  stomach,  and  the  tumor  may  be  discov- 
ered accidentally  after  death.  In  a  second  group  the  symptoms  of  carcinoma 
are  present,  not  of  the  stomach,  but  of  the  liver  or  some  other  organ,  or  there 
are  subcutaneous  nodules,  or,  as  in  one  of  our  cases,  secondary  masses  on  the 
ribs  and  vertebrae.  In  a  third  group,  seen  particularly  in  elderly  persons  in 
institutions,  there  is  gradual  asthenia,  without  nausea,  vomiting,  or  other 
local  symptoms. 

Features  of  Onset. — Of  the  150  cases  in  our  series,  48  complained  of  pain, 
44  of  dyspepsia,  21  of  vomiting,  13  of  loss  in  weight,  3  of  difficulty  in  swallow- 
ing, 1  of  tumor.  In  7  the  features  of  onset  suggested  pernicious  anaemia. 
In  37  cases  there  was  a  history  of  sudden  onset. 

General  Symptoms. — Loss  of  Weight. — Progressive  emaciation  is  one  of 
the  most  constant  features  of  the  disease.  In  79  of  our  cases  in  which  exact 
figures  were  taken:  To  30  pounds,  32  cases;  30  to  50  pounds,  36  cases;  50  to 
60  pounds,  5  cases;  60  to  70  pounds,  4;  over  70  pounds,  1 ;  100  pounds,  a  case 
of  cancer  at  the  cardiac  end  with  obstruction  to  swallowing.  The  loss  in 
weight  is  not  always  progressive.  We  see  increase  in  weight  under  three  con- 
ditions: (a)  Proper  dieting,  with  treatment  of  the  associated  catarrh  of  the 
stomach;  (&)  in  cases  of  cancer  of  the  pylorus  after  relief  of  the  dilatation 


482  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

of  the  organ  by  lavage,  etc.;  (c)  after  a  profound  mental  impression.  I  have 
known  a  gain  of  ten  pounds  to  follow  the  visit  of  an  optimistic  consultant. 
In  Keen  and  D.  D,  Stewart's  case  there  was  a  gain  of  seventy  pounds  after 
an  exploratory  operation ! 

Loss  in  strength  is  usually  proportionate  to  the  loss  in  weight.  One  sees 
sometimes  remarkable  vigor  almost  to  the  close,  but  this  is  exceptional. 

Ancemia  is  present  in  a  large  proportion  of  all  cases,  and  with  the  emacia- 
tion gives  the  picture  of  cachexia.  There  is  often  a  yellow  or  lemon  tint  of 
the  skin.  In  59  cases  careful  blood-counts  were  made,  in  3  the  red  corpuscles 
were  above  6,000,000  per  cubic  millimetre.  This  occurs  in  the  concentrated 
condition  of  the  blood  in  certain  cases  of  cancer  of  the  pylorus  with  dilatation 
of  the  stomach.  The  average  count  in  the  59  cases  was  3,712,186  per  cubic 
millimetre.  In  only  8  cases  was  the  count  below  2,000,000,  and  in  none  below 
1,000,000.  The  average  of  the  hsemoglobin  was  44.9  per  cent.  In  only  9  was 
it  below  30  per  cent.  In  62  cases  in  which  the  leucocytes  were  counted  there 
were  only  18  cases  in  which  they  were  above  12,000  per  cubic  millimetre;  in 
only  3  cases  were  they  above  20,000.  As  mentioned,  there  were  7  cases  in 
which  the  features  of  onset  suggested  a  primary  anaemia.  To  this  question 
we  shall  return  under  diagnosis. 

Among  other  general  symptoms  may  be  mentioned  fever^  which  was  present 
at  some  time  in  74  of  our  150  cases.  In  only  13  of  these  did  the  temperature 
rise  above  101°.  In  2  it  was  above  103°.  Fifteen  presented  fairly  constant 
elevation  of  temperature.  Eight  presented  sudden  rises.  Two  cases  had 
chill,  with  elevation  to  103°  and  104°.  Chills  may  be  associated  with  sup- 
puration at  the  base  of  the  cancer. 

Urine. — There  may  be  no  changes  throughout;  in  65  of  our  cases  there 
were  no  alterations,  in  36  albumin  was  found,  and  in  34  albumin  with  tube- 
casts.  Glycosuria,  peptonuria,  and  acetonuria  have  been  described.  Indican 
is  common. 

(Edema. — Swelling  of  the  ankles  is  of  frequent  occurrence  toward  the 
close.  In  some  cases  there  is  even  early  a  general  anasarca,  usually  in  com- 
bination with  extreme  anaemia.     The  cancer  is  usually  overlooked. 

The  howels  are  often  constipated.  In  only  12  cases  in  our  series  was 
diarrhoea  present.  In  2  cases  blood  was  passed  per  rectum.  There  are  no 
special  cardiac  symptoms;  the  pulse  becomes  progressively  weaker.  '  Throm- 
bosis of  one  femoral  vein  may  occur  or,  as  in  one  of  our  cases,  wide-spread 
thrombosis  in  the  superficial  veins  of  the  body. 

Symptoms  on  the  part  of  the  nervous  system  are  rare;  consciousness  is 
often  retained  to  the  end.  Coma  may  occur  similar  to  that  seen  in  diabetes, 
and  is  believed  to  be  due  to  an  acid  intoxication. 

FuNCTioxAL  Disturbances, — Anorexia,  loss  of  desire  for  food,  is  a  fre- 
quent and  valuable  symptom,  more  constant  perhaps  than  any  other.  Nausea 
is  a  striking  feature  in  many  cases;  there  is  often  a  sudden  repulsion  at  the 
sight  of  food.     In  exceptional  cases  the  appetite  is  retained  throughout. 

Vomiting  may  come  on  early,  or  only  after  the  dyspepsia  has  persisted 
for  some  time.  It  occurred  in  128  cases  in  our  series.  At  first  it  is  at  long 
intervals,  but  subsequently  it  is  more  frequent,  and  may  recur  several  times 
in  the  day.  There  are  cases  in  which  it  comes  on  in  paroxysms  and  then 
subsides;  in  other  cases,  it  sets  in  early,  persists  with  great  violence,  and 


DISEASES  OF  THE  STOMACH.  483 

may  cause  a  fatal  termination  within  a  few  weeks.  Vomiting  is  more  fre- 
quent when  the  cancer  involves  the  orifices,  particularly  the  pylorus,  in 
which  case  it  is  usually  delayed  for  an  hour  or  more  after  taking  the  food. 
When  the  cardiac  orifice  is  involved  it  may  follow  at  a  shorter  interval. 
Extensive  disease  of  the  fundus  or  of  the  anterior  or  posterior  wall  may 
be  present  without  the  occurrence  of  vomiting.  The  food  is  sometimes  very 
little  changed,  even  after  it  has  remained  in  the  stomach  for  twenty-four 
hours. 

Hcemorrliage  occurred  in  36  of  our  150  cases;  in  33  the  blood  was  dark 
and  altered,  in  3  it  was  bright  red.  In  2  cases  vomiting  of  blood  was  the 
first  symptom.  The  bleeding  is  rarely  profuse;  more  commonly  there  is 
slight  oozing,  and  the  blood  is  mixed  with,  or  altered  by  the  secretions,  and, 
when  vomited,  the  material  is  dark  brown  or  black,  the  so-called  "  coffee- 
ground  "  vomit.  The  blood  can  be  recognized  by  the  microscope  as  shadows 
of  the  red  blood-corpuscles  and  irregular  masses  of  altered  blood  pigment. 
In  cases  of  doubt  the  spectroscope  may  be  employed  or  haemin  crystals 
obtained. 

Pain,  an  early  and  important  symptom,  was  present  in  130  of  our  cases. 
It  is  very  variable  in  situation,  and  while  most  common  in  the  epigastrium, 
it  may  be  referred  to  the  shoulders,  the  back,  or  the  loins.  The  pain  is  de- 
scribed as  dragging,  burning,  or  gnawing  in  character,  and  very  rarely  occurs 
in  severe  paroxysms  of  gastralgia,  as  in  gastric  ulcer.  As  a  rule,  the  pain  is 
aggravated  by  taking  food.  There  is  usually  marked  tenderness  on  pressure 
in  the  epigastric  region.  The  areas  of  skin  tenderness  are  referred,  as  Head 
has  shown,  to  the  region  between  the  nipple  and  the  umbilicus  in  front  and 
behind  from  the  fifth  to  the  twelfth  thoracic  spine. 

■  Examination  of  the  Stomach  Contents. — The  vomitus  in  suspected 
eases  should  be  carefully  studied,  particularly  as  to  quantity  and  character 
of  ingredients.  Large  amounts  brought  up  at  intervals  of  a  few  days,  with 
the  appearances  already  described,  are  characteristic  of  dilatation  of  the 
stomach.  Some  of  the  material  should  be  spread  in  a  large  glass  plate  and 
any  suspicious  portions  picked  out  for  examination.  Bacteria  in  large  num- 
bers occur,  one,  the  Oppler-Boas  bacillus — an  unusually  long  non-mobile  form 
— is  supposed  to  be  of  diagnostic  value,  and  to  be  largely  responsible  for  the 
formation  of  lactic  acid.  The  yeast  fungus  is  very  commonly  found,  sarcinse 
less  frequently  than  in  dilatation  from  stricture.  Blood  is  a  most  important 
ingredient;  the  persistent  presence  microscopically  of  red  corpuscles  in  the 
early  morning  washings  is  always  very  suspicious.  Later,  when  coffee-ground 
vomiting  takes  place,  the  macroscopic  evidence  is  sufficient.  In  cases  of  doubt 
the  spectroscope  may  be  used  or  the  test  made  for  haemin  crystals.  Fragments 
of  the  new  growth  may  be  vomited  or  may  appear  in  the  washings.  Positive 
evidence  of  cancer  may  be  obtained  from  them. 

Examination  of  the  Test  BreaTcfast.—The  Ewald  test  meal,  consisting 
of  a  slice  of  stale  bread  and  a  large  cup  of  weak  tea  without  cream  or  sugar, 
is  given  at  7  a.  m.  and  withdrawn  at  8  a.  m.  The  Boas  test  meal,  consisting 
of  a  gruel  made  of  a  tablespoonful  of  oatmeal  flour  in  a  litre  of  water,  is 
used  in  the  estimation  of  lactic  acid.  As  an  outcome  of  the  enormous  num- 
ber of  observations  made  of  late  years,  it  may  be  said  that  free  HCl  is  absent 
in  a  large  proportion  of  all  cases  of  cancer  of  the  stomach.     Of  94  cases  in 


484  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

which  the  contents  were  examined  in  84  free  HCl  was  absent.  In  5  Tin- 
doubted  cases  the  reaction  was  good;  in  3  of  these  the  history  suggested 
previous  ulcer.  HCl  may  be  absent  in  chronic  gastritis  and  in  atrophy  of  the 
gastric  mucosa.  The  presence  of  lactic  acid  after  Boas'  test  meal  is  regarded 
as  a  valuable  sign. 

Physical  Examination. — Inspection. — After  a  preliminary  survey,  em- 
bracing the  facies,  state  of  nutrition,  etc.,  particular  direction  is  given  to  the 
abdomen.  An  all-important  matter  is  to  have  the  patient  in  a  good  light. 
Fulness  in  the  epigastric  region,  inequality  in  the  infracostal  grooves,  the 
existence  of  peristalsis,  a  wide  area  of  aortic  pulsation,  the  presence  of  sub- 
cutaneous nodules  or  small  masses  about  the  navel,  and,  lastly,  a  well-defined 
tumor  mass — these,  together  or  singly,  may  be  seen  on  careful  inspection. 
I  can  not  emphasize  too  strongly  the  value  of  this  method  of  examination. 
In  62  of  the  150  cases  a  positive  tumor  could  be  seen.  In  52  the  tumor 
descended  with  inspiration;  in  36  peristalsis  was  visible;  in  3  cases  move- 
ments were  visible  in  the  tumor  itself.  In  10  cases  with  visible  peristalsis 
no  tumor  was  seen,  but  could  be  felt  on  palpation.  Inflation  with  carbonic- 
acid  gas  may  be  tried,  except  when  hgemorrhage  has  been  profuse  or  the  cancer 
is  very  extensive.  The  dilatation  often  renders  evident  the  peristalsis  or  may 
bring  a  tumor  into  view.  The  presence  of  subcutaneous  and  umbilical  nodules 
is  sometimes  a  very  great  help.  They  were  found  in  5  of  our  series.  Palpa- 
tion.— In  115  cases  a  tumor  could  be  felt;  in  48  in  the  epigastric  region,  in 
25  in  the  umbilical,  in  18  in  the  left  hypochondriac,  in  17  in  the  right  hypo- 
chondriac region,  while  in  7  cases  a  mass  descended  in  deep  inspiration  from 
beneath  the  left  costal  margin.  These  figures  illustrate  in  how  large  a  propor- 
tion of  the  cases  the  tumor  is  in  evidence.  In  rare  cases  examination  in  the 
knee-elbow  position  is  of  value.  Mobility  in  gastric  tumor  is  a  point  of  much 
importance.  First,  the  change  with  respiration,  already  referred  to;  a  mass 
may  descend  3  or  4  inches  in  deep  inspiration;  secondly,  the  communicated 
pulsation  from  the  aorta,  which  is  often  in  its  extent  suggestive;  thirdly,  the 
intrinsic  movements  in  the  hypertrophied  muscularis  in  the  neighborhood 
of  the  cancer.  This  may  give  a  remarkable  character  to  the  mass,  causing 
it  to  appear  and  disappear,  lifting  the  abdominal  wall  in  the  epigastric  region ; 
and,  fourthly,  mechanical  movements,  with  inflation,  with  change  of  posture, 
or  communicated  with  the  hand.  Tumors  of  the  pylorus  are  the  most  mov- 
able, and  in  extreme  cases  can  be  displaced  to  either  hypochondrium  or  pushed 
far  down  below  the  navel  (see  illustrative  cases  in  my  Lectures  on  the  Diag- 
nosis of  Abdominal  Tumors).  Pain  on  palpation  is  common;  the  mass  is 
usually  hard,  sometimes  nodular.  Gas  can  at  times  be  felt  gurgling  through 
the  tumor  at  the  pyloric  region. 

Percussion  gives  less  important  indications — the  note  over  a  tumor  is 
rarely  flat,  more  often  a  flat  tympany.  Auscultation  may  reveal  the  gurgling 
through  the  pylorus ;  sometimes  a  systolic  bruit  is  transmitted  f rora  the  aorta, 
and  when  a  local  peritonitis  exists  a  friction  may  be  heard. 

Complications. — Secondary  growths  are  common.  In  44  autopsies  in  our 
series  there  were  metastases  in  38;  in  29  the  lymph-glands  were  involved; 
in  23  the  liver^  in  11  the  peritonaeum,  in  8  the  pancreas,  in  8  the  bowel,  in 
4  the  lung,  in  3  the  pleura,  in  4  the  kidneys,  and  in  2  the  spleen.  In  8  no 
deposits  were  found. 


DISEASES  OF  THE  STOMACH.  485 

Perforation  may  lead  to  peritonitis,  but  in  3  of  our  4  cases  there  was  no 
general  involvement.  Cancerous  ascites  is  not  very  uncommon.  Dock  has 
called  attention  to  the  value  of  the  examination  of  the  fluid  in  such  cases 
as  a  help  to  diagnosis.  The  cells  show  mitoses  and  are  very  characteristic. 
Secondary  cancer  of  the  liver  is  very  common;  the  enlargement  may  be  very 
great,  and  such  cases  are  not  infrequently  mistaken  for  primary  cancer  of 
the  organ.  Involvement  of  the  lymph-glands  may  give  valuable  indications. 
There  may  be  early  enlargement  of  a  gland  at  the  posterior  border  of  the 
left  sterno-cleido-mastoid  muscle;  later  adjacent  glands  may  become  affected. 
This  occurs  also  in  uterine  cancer.  According  to  Williams,  Troisier  was  the 
first  to  describe  this  condition,  which  must  not  be  confounded  with  the 
pseudo-lipome  sus-claviculaire  of  Verneuil. 

A  very  remarkable  picture  is  presented  when  the  cancer  sloughs  or  be- 
comes gangrenous ;  the  vomitus  has  a  foul  odor,  often  of  a  penetrating  nature, 
to  be  perceived  throughout  the  room.  In  cases  in  which  the  ulcer  perforates 
the  colon,  the  vomiting  may  be  faecal.  I  have,  however,  met  with  the  faecal 
odor  in  a  case  with  incessant  vomiting ;  there  was  no  perforation  of  the  colon 
at  autopsy. 

Course. — ^While  usually  chronic  and  lasting  from  a  year  to  eighteen 
months,  acute  cancer  of  the  stomach  is  by  no  means  infrequent.  Of  the  69 
cases  in  which  we  could  determine  accurately  the  duration,  15  lasted  under 
three  months,  16  from  three  to  six  months,  14  from  six  to  twelve  months — 
a  total  of  45  under  one  year.  Four  cases  lasted  for  two  years  or  over.  One 
case  lived  for  at  least  two  years  and  a  half. 

Diagnosis. — In  115  of  our  150  cases  a  tumor  existed,  and  with  this  the 
recognition  is  rarely  in  doubt.  Practically  the  chief  difficulty  is  in  those  cases 
which  present  gastric  symptoms  or  ansemia,  or  both,  without  the  presence 
of  tumor.  In  the  one  a  chronic  gastritis  is  suspected ;  in  the  other  a  primary 
anaemia.  In  chronic  gastritis  the  history  of  long-standing  dyspepsia,  the  ab- 
sence of  cachexia,  the  absence  of  lactic  acid  in  the  test  meal,  and  the  less 
striking  blood  changes  are  the  important  points  for  consideration.  The  cases 
with  grave  ancemia  without  tumor  offer  the  greatest  difficulty.  The  blood- 
count  is  rarely  so  low  as  in  pernicious  anaemia,  a  point  on  which  F.  P.  Henry 
has  laid  special  stress.  In  only  8  of  our  59  cases  with  careful  blood  exami- 
nation was  the  number  below  3,000,000  per  cubic  millimetre.  The  lower 
color  index,  as  in  secondary  anaemia,  the  absence  of  megaloblasts,  and  a  leuco- 
cytosis  speak  for  cancer.  Some  lay  stress  on  the  differential  count  of  the 
leucocytes,  but  there  is  not  evidence  enough  to  enable  us  to  speak  positively 
on  this  point.  The  digestion  leucocytosis  might  be  a  help  in  some  cases. 
The  chemical  findings  are  of  greater  value.  The  constant  presence  of  lactic 
acid  and  the  absence  of  HCl  have  in  several  of  our  cases  suggested  the  diag- 
nosis of  cancer,  which  has  been  verified  later  on  by  the  development  of  a 
tumor. 

From  ulcer  of  the  stomach  malignant  disease  is,  as  a  rule,  readily  recog- 
nized. The  ulcus  carcinomatosum  usually  presents  a  well-marked  history  of 
ulcer  for  years.  Hemmeter  has  given  a  good  account  of  this  rare  condition 
in  his  recent  work  on  the  stomach.  The  greatest  difficulty  is  offered  when 
there  is  ulcer  with  tumor  due  to  cicatricial  contraction  about  the  pylorus.  In 
3  such  cases  we  mistook  the  mass  for  cancer,  and  even  at  operation  it  may 


486  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

(as  in  one  of  them)  be  impossible  to  say  whether  a  neoplasm  is  present. 
The  persistent  hyperchlorhydria  is  the  most  important  single  feature  of  ulcer, 
and,  taken  with  the  gastralgic  attacks  and  the  haemorrhages,  rarely  leave  doubt 
as  to  the  condition. 

Nowadays,  when  exploratory  laparotomy  may  be  advised  with  such  safety, 
the  surgeon  often  makes  the  diagnosis. 

The  practitioner  should  recognize  the  fact  that  there  are  cases  of  cancer 
of  the  stomach  in  which  a  positive  diagnosis  can  not  be  reached  for  weeks 
or  months  by  any  known  means  at  our  command. 

Treatment. — In  early  surgical  treatment  lies  the  only  hope,  but  there  is 
great  difiSculty  in  the  diagnosis,  and  it  would  be  absurd  to  suggest  operation  in 
every  case  of  dyspepsia  of  three  months'  standing  in  persons  above  forty  years 
of  age.  Operated  upon  early,  complete  removal  is  sometimes  possible.  In  a 
majority  of  cases  the  operation  is  only  palliative.  In  suitable  cases  early  explo- 
ration should  be  advised ;  the  operation  per  se  is  sometimes  beneficial  and  the 
patient  is  rarely  the  worse  for  it.  The  diet  should  consist  of  readily  digested 
substances  of  all  sorts.  Many  patients  do  best  on  milk  alone.  Washing  out 
the  stomach,  which  may  be  done  with  a  soft  tube  without  any  risk,  is  par- 
ticularly advantageous  when  there  is  obstruction  at  the  pylorus,  and  is  by 
far  the  most  satisfactory  means  of  combating  the  vomiting.  The  excessive 
fermentation  is  also  best  treated  by  lavage.  When  the  pain  becomes  severe, 
particularly  if  it  disturbs  the  rest  at  night,  morphia  must  be  given.  One- 
eighth  of  a  grain,  combined  with  carbonate  of  soda  (gr.  v),  bismuth  (gr. 
v-x),  usually  gives  prompt  relief,  and  the  dose  does  not  always  require  to  be 
increased.  Creasote  (TTt  j-ij)  and  carbolic  acid  are  very  useful.  The  bleed- 
ing in  gastric  cancer  is  rarely  amenable  to  treatment. 

Other  Forms  of  Tumor. — Non-cancerous  tumors  of  the  stomach  rarely 
cause  inconvenience.  Polypi  (poly adenomata)  are  common  and  they  may 
be  numerous;  as  many  as  150  have  been  reported  in  one  case.  There  is  a 
form  in  which  the  adenoma  exists  as  an  extensive  area  slightly  raised  above 
the  level  of  the  mucosa — polyadenome  en  nappe  of  the  French.  H.  B.  An- 
derson has  described  a  case  of  remarkable  multiple  cysts  in  the  walls  of  the 
stomach  and  small  intestine.  Sarcomata  are  very  rare.  Fibromata  and 
lipomata  have  been  described. 

Foreign  bodies  occasionally  produce  remarkable  tumors  of  the  stomach. 
The  most  extraordinary  is  the  hair  tumor,  of  which  there  are  16  cases  in  the 
literature.  The  cases  occur  in  hysterical  women  who  have  been  in  the  habit 
of  eating  their  own  hair.  A  specimen  in  the  medical  museum  of  McGill 
University  is  in  two  sections,  which  form  an  exact  mould  of  the  stomach. 
The  tumors  are  large,  very  puzzling,  and  are  usually  mistaken  for  cancer. 
Of  7  cases  operated  upon,  6  recovered;  in  9  cases  the  condition  was  found 
post  mortem  (Schulten). 

VI.     HYPERTROPHIC    STENOSIS    OF   THE    PYLORUS. 

1.  In  Adults. — Microscopically,  the  condition  is  found  to  be  very  largely 
hypertrophy  of  the  muscularis  and  submucosa  of  the  pylorus.  It  was  well 
described  by  the  older  writers.  The  symptoms  are  those  of  dilatation  of  the 
stomach.    The  condition  has  been  fully  discussed  by  Boas  (Archiv  fiir  Ver- 


DISEASES  OF  THE  STOMACH.  487 

dauimgskrankheiten,  Bd.  4,  I),  who  reports  two  interesting  cases  with  suc- 
cessful gastro-enterostomy.  The  question  is  whether  some  of  these  cases  may 
not  really  be  congenital^  as  there  have  been  instances  reported  in  girls  as 
early  as  the  twelfth  and  sixteenth  years. 

2.  Congenital. — First  described  in  1897  by  John  Thomson,  of  Edinburgh, 
much  attention  has  been  paid  to  this  condition,  which  seems  very  common. 
Still  reports  20  cases  (1905). 

In  some  cases  a  true  hyperplasia  exists,  but  in  others,  as  Thomson  holds, 
spasmodic  contraction  is  the  important  factor.  The  diagnosis  is  easy — visible 
peristalsis  and  palpable  tumor. 

An  extraordinary  number  of  cases  have  been  reported  within  the  past  few 
years,  and  of  33  operated  upon  17  have  recovered  (Clogg,  November,  1904). 
Dieting,  nasal  feeding,  and  lavage  should  be  tried  before  operation.  In  the 
case  of  a  bottle-fed  baby,  a  wet-nurse  should  be  obtained. 

VII.    HEMORRHAGE    FROM   THE    STOMACH. 

(Heematemesis.) 

Etiology. — Gastrorrliagia,  as  this  symptom  is  called,  may  result  from 
many  conditions,  local  or  general.  1.  In  local  disease :  (a)  cancer;  (&)  ulcer; 
(c)  disease  of  the  blood-vessels,  such  as  miliary  aneurisms  and  occasionally 
varicose  veins;  (d)  acute  congestion,  as  in  gastritis,  and  possibly  in  vicarious 
haemorrhage;  (e)  following  operations  in  the  abdomen,  particularly  when 
the  omentum  is  wounded,  erosions  of  the  gastric  mucosa  may  occur,  from 
which  hsemorrhage  takes  place.  Many  cases  have  followed  operation  for 
appendicitis.  It  is  a  very  fatal  complication,  as  it  is  usually  associated  with 
peritonitis  ( Eichardson  ) . 

2.  Passive  congestion  due  to  obstruction  in  the  portal  system.  This  may 
be  either  (a)  hepatic,  as  in  cirrhosis  of  the  liver,  thrombosis  of  the  portal 
vein,  or  pressure  upon  the  portal  vein  by  tumor,  and  secondarily  in  cases 
of  chronic  disease  of  the  heart  and  lungs;  (6)  splenic.  Gastrorrhagia  is  by 
no  means  an  uncommon  symptom  in  enlarged  spleen,  and  is  explained  by  the 
intimate  relations  which  exist  between  the  vasa  brevia  and  the  splenic  cir- 
culation, 

3.  Toxic:  (a)  The  poisons  of  the  specific  fevers,  small-pox,  measles,  yellow 
fever;  (&)  poisons  of  unknown  origin,  as  in  acute  yellow  atrophy  and  in 
purpura;   (c)  phosphorus. 

4.  Traumatism:  (a)  Mechanical  injuries,  such  as  blows  and  wounds,  and 
occasionally  by  the  stomach- tube ;  (&)  the  result  of  severe  corrosive  poisons. 

5.  Certain  constitutional  diseases:  (a)  Haemophilia;  (b)  profound  anae- 
mias, whether  idiopathic  or  due  to  splenic  enlargements  or  to  malaria;  (c) 
cholaemia. 

6.  In  certain  nervous  affections,  particularly  hysteria,  and  occasionally 
in  progressive  paralysis  of  the  insane  and  epilepsy. 

7.  The  blood  may  not  always  come  primarily  from  the  stomach.  Thus 
it  may  belong  to  the  nose  or  the  pharynx.  In  haemoptysis  some  of  the  blood 
may  find  its  way  into  the  stomach.  Again,  in  bleeding  from  the  oesophagus 
blood  may  trickle  into  the  stomach,  from  which  it  is  ejected.     This  occurs 


4:SS  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

in  the  case  of  rapture  of  aneurism  and  of  tlie  oesophageal  varices.  A  cliild 
may  draw  blood  with  the  milk  from  the  mother's  breast  even  in  consideraljle 
quantities  and  then  vomit  it. 

8.  Gastrostaxis. — Under  this  name  Hale  White  describes  cases  of  hemor- 
rhage from  the  stomach  in  young  girls  without  any  lesion  of  the  mucosa. 
They  are  often  mistaken  for  ulcer.     He  has  collected  29  cases. 

9.  Miscellaneous  causes:  Aneurism  of  the  aorta  or  of  its  branches  may 
rapture  into  the  stomach.  There  are  instances  in  which  a  patient  has  vom- 
ited blood  once  without  ever  having  a  recurrence  or  without  developing 
symptoms  pointing  to  disease  of  the  stomach. 

In  new-born  infants  hematemesis  ma}'  occur  alone  or  in  connection  with 
bleeding  from  other  mucous  membranes. 

In  medical  practice,  haemorrhage  from  the  stomach  occurs  most  fre- 
quently in  connection  with  cirrhosis  of  the  liver  and  ulcer  of  the  stomach. 

Morbid  Anatomy. — When  death  has  occurred  from  the  hfematemesis  there 
are  signs  of  intense  ana?mia.  The  lesion  is  evident  in  cancer  and  in  ulcer  of 
the  stomach.  It  is  to  be  borne  in  mind  that  fatal  haemorrhage  may  come 
from  a  small  miliary  aneurism  communicating  with  the  surface  by  a  pin- 
hole perforation,  or  the  bleeding  may  be  due  to  the  rapture  of  a  submucous 
vein  and  the  erosion  in  the  mucosa  may  be  small  and  readily  overlooked. 
It  may  require  a  careful  and  prolonged  search  to  avoid  overlooking  such 
lesions.  In  the  large  group  associated  with  portal  obstruction,  whether  due 
to  hepatic  or  splenic  disease,  the  mucosa  is  usually  pale,  smooth,  and  shows 
no  trace  of  any  lesion.  In  cirrhosis,  fatal  by  hemorrhage,  one  may  some- 
times search  in  vain  for  any  focal  lesion  to  account  for  the  gastrorrhagia,  and 
we  must  conclude  that  it  is  possible  for  even  the  most  profuse  bleeding  to 
occur  by  diapedesis.  The  stomach  may  be  distended  with  blood  and  yet  the 
source  of  the  haemorrhage  be  not  apparent  either  in  the  stomach  or  in  the 
portal  system.  In  such  cases  the  oesophagus  should  be  examined,  as  the  bleed- 
ing may  come  from  that  source.  In  toxic  cases  there  are  invariably  haemor- 
rhages in  the  mucous  membrane  itself. 

Symptoms. — In  rare  instances  fatal  syncope  may  occur  without  any  vom- 
iting. In  a  case  of  the  kind,  in  which  the  woman  had  fallen  over  and  died 
in  a  ie^y  minutes,  the  stomach  contained  between  three  and  four  pounds  of 
blood.  The  sudden  profuse  bleedings  rapidly  lead  to  profound  anaemia. 
When  due  to  ulcer  or  cirrhosis  the  bleeding  usually  recurs  for  several  days 
Fatal  haemorrhage  from  the  stomach  is  met  with  in  ulcer,  cirrhosis,  enlarge- 
ment of  the  spleen,  and  in  instances  in  which  an  aneurism  ruptures  into  the 
stomach  or  oesophagus.  Gastrorrhagia  may  occur  in  splenic  anaemia  or  in 
leukemia  before  the  condition  has  aroused  attention. 

The  vomited  blood  may  be  fluid  or  clotted;  it  is  usually  dark  in  color, 
but  in  the  basin  the  outer  part  rapidly  becomes  red  from  the  action  of  the 
air.  The  longer  blood  remains  in  the  stomach  the  more  altered  is  it  when 
ejected. 

The  amount  of  blood  lost  is  very  variable,  and  in  the  course  of  a  day  the 
patient  may  bring  up  tliree  or  four  pounds,  or  even  more.  In  a  case  under 
the  care  of  George  Boss,  in  the  Montreal  General  Hospital,  the  patient  lost 
during  seven  days  ten  pounds,  by  measurement,  of  blood.  The  usual  symp- 
toms of  anaemia  develop  rapidly,  and  there  may  be  slight  fever,  and  subse- 


DISEASES  OF  THE  STOMACH.  489 

quently  oedema  may  occur.  Syncope,  convulsions,  and  occasionally  hemiplegia 
occur  after  very  profuse  haemorrhage.  Blindness  may  follow,  the  result  either 
of  thrombosis  of  the  retinal  arteries  or  veins,  or  an  acute  degeneration  of  the 
ganglion  cells  of  the  retina. 

Diagnosis. — In  a  majority  of  instances  there  is  no  question  as  to  the 
origin  of  the  blood.  Occasionally  it  is  difficult,  particularly  if  the  case  has 
not  been  seen  during  the  attack.  Examination  of  the  vomit  readily  deter- 
mines whether  blood  is  present  or  not.  The  materials  vomited  may  be  stained 
by  wine,  the  juice  of  strawberries,  raspberries,  or  cranberries,  which  give  a 
color  very  closely  resembling  that  of  fresh  blood,  while  iron  and  bismuth 
and  bile  may  produce  the  blackish  color  of  altered  blood.  In  such  cases  the 
microscope  will  show  clearly  the  presence  of  the  shadowy  outlines  of  the  red 
blood-corpuscles,  and,  if  necessary,  spectroscopic  and  chemical  tests  may  be 
applied. 

Deception  is  sometimes  practised  by  hysterical  patients,  who  swallow  and 
then  vomit  blood  or  colored  liquids.  With  a  little  care  such  cases  can  usually 
be  detected.  The  cases  must  be  excluded  in  which  the  blood  passes  from  the 
nose  or  pharynx,  or  in  which  infants  swallow  it  with  the  milk. 

There  is  not  often  difficulty  in  distinguishing  between  haemoptysis  and 
hsematemesis,  though  the  coughing  and  the  vomiting  are  not  infrequently 
combined.     The  following  are  points  to  be  borne  in  mind  in  the  diagnosis : 

H^MATEMESIS.  HEMOPTYSIS. 

1.  Previous  history  points  to  gas-  1.  Cough  or  signs  of  some  pul- 
tric,  hepatic,  or  splenic  disease.                 monary  or  cardiac  disease  precedes, 

in  many  cases,  the  haemorrhage. 

2.  The  blood  is  brought  up  by  2.  The  blood  is  coughed  up,  and 
.vomiting,  prior  to  which  the  patient  is  usually  preceded  by  a  sensation  of 
may  experience  a  feeling  of  giddiness  tickling  in  the  throat.  If  vomiting 
or  faintness.  occurs,  it  follows  the  coughing. 

3.  The  blood  is  usually  clotted,  3.  The  blood  is  frothy,  bright  red 
mixed  with  particles  of  food,  and  has  in  color,  alkaline  in  reaction.  If 
an  acid  reaction.  It  may  be  dark,  clotted,  rarely  in  such  large  coagula, 
grumous,  and  fluid.  and  muco-pus  may  be  mixed  with  it. 

4.  Subsequent  to  the  attack  the  4.  The  cough  persists,  physical 
patient  passes  tarry  stools,  and  signs  «igns  of  local  disease  in  the  chest 
of  disease  of  the  abdominal  viscera  may  usually  be  detected,  and  the 
may  be  detected.  sputa  may  be  blood-stained  for  many 

days. 

Prognosis. — Except  in  the  case  of  rupture  'of  an  aneurism  or  of  large 
veins,  hsematemesis  rarely  proves  fatal.  In  my  experience  death  has  followed 
more  frequently  in  cases  of  cirrhosis  and  splenic  enlargement  than  in  ulcer 
or  cancer.  In  ulcer  it  is  to  be  remembered  that  in  the  chronic  hsemorrhagic 
form  the  bleeding  may  recur  for  years.  The  treatment  of  haematemesis  is 
considered  under  gastric  ulcer. 


490  DISEASES  OF   THE  DIGESTIVE  SYSTEM. 

Vin.    NEUROSES    OF    THE    STOMACH. 

(Nervous  Dyspepsia.) 

The  studies  of  Leube,  Ewald,  Oser,  Rosenbach,  and  many  others  have 
shown  that  serious  functional  disturbances  of  the  stomach  may  occur  without 
any  discoverable  anatomical  basis.  The  cases  are  met  with  most  frequently 
in  those  who  have  either  inherited  a  nervous  constitution  or  who  have  gradu- 
ally, through  indiscretions,  brought  about  a  condition  of  nervous  prostration. 
Not  infrequently,  however,  the  gastric  symptoms  stand  so  far  in  the  fore- 
ground that  the  general  neuropathic  character  of  the  patient  quite  escapes 
notice.  Sometimes  the  gastric  manifestations  have  apparently  a  reflex  origin 
depending  on  organic  disturbances  in  remote  parts  of  the  body. 

The  nervous  derangements  of  the  stomach  may  be  divided  into  motor, 
secretory,  and  sensory  neuroses.  These  disturbances  rarely  occur  singly;  they 
are  usually  met  with  in  combined  forms.  The  clinical  picture  resulting  from 
such  a  complex  of  gastric  neuroses  is  known  as  nervous  dyspepsia.  As  Leube 
has  pointed  out,  the  sensory  disturbances  usually  play  the  more  important  part. 

The  sufferer  from  nervous  dyspepsia  presents  a  varying  picture.  All 
grades  occur,  from  the  emaciated  skeleton-like  patient  with  anorexia  nervosa 
to  the  well-nourished,  healthy-looking,  fresh-complexioned  individual  whose 
only  complaint  is  distress  and  uneasiness  after  eating.  I  have  followed 
Eiegel's  classification. 

I.  Motor  Neuroses. — (a)'  Htpeekinesis  or  Supermotility. — An  increase 
in  the  normal  motor  activity  of  the  stomach  results  in  too  early  a  discharge 
of  the  ingesta  into  the  intestine.  It  is  more  commonly  a  secondary  neurosis 
dependent  upon  superacidity  or  supersecretion  of  the  gastric  juice;  but  it 
may  occur  primarily,  possibly  from  reflex  causes.  The  diagnosis  is  to  be 
reached  only  by  means  of  the  stomach-tube.  It  gives  rise  to  no  characteristic 
clinical  symptoms. 

(&)  Peristaltic  Unrest. — This  condition,  as  described  by  Kussmaul,  is 
an  extremely  common  and  distressing  symptom  in  neurasthenia.  Shortly 
after  eating  the  peristaltic  movements  of  the  stomach  are  increased,  and 
borborygmi  and  gurgling  may  be  heard,  even  at  a  distance.  The  subjective 
sensations  are  most  annoying,  and  it  would  appear  as  if  in  the  hypergesthetic 
condition  of  the  nervous  system  the  patient  felt  normal  peristalsis,  just  as  in 
these  states  the  usual  beating  of  the  heart  may  be  perceptible  to  him.  A 
further  analogy  is  afforded  by  the  fact  that  emotion  increases  this  peristalsis. 
It  may  extend  to  the  intestines,  particularly  to  the  duodenum,  and  on  palpa- 
tion over  this  region  the  gurgling  is  most  marked.  The  movement  may  be 
anti-peristalsis,  in  which  the  wave  passes  from  right  to  left,  a  condition  which 
may  also  extend  to  the  intestines.  There  are  cases  on  record  in  which  colored 
enemata  or  even  scybala  have  been  discharged  from  the  mouth. 

(c)  jSTervous  Eructations. — Aerophagia. — In  this  condition  severe  attacks 
of  noisy  eructations,  following  one  another  often  in  rapid  succession,  occur. 
When  violent  they  last  for  hours  or  days.  At  other  times  they  occur  in  parox- 
ysms, depending  often  upon  mental  excitement.  They  are  more  commonly 
observed  in  hysterical  women  and  neurasthenics,  but  also,  not  infrequently. 


DISEASES  OF   THE  STOMACH.  491 

in  children.  The  hysterical  nature  of  the  affection  is  sometimes  testified 
to  by  the  occurrence,  especially  in  children,  of  several  instances  in  one 
household. 

The  expelled  gas  in  these  cases  is  atmospheric  air,  which  is  swallowed  or 
aspirated  from  without.  Sometimes  the  whole  process  may  be  clearly  ob- 
served, but  in  other  instances  the  act  of  swallowing  may  be  almost  or  quite 
imperceptible.  Bouveret  considers  the  condition  due  to  a  spasm  of  the  phar- 
ynx which  causes  involuntary  swallowing.  Oser  has  suggested  that  the  air 
may  enter  by  aspiration,  the  stomach  acting  like  an  elastic  rubber  bag  which 
tends  to  fill  again  after  the  air  is  expressed.  It  is  quite  possible  that  in  some 
instances  the  eructations  consist  of  gas  which  has  never  actually  reached  the 
stomach,  but  is  brought  up  from  the  oesophagus. 

(d)  Nervous  Vomiting. — A  condition  which  is  not  associated  with  ana- 
tomical changes  in  the  stomach  or  with  any  state  of  the  contents,  but  is  due 
to  nervous  influences  acting  either  directly  or  indirectly  upon  the  centres 
presiding  over  the  act  of  vomiting.  The  patients  are,  as  a  rule,  women — • 
usually  brunettes — and  the  subject  of  more  or  less  marked  hysterical  mani- 
festations. A  special  feature  of  this  form  is  the  absence  of  the  preliminary 
nausea  and  of  the  straining  efforts  of  the  ordinary  act  of  vomiting.  It  is 
rather  a  regurgitation,  and  without  visible  effort  and  without  gagging  the 
mouth  is  filled  with  the  contents  of  the  stomach,  which  are  then  spat  out. 
It  comes  on,  as  a  rule,  after  eating,  but  may  occur  at  irregular  intervals.  In 
some  eases  the  nutrition  is  not  impaired,  a  feature  which  may  give  a  clew  to 
the  true  nature  of  the  disease,  as  there  may  be  no  other  hysterical  manifesta- 
tion present.  As  noted  by  Tuckwell,  it  may  occur  in  children,  and  Edsall 
suggests  that  this  recurring  vomiting  is  an  acid  intoxication,  as  in  some  eases 
acetone  and  diacetic  acid  have  been  found  in  the  urine.  Treatment  with  full 
doses  of  20  grains  of  bicarbonate  of  soda  every  two  hours  has  been  found  to 
relieve  it.  Nervous  vomiting  may  be  a  very  serious  condition.  We  have  had 
at  least  two  fatal  cases.  In  some  instances,  after  persisting  for  weeks  or  months 
at  home  the  patient  gets  well  in  a  few  days  in  hospital.  In  other  instances  the 
course  is  protracted,  and  the  cases  are  among  the  most  trying  we  are  called 
upon  to  treat. 

A  type  of  vomiting  is  that  associated  with  certain  diseases  of  the  nervous 
system — particularly  locomotor  ataxia — forming  part  of  the  gastric  crises, 
Leyden  has  reported  cases  of  primary  periodic  vomiting,  which  he  regards 
as  a  neurosis. 

(e)  Rumination;  Mertcismus. — In  this  remarkable  and  rare  condition 
the  patients  regurgitate  and  chew  the  cud  like  ruminants.  It  occurs  in  neuras- 
thenic or  hysterical  persons,  epileptics,  and  idiots.  In  some  patients  it  is 
hereditary.  There  is  an  instance  in  which  a  governess  taught  it  to  two  chil- 
dren. The  habit  may  persist  for  years,  and  does  not  necessarily  impair  the 
health. 

(f)  Spasm  of  the  Cardia. — Spasmodic,  usually  painful  contraction  of 
the  circular  muscle  fibres  at  the  cardiac  orifice  may  follow  the  introduction 
of  a  sound,  hasty  eating,  or  the  taking  of  too  hot  or  too  cold  food.  It  may 
occur  in  tetanus  and  also  in  hysterical  and  neurasthenic  individuals,  especially 
in  air  swallowers,  in  whom,  if  it  be  combined  with  pyloric  spasm,  it  may 
result  in  painful  gastric  distention — "  pneumatosis.^'     Here  the  spasm  may 


492  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

be  of  considerable  duration.     The  condition  is  rare  and  practically  not  of 
much  moment. 

(g)  Pyloeic  Spasm. — This  is  usually  a  secondary  occurrence,  following 
superacidity,  supersecretion,  ulcer,  or  the  introduction  into  the  stomach  of 
irritating  substances.  The  spasm  often  causes  pain  in  the  region  of  the 
pylorus  and  increased  gastric  peristalsis.  In  cases  where  the  spasm  is  com- 
bined with  superacidity  and  supersecretion  marked  dilatation  with  atony  may 
follow;  it  is  questionable,  however,  whether  a  primary  nervous  pyloric  spasm 
ever  gives  rise  to  serious  results. 

(h)  Atony  of  the  Stomach, — Motor  insufficiency  of  the  stomach  is  gen- 
erally due  to  injudicious  feeding,  to  organic  disease  of  the  stomach  itself,  or 
to  general  wasting  processes.  In  some  otherwise  normal  individuals  of  neu- 
rotic temperaments  an  atony  may,  however,  occur  which  possibly  deserves  to 
be  classed  among  the  neuroses.  The  symptoms  are  usually  those  of  a  moderate 
dilatation,  and  are  often  associated  with  marked  sensory  disturbances — feel- 
ings of  weight  and  pressure,  distention,  eructations,  and  so  forth. 

Great  care  must  be  taken  in  the  diagnosis  to  rule  out  all  other  possible 
causes. 

(t)  Insufficiency  or  Incontinence  of  the  Pyloeus. — This  condition 
was  described  first  by  de  Sere  and  later  by  Ebstein,  It  may  be  recognized  by 
the  rapid  passing  of  gas  from  the  stomach  into  the  bowel  on  attempts  at 
inflation  of  the  former,  as  well  as  by  the  presence  of  bile  and  intestinal  con- 
tents in  the  stomach.     There  are  no  distinctive  clinical  symptoms. 

(;')  Insufficiency  of  the  Caedia. — This  condition  is  only  recognized  by 
the  occurrence  of  eructations  or  in  rumination. 

II.  Secretory  Neuroses. — (a)  Hyperacidity;  Superacidity;  Hyper- 
CHLOEHYDEiA. — Ncrvous  dyspepsia  with  hyperacidity  of  the  gastric  juices. 
The  symptoms  depend  upon  the  secretion  of  an  abnormally  acid  gastric  juice 
at  the  time  of  digestion.  This  is  a  common  form  of  dyspepsia  in  young  and 
neurotic  individuals.  Oswald  has  pointed  out  its  remarkable  frequency  in 
chlorotic  girls.  The  sjanptoms  are  very  variable.  They  do  not,  as  a  rule, 
immediately  follow  the  ingestion  of  food,  but  occur  one  to  three  hours  later, 
at  the  height  of  digestion.  There  is  a  sense  of  weight  and  pressure,  some- 
times of  burning  in  the  epigastrium,  commonly  associated  with  acid  eructa- 
tions. -  If  vomiting  occurs,  the  pain  is  relieved.  The  patient  is  usually  rela- 
tively well  nourished,  and  the  appetite  is  often  good,  though  the  sufferer  may 
be  afraid  to  eat  on  account  of  the  anticipated  pain.  Its  association  with  ulcer 
has  been  referred  to.    There  is  commonly  constipation. 

(&)  Supeeseceetion,  Inteemittent  and  Continuous. — This  is  a  form 
of  dyspepsia  which  has  been  long  recognized,  but  of  late  has  been  specially 
studied  by  Eeichmann  and  others.  The  increased  flow  of  the  gastric  juice 
may  be  intermittent  or  continuous.  The  secretion  under  such  circumstances 
is  usually  superacid,  though  this  is  not  always  the  case.  The  periodical  form 
— the  gastroxynsis  of  Eossbach — may  be  quite  independent  of  the  time  of 
digestion.  Great  quantities  of  highly  acid  gastric  juice  may  be  secreted  in 
a  very  small  space  of  time.  Such  cases  are  rare,  and  are  especially  associated 
either  with  profound  neurasthenia  or  with  locomotor  ataxia.  The  attack  may 
last  for  several  days.  It  usually  sets  in  with  a  gnawing,  unpleasant  sensation 
in  the  stomach,  severe  headache,  and  shortly  after  the  patient  vomits  a  clear, 


DISEASES  OF   THE  STOMACH.  493 

watery  secretion  of  such  acidity  that  the  throat  is  irritated  and  made  raw  and 
sore.  As  mentioned,  the  attacks  may  be  quite  independent  of  food.  Con- 
tinuous supersecretion  is  more  common.  The  constant  presence  of  fluid  in 
the  stomach,  together  with  the  pyloric  spasm,  which  commonly  results  from 
the  irritation  of  the  overacid  gastric  juice,  are  followed  by  a  more  or  less 
extensive  dilatation.  Digestion  of  the  starches  is  retarded,  and  there  are 
eructations  of  acid  fluid  and  gastric  distress.  This  secretion  of  highly  acid 
gastric  juice  may  continue  when  the  stomach  is  free  from  food.  In  these 
cases  pain,  burning  acid  eructations,  and  even  vomiting,  occurring  during  the 
night  and  early  in  the  morning,  are  rather  characteristic. 

(c)  Nervous  Subacidity  or  Inacidity;  Achylia  Gastrica  Nervosa. — 
Lack  of  the  normal  amount  of  acid  is  found  in  chronic  catarrh,  and  particu- 
larly in  cancer.  As  Leube  has  shown,  a  reduction  in  the  normal  amount  of 
acid  may  exist  with  the  most  pronounced  symptoms  of  nervous  dyspepsia  and 
yet  the  stomach  will  be  free  from  food  within  the  regular  time.  A  condition 
in  which  free  acid  is  absent  in  the  gastric  juice  may  occur  in  cancer,  in  ex- 
treme sclerosis  of  the  mucous  membrane,  as  a  nervous  manifestation  of  hysteria, 
and  occasionally  of  tabes.  In  most  of  these  cases,  though  there  be  no  free 
acid,  yet  the  other  digestive  ferments — pepsin  and  the  curdling  ferments — 
or  their  zymogens  are  to  be  demonstrated  in  the  gastric  juice.  There  may, 
however,  be  a  complete  absence  of  the  gastric  secretion.  To  these  cases  Ein- 
horn  has  given  the  name  of  achylia  gastrica.  This  condition  was'  at  first 
thought  to  occur  only  in  cases  of  total  atrophy  of  the  gastric  mucosa,  but 
recent  observations  have  shown  that  it  may  occur  as  a  neurosis.  In  a  case 
of  Einhorn's  the  gastric  secretions  returned  after  five  years  of  total  achylia 
gastrica. 

The  symptoms  of  subacidity,  or  even  of  achylia  gastrica,  vary  greatly  in 
intensity;  they  may  be  almost  or  quite  absent  in  cases  of  advanced  atrophy  of 
the  mucosa,  and,  as  a  rule,  are  not  marked  so  long  as  the  -motor  activity 
of  the  stomach  remains  good.  If  atony,  however,  occur  and  abnormal  fer- 
mentative processes  arise,  severe  gastric  and  intestinal  symptoms  may  follow. 
In  the  cases  associated  with  hysteria  and  neurasthenia,  even  though  the  food 
may  be  well  taken  care  of  by  the  intestines,  there  are  very  commonly  grave 
sensory  disturbances  in  the  region  of  the  stomach,  in  addition  to  the  general 
nervous  symptoms. 

III.  Sensory  Neuroses. — (a)  Hyperesthesia. — In  this  condition  the  pa- 
-^tients  complain  of  fulness,  pressure,  weight,  burning,  and  so  forth,  during 
digestion,  just  such  symptoms  as  accompany  a  variety  of  organic  diseases  of 
the  stomach,  and  yet  in  all  other  respects  the  gastric  functions  appear  quite 
normal.  Sometimes  these  distressing  sensations  are  present  even  when  the 
stomach  is  empty.  These  symptoms  are  usually  associated  with  other  mani- 
festations of  hysteria  and  neurasthenia.  The  pain  often  follows  particular 
articles  of  food.  An  hysterical  patient  may  apparently  sufEer  excruciating  pain 
after  taking  the  smallest  amount  of  food  of  any  sort,  while  anything  pre- 
scribed as  a  medicine  may  be  well  borne.  In  severe  cases  the  patient  may  be 
reduced  to  an  extreme  degree  by  starvation. 

(b)  Gastralgia ;  Gastrodynia. — Severe  pains  in  the  epigastrium,  parox- 
ysmal in  character,  occur  (1)  as  a  manifestation  of  a  functional  neurosis,  in- 
dependent of  organic  disease,  and  usually  associated  with  other  nervous  symp- 


494  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

toms  (it  is  this  form  which  will  here  be  described)  ;  (3)  in  chronic  disease 
of  the  nervous  system,  forming  the  so-called  gastric  crises;  and  (3)  in  organic 
disease  of  the  stomach,  such  as  ulcer  or  cancer. 

The  functional  neurosis  occurs  chiefly  in  women,  very  commonly  in  con- 
nection with  disturbed  menstrual  function  or  with  pronounced  hysterical  symp- 
toms. The  affection  may  set  in  as  early  as  puberty,  but  it  is  more  common  at 
the  menopause.  Anaemic,  constipated  women  who  have  worries  and  anxieties 
at  home  are  most  prone  to  the  affection.  It  is  more  frequent  in  brunettes  than 
in  blondes.  Attacks  of  it  sometimes  occur  in  robust,  healthy  men.  More 
often  it  is  only  one  feature  in  a  condition  of  general  neurasthenia  or  a  mani- 
festation of  that  form  of  nervous  dyspepsia  in  which  the  gastric  juice  or 
hydrochloric  acid  is  secreted  in  excess.  I  am  very  sceptical  as  to  the  existence 
of  a  gastralgia  of  purely  malarial  origin. 

The  symptoms  are  very  characteristic;  the  patient  is  suddenly  seized  with 
agonizing  pains  in  the.  epigastrium,  which  pass  toward  the  back  and  around 
the  lower  ribs.  The  attack  is  usually  independent  of  the  taking  of  food,  and 
may  recur  at  definite  intervals,  a  periodicity  which  has  given  rise  to  the  sup- 
position in  some  cases  that  the  affection  is  due  to  malaria.  The  most  marked 
periodicity,  however,  may  be  in  the  gastralgic  attacks  of  ulcer.  They  fre- 
quently come  on  at  night.  Vomiting  is  rare;  more  commonly  the  taking  of 
food  relieves  the  pain.  To  this,  however,  there  are  striking  exceptions.  Pres- 
sure upon  the  epigastrium  commonly  gives  relief,  but  deep  pressure  may  be 
painful.  It  seems  scarcely  necessary  to  separate  the  forms,  as  some  have  done, 
into  irritative  and  depressive,  as  the  cases  insensibly  merge  into  each  other. 
Stress  has  been  laid  upon  the  occurrence  of  painful  points,  but  they  are  so 
common  in  neurasthenia  that  very  little  importance  can  be  attributed  to  them. 

The  diagnosis  offers  many  difficulties.  Organic  disease  either  of  the  stom- 
ach or  of  the  nervous  system,  particularly  the  gastric  crises  of  locomotor 
ataxia,  must  be  excluded.  In  the  case  of  ulcer  or  cancer  this  is  not  always 
easy.  The  fact  that  the  pain  is  most  marked  when  the  stomach  is  empty  and 
is  relieved  by  the  taking  of  food  is  sometimes  regarded  as  pathognomonic  of 
simple  gastralgia,  but  to  this  there  are  many  exceptions,  and  in  cancer  the 
pains  may  be  relieved  on  eating.  The  prolonged  intervals  between  the  attacks 
and  their  independence  of  diet  are  important  features  in  simple  gastralgia; 
but  in  many  instances  it  is  less  the  local  than  the  general  symptoms  of  the 
case  which  enable  us  to  make  the  diagnosis.  In  gall-stone  colic  jaundice  is 
frequently  absent,  and  in  any  long-standing  case  of  gastralgia,  in  which  the 
attacks  recur  at  intervals  for  years,  the  question  of  cholelithiasis  should  be 
considered.  There  may  be  hyperacidity  associated  with  gastric  atony.  In  one 
such  case  recently  we  treated  the  case  for  weeks  as  one  of  painful  nervous 
dyspepsia  until  a  more  severe  attack  than  usual  was  followed  by  jaundice.  At 
the  same  time,  there  was  a  neurotic  physician  in  the  hospital  who  had  had 
recurring  attacks  of  abdominal  pain  of  the  greatest  severity,  and  once,  he 
said,  with  jaundice.    At  operation  his  gall-bladder  was  normal ! 

(c)  Anomalies  of  the  Sense  of  Hunger  and  Eepletion;  Bulimia. — 
Abnormally  excessive  hunger  coming  on  often  in  paroxysmal  attacks,  which 
cause  the  patient  to  commit  extraordinary  excesses  in  eating.  This  condition 
may  occur  in  diabetes  mellitus  and  sometimes  in  gastric  disorders,  particularly 
those  associated  with  supersecretion.    It  is,  however,  more  commonly  seen  in 


DISEASES  OF  THE  STOMACH.  495 

hysteria  and  in  psyclioses.  It  may  occur  in  cerebral  tumors,  in  Graves'  dis- 
ease, and  in  epilepsy. 

The  attacks  often  begin  suddenly  at  night,  the  patient  waking  with  a 
feeling  of  faintness  and  pain,  and  an  uncontrollable  desire  for  food.  Some- 
times such  attacks  occur  immediately  after  a  large  meal.  The  attack  may 
be  relieved  by  a  small  amount  of  food,  while  at  other  times  enormous  quan- 
tities may  be  taken.  In  obstinate  cases  gastritis,  atony,  and  dilatation  fre- 
quently result  from  the  abuse  of  the  stomach. 

Ahoria. — An  absence  of  the  sense  of  satiety.  This  condition  is  commonly 
associated  with  bulimia  and  polyphagia,  but  not  always.  The  patient  always 
feels  "  empty."  There  are  usually  other  well-marked  manifestations  of  hys- 
teria or  neurasthenia. 

Anorexia  Nervosa. — This  condition,  which  is  a  manifestation  of  a  neurotic 
temperament,  is  discussed  subsequently  under  the  general  heading  of  Hysteria. 

Treatment  of  Neuroses  of  the  Stomach. — The  most  important  part  of  the 
treatment  of  nervous  dyspepsia  is  often  that  directed  toward  the  improvement 
of  the  general  physical  and  mental  condition  of  the  patient.  The  possibility 
that  the  symptoms  may  be  of  reflex  origin  should  be  borne  in  mind.  A  large 
proportion  of  cases  of  nervous  dyspepsia  are  dependent  upon  mental  and  physi- 
cal exhaustion  or  worry,  and  a  vacation  or  a  change  of  scene  will  often  accom- 
plish what  years  of.  treatment  at  home  have  failed  to  do.  The  manner  of  life 
of  the  patient  should  be  investigated  and  a  proper  amount  of  physical  exercise 
in  the  open  air  insisted  upon.  This  alone  will  in  some  cases  be  sufficient  to 
cause  the  disappearance  of  the  s5^mptoms. 

Many  cases  of  nervous  dyspepsia  with  marked  neurasthenic  or  hysterical 
symptoms  do  well  on  the  Weir  Mitchell  treatment,  and  in  obstinate  forms  it 
should  be  given  a  thorough  trial.  The  most  striking  results  are  perhaps  seen 
in  the  case  of  anorexia  nervosa,  which  will  be  referred  to  subsequently.  It  is 
also  of  value  in  nervous  vomiting. 

In  cardiac  ^pasm  care  should  be  taken  to  eat  slowly,  to  avoid  swallowing 
too  large  morsels  or  irritating  substances.  The  methodical  introduction  of 
thick  sounds  may  be  of  value. 

The  treatment  in  atony  of  the  stomach  should  be  similar  to  that  adopted 
in  moderate  dilatation — the  administration  of  small  quantities  of  food  at 
frequent  intervals;  the  limitation  of  the  fluids,  which  should  also  be  taken 
in  small  amounts  at  a  time ;  lavage.    Strychnine  in  full  doses  may  be  of  value. 

In  the  distressing  cases  of  hyperacidity,  in  addition  to  the  treatment  of 
the  general  neurotic  condition,  alkalies  must  be  employed  either  in  the  form 
of  magnesia  or  bicarbonate  of  soda.  These  should  be  given  in  large  doses 
and  at  the  height  of  digestion.  The  burning  acid  eructations  may  be  re- 
lieved in  this  way.  The  diet  should  be  mainly  albuminous,  and  should  be 
administered  in  a  non-irritating  form.  Stimulating  condiments  and  alcohol 
should  be  avoided.  Starches  should  be  sparingly  allowed,  and  only  in  most 
digestible  forms.     Fats  are  fairly  well  borne. 

Limiting  the  patient  to  a  strictly  meat  diet  is  a  valuable  procedure  in  many 
cases  of  dyspepsia  associated  with  hyperacidity.  The  meat  should  be  taken 
either  raw  or,  if  an  insuperable  objection  exists  to  this,  very  slightly  cooked. 
It  is  best  given  finely  minced  or  grated  on  stale  bread.  An  ample  dietary  is 
3:|  ounces  (100  grammes)  of  meat,  two  medium  slices  of  stale  bread,  and  an 


496  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

ounce  (30  grammes)  of  butter.  This  may  be  taken  three  times  a  day  with 
a  glass  of  Apollinaris  water,  soda  water,  or,  what  is  just  as  satisfactory,  spring 
water.  The  fluid  should  not  be  taken  too  cold.  Special  care  should  be  taken 
in  the  examination  of  the  meat  to  guard  against  tape-worm  infection,  but 
suitable  instructions  on  this  point  can  be  given.  This  is  suiBcient  for  an 
adult  man,  and  many  obstinate  cases  yield  satisfactorily  to  a  month  or  six 
weeks  of  this  treatment,  after  which  time  the  less  readily  digested  articles  of 
food  may  be  gradually  added  to  the  dietary. 

In  supersecretion  the  use  of  the  stomach-tube  is  of  the  greatest  value.  In 
the  periodical  form  it  should  be  used  as  soon  as  the  attack  begins.  The 
stomach  may  be  washed  with  alkaline  solutions  or  solutions  of  nitrate  of 
silver,  1  to  1,000,  may  be  used.  Where  this  is  impracticable  the  taking  of 
albuminous  food  may  give  relief.  One  of  my  patients  used  to  have  by  his 
bedside  two  hard-boiled  eggs,  by  the  eating  of  which  nocturnal  attacks  were 
alleviated.    Alkalies  in  large  doses  are  also  indicated. 

In  cases  of  continued  supersecretion  there  is  usually  atony  and  dilatation. 
The  diet  here  should  be  much  as  in  superacidity,  but  should  be  administered 
in  smaller  quantities  at  frequent  intervals.  Lavage  with  alkaline  solutions 
or  with  nitrate  of  silver  is  of  great  value.  To  relieve  pain  large  quantities  of 
bicarbonate  of  soda  or  magnesia  should  be  'given  at  the  height  of  digestion. 

In  suh  acidity  a  carefully  regulated,  easily  digestible  mixed  diet,  not  too 
rich  in  albuminoids,  is  advisable.  Bitter  tonics  before  meals  are  sometimes 
of  value.  In  acliylia  gastrica  the  use  of  predigested  foods  and  of  hydrochloric 
acid  in  full  doses  may  be  of  assistance. 

In  marked  hypercesthesia,  beside  the  treatment  of  the  general  condition, 
nitrate  of  silver  in  doses  of  gr.  -J-J,  taken  in  §  iij-o  iv  of  water  on  an  empty 
stomach,  is  advised  by  Rosenheim. 

In  some  instances  rectal  feeding  may  have  to  be  resorted  to. 

The  gastralgia,  if  very  severe,  requires  morphia,  which  is  best  adminis- 
tered subcutaneously  in  combination  with  atropia.  In  the  milder  attacks  the 
combination  of  morphia  (gr.  |)  with  cocaine  and  belladonna  is  recommended 
by  Ewald.  The  greatest  caution  should,  however,  be  exercised  in  these  cases 
in  the  use  of  the  hypodermic  syringe.  It  is  preferable,  if  opium  is  necessary, 
to  give  it  by  the  mouth,  and  not  to  let  the  patient  know  the  character  of  the 
drug.  Chloroform,  in  from  10-  to  20-drop  doses,  or  Hoffman's  anodyne  will 
sometimes  allay  the  severe  pains.  The  general  condition  should  receive  careful 
attention,  and  in  many  cases  the  attacks  recur  until  the  health  is  restored  by 
change  of  air  with  the  prolonged  use  of  arsenic.  If  there  is  anaemia  iron  may 
be  given  freely.  Nitrate  of  silver  in  doses  of  gr.  ^  to  ^  in  a  large  claret-glass 
of  water  taken  on  an  empty  stomach  is  useful  in  some  cases. 

There  are  forms  of  nervous  dyspepsia  occurring  in  women  who  are  often 
well  nourished  and  with  a  good  color,  yet  who  suffer — ^particularly  at  night — 
with  flatulency  and  abdominal  distress.  The  sleep  may  be  quiet  and  undis- 
turbed for  two  or  three  hours,  after  which  they  are  aroused  with  painful 
sensations  in  the  abdomen  and  eructations.  The  appetite  and  digestion  may 
appear  to  be  normal.  Constipation  is,  however,  usually  present.  In  many 
of  these  patients  the  condition  seems  rather  intestinal  dyspepsia,  and  the 
distress  is  due  to  the  accumulation  of  gases,  the  result  of  excessive  putrefac- 
tion.   The  fats,  starches,  and  sugars  should  be  restricted.    A  diastase  ferment 


DISEASES  OF  THE  INTESTINES.  497 

is  sometimes  useful.  The  flatulency  may  be  treated  by  the  methods  above 
mentioned.  Naphthalin,  salicylate  of  bismuth,  and  salol  have  been  recom- 
mended. Some  of  these  cases  obtain  relief  from  thorough  irrigation  of  the 
colon  at  bedtime. 

The  treatment  of  anorexia  nervosa  is  described  subsequently. 


G.    DISEASES  OF  THE  INTESTINES. 

I.    DISEASES    OF    THE    INTESTINES   ASSOCIATED 
WITH    DIARRHCEA. 

Catarrhal  Enteritis;  Diarrhcea. 

In  the  classification  of  catarrhal  enteritis  the  anatomical  divisions  of  the 
bowel  have  been  too  closely  followed,  and  a  duodenitis,  jejunitis,  ileitis,  typhli- 
tis, colitis,  and  proctitis  have  been  recognized ;  whereas  in  a  majority  of  cases 
the  entire  intestinal  tract,  to  a  greater  or  lesser  extent,  is  involved,  sometimes 
the  small  most  intensely,  sometimes  the  large  bowel:  but  during  life  it  may 
be  quite  impossible  to  say  which  portion  is  specially  affected. 

Etiology. — The  causes  may  be  either  primary  or  secondary.  Among  the 
causes  of  primary  catarrhal  enteritis  are :  (a)  Improper  food,  one  of  the  most 
frequent,  especially  in  children,  in  whom  it  follows  overeating,  or  the  ingestion 
of  unripe  fruit.  In  some  individuals  special  articles  of  diet  will  always  pro- 
duce a  slight  diarrhoea,  which  may  not  be  due  to  a  catarrh  of  the  mucosa,  but 
to  increased  peristalsis  induced  by  the  offending  material.  (&)  Various  toxic 
substances.  Many  of  the  organic  poisons,  such  as  those  produced  in  the  de- 
composition of  milk  and  articles  of  food,  excite  the  most  intense  intestinal 
catarrh.  Certain  inorganic  substances,  as  arsenic  and  mercury,  act  in  the 
same  way.  (c)  Changes  in  the  weather.  A  fall  in  the  temperature  of  from 
twenty  to  thirty  degrees,  particularly  in  the  spring  or  autumn,  may  induce — 
how,  it  is  difficult  to  say — an  acute  diarrhoea.  We  speak  of  this  as  a  catarrhal 
process,  the  result  of  cold  or  of  chill.  On  the  other  hand,  the  diarrhoeal  dis- 
eases of  children  are  associated  in  a  very  special  way  with  the  excessive  heat 
of  summer  months,  (d)  Changes  in  the  constitution  of  the  intestinal  secre- 
tions. We  know  too  little  about  the  succus  entericus  to  be  able  to  speak  of 
influences  induced  by  change  in  its  quantity  or  quality.  It  has  long  been 
held  that  an  increase  in  the  amount  of  bile  poured  into  the  bowel  might  excite 
a  diarrhoea ;  hence  the  term  bilious  diarrhoea,  so  frequently  used  by  the  older 
writers.  Possibly  there  are  conditions  in  which  an  excessive  amount  of  bile 
is  poured  into  the  intestine,  increasing  the  peristalsis,  and  hurrying  on  the 
contents;  but  the  opposite  state,  a  scanty  secretion,  by  favoring  the  natural 
fermentative  processes,  much  more  commonly  causes  an  intestinal  catarrh. 
Absence  of  the  pancreatic  secretion  from  the  intestine  has  been  associated  in 
certain  cases  with  a  fatty  diarrhoea,  (e)  Nervous  influences.  It  is  by  no 
means  clear  how  mental  states  act  upon  the  bowels,  and  yet  it  is  an  old  and 
trustworthy  observation,  which  every-day  experience  confirms,  that  the  mental 
state  may  profoundly  affect  the  intestinal  canal.  These  influences  should  not 
properly  be  considered  under  catarrhal  processes,  as  they  result  simply  from 
33 


498  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

increased  peristalsis  or  increased  secretion,  and  are  usually  described  under 
the  heading  nervous  diarrhwa.  In  children  it  frequently  follows  fright.  It  is 
common,  too,  in  adults  as  a  result  of  emotional  disturbances.  Cahstatt  men- 
tions a  surgeon  who  always  before  an  important  operation  had  watery  diar- 
rhoea. In  hysterical  women  it  is  seen  as  an  occasional  occurrence,  due  to 
transient  excitement,  or  as  a  chronic^,  protracted  diarrhoea,  which  may  last 
for  months  or  even  years. 

Among  the  secondary  causes  of  intestinal  catarrh  may  be  mentioned :  (a) 
Infectious  diseases.  Dysentery,  cholera,  typhoid  fever,  pyaemia,  septicaemia, 
tuberculosis,  and  pneumonia  are  occasionally  associated  with  intestinal  catarrh. 
In  dysentery  and  typhoid  fever  the  ulceration  is  in  part  responsible  for  the 
catarrhal  condition,  but  in  cholera  it  is  probably  a  direct  influence  of  the 
bacilli  or  of  the  toxic  materials  produced  by  them.  (&)  The  extension  of 
inflammatory  processes  from  adjacent  parts.  Thus,  in  peritonitis,  catarrhal 
swelling  and  increased  secretion  are  always  present  in  the  mucosa.  In  cases 
of  invagination,  hernia,  tuberculous  or  cancerous  ulceration,  catarrhal  proc- 
esses are  common,  (c)  Circulatory  disturbances  cause  a  catarrhal  enteritis, 
usually  of  a  very  chronic  character.  This  is  common  in  diseases  of  the  liver, 
such  as  cirrhosis,  and  in  chronic  affections  of  the  heart  and  lungs — all  condi- 
tions, in  fact,  which  produce  engorgement  of  the  terminal  branches  of  the 
portal  vessels,  (d)  In  the  cachectic  conditions  met  with  in  cancer,  profound 
anaemia,  Addison's  disease,  and  Bright's  disease  intestinal  catarrh  may  occur 
as  a  terminal  event. 

Morbid  Anatomy. — Changes  in  the  mucous  membrane  are  not  always  visi- 
ble, and  in  cases  in  which,  during  life,  the  symptoms  of  intestinal  catarrh 
have  been  marked,  neither  redness,  swelling,  nor  increased  secretion — the  three 
signs  usually  laid  down  as  characteristic  of  catarrhal  inflammation — ^may  be 
present  post  mortem.  It  is  rare  to  see  the  mucous  membrane  injected;  more 
commonly  it  is  pale  and  covered  with  mucus.  In  the  upper  part  of  the  small 
intestine  the  tips  of  the  valvulee  conniventes  may  be  deeply  injected.  Even  in 
extreme  grades  of  portal  obstruction  intense  hyperaemia  is  not  often  seen. 
The  entire  mucosa  may  be  softened  and  infiltrated,  the  lining  epithelium 
swollen,  or  even  shed,  and  appearing  as  large  flakes  among  the  intestinal 
contents.  This  is,  no  doubt,  a  post-mortem  change.  The  lymph  follicles  are 
almost  always  swollen,  particularly  in  children.  The  Peyers  patches  may 
be  prominent  and  the  solitary  follicles  in  the  large  and  small  bowel  ,may  stand 
out  with  distinctness  and  present  in  the  centres  little  erosions,  the  so-called 
follicular  ulcers.  This  may  be  a  striking  feature  in  the  intestine  in  all  forms 
of  catarrhal  enteritis  in  cliildren,  quite  irrespective  of  the  intensity  of  the 
diarrhoea. 

When  the  process  is  more  chronic  the  mucosa  is  flrmer,  in  some  instances 
thickened,  in  others  distinctly  thinned,  and  the  villi  and  follicles  present  a 
slaty  pigmentation. 

Symptoms. — Acute  and  chronic  forms  may  be  recognized.  The  important 
symptom  of  both  is  diarrhoea,  which,  in  the  majority  of  instances,  is  the  sole 
indication  of  this  condition.  It  is  not  to  be  supposed  that  diarrhoea  is  invari- 
ably caused  by,  or  associated  with,  catarrhal  enteritis,  as  it  may  be  produced 
by  nervous  and  other  influences.  It  is  probable  that  catarrh  of  the  jejunum 
may  exist  without  any  diarrhoea;  indeed,  it  is  a  very  common  circumstance 


DISEASES  OF  THE  INTESTINES.  499 

to  find  post  mortem  a  catarrhal  state  of  the  small  bowel  in  persons  who  have 
not  had  diarrhoea  during  life.  The  stools  vary  extremely  in  character.  The 
color  depends  upon  the  amount  of  bile  with  which  they  are  mixed,  and  they 
may  be  of  a  dark  or  blackish  brown,  or  of  a  light -yellow,  or  even  of  a  grayish- 
white  tint.  The  consistence  is  usually  very  thin  and  watery,  but  in  some 
instances  the  stools  are  pultaceous  like  thin  gruel.  Portions  of  undigested 
food  can  often  be  seen  (lienteric  diarrhoea),  and  flakes  of  yellowish-brown 
mucus.  Microscopically  there  are  innumerable  micro-organisms,  epithelium 
and  mucous  cells,  crystals  of  phosphate  of  lime,  oxalate  of  lime,  and  occasion- 
ally cholesterin  and  Charcot's  crystals. 

Pain  in  the  abdomen  is  usually  present  in  the  acute  catarrhal  enteritis, 
particularly  when  due  to  food.  It  is  of  a  colicky  character,  and  when  the 
colon  is  involved  there  may  be  tenesmus.  More  or  less  tympanites  exists,  and 
there  are  gurgling  noises  or  borborygmi,  due  to  the  rapid  passage  of  fluid  and 
gas  from  one  part  to  another.  In  the  very  acute  attacks  there  may  be  vomit- 
ing. Fever  is  not,  as  a  rule,  present,  but  there  may  be  a  slight  elevation  of 
one  or  two  degrees.  The  appetite  is  lost,  there  is  intense  thirst,  and  the 
tongue  is  dry  and  coated.  In  very  acute  cases,  when  the  quantity  of  fluid 
lost  is  great  and  the  pain  excessive,  there  may  be  collapse  symptoms.  The 
number  of  evacuations  varies  from  four  or  five  to  twenty  or  more  in  the 
course  of  the  day.  The  attack  lasts  for  two  or  three  days,  or  may  be  prolonged 
for  a  week  or  ten  days. 

Chronic  catarrh  of  the  bowels  may  follow  the  acute  form,  or  may  come  on 
gradually  as  an  independent  affection  or  as  a  sequence  of  obstruction  in  the 
portal  circulation.  It  is  characterized  by  diarrhoea,  with  or  without  colic. 
The  dejections  vary;  when  the  small  bowel  is  chiefly  involved  the  diarrhoea 
is  of  a  lienteric  character,  and  when  the  colon  is  affected  the  stools  are  thin 
and  mixed  with  much  mucus.  A  special  form  of  mucous  diarrhoea  will  be 
subsequently  described.  The  general  nutrition  in  these  chronic  cases  is 
greatly  disturbed;  there  may  be  much  loss  of  flesh  and  great  pallor.  The 
patients  are  inclined  to  suffer  from  low  spirits,  or  hypochondriasis  may  develop. 

Diagnosis. — It  is  important,  in  the  first  place,  to  determine,  if  possible, 
whether  the  large  or  small  bowel  is  chiefly  affected.  In  catarrh  of  the  small 
bowel  the  diarrhoea  is  less  marked,  the  pains  are  of  a  colicky  character,  bor- 
borygmi are  not  so  frequent,  the  faeces  usually  contain  portions  of  food,  and 
are  more  yellowish-green  or  grayish-yellow  and  flocculent  and  do  not  contain 
much  mucus.  When  the  large  intestine  is  at  fault  there  may  be  no  pain 
whatever,  as  in  the  catarrh  of  the  large  intestine  associated  with  tuberculosis 
and  Bright's  disease.  When  present,  the  pains  are  most  intense  and,  if  the 
lower  portion  of  the  bowel  is  involved,  there  may  be  marked  tenesmus.  The 
stools  have  a  uniform  soupy  consistence ;  they  are  grayish  in  color  and  granu- 
lar throughout,  with  here  and  thei:e  flakes  of  mucus,  or  they  may  contain 
very  large  quantities  of  mucus. 

There  are  no  positive  symptoms  by  which  the  diagnosis  of  duodenitis  can 
be  made.  It  is  usually  associated  with  acute  gastritis  and,  if  the  process 
extends  into  the  bile-duct,  with  jaundice.  Neither  jejunitis  nor  ileitis  can 
be  separated  from  general  intestinal  catarrh. 

The  Cceliac  Affection. — Under  this  heading  Gee  has  described  an  intestinal 
disorder,  most  commonly  met  with  in  children  between  the  ages  of  one  and 


500  DISEASES  OF   THE  DIGESTIVE  SYSTEM. 

five,  characterized  by  the  occurrence  of  pale,  loose  stools,  not  unlike  gruel  or 
oatmeal  porridge.  They  are  bulky,  not  watery,  yeasty,  frothy,  and  extremely 
offensive.  The  affection  has  received  various  names,  such  as  diarrhoea  alia  or 
diarrhcea  cliylosa.  It  is  not  associated  with  tuberculous  or  other  hereditary 
disease.  It  begins  insidiously  and  there  are  progressive  wasting,  weakness, 
and  pallor.  The  belly  becomes  doughy  and  inelastic.  There  is  often  flatu- 
lency. Fever  is  usually  absent.  The  disease  is  lingering  and  a  fatal  termina- 
tion is  common.  So  far  nothing  is  known  of  the  pathology  of  the  disease. 
Ulceration  of  the  intestines  has  been  met  with,  but  it  is  not  constant. 

Sprue  or  Psilosis. — A  remarkable  disease  of  the  tropics,  characterized  by 
"  a  peculiar,  inflamed,  superficially  ulcerated,  exceedingly  sensitive  condition, 
of  the  mucous  membrane  of  the  tongue  and  mouth;  great  wasting  and  anae- 
mia; pale,  copious,  and  often  loose,  frequent,  and  frothy  fermenting  stools; 
very  generally  by  more  or  less  diarrhoea;  and  also  by  a  marked  tendency  to 
relapse  ''  ( Manson ) . 

It  is  very  prevalent  in  India,  Chiaa,  and  Java.  i«[othuig  definite  is  known 
as  to  its  cause. 

AYhen  fully  established  the  chief  s}Taptoms  are  a  disturbed  condition  of 
the  bowels,  pale,  yeasty-looking  stools,  a  raw,  bare,  sore  condition  of  the 
tongue,  mouth,  and  gullet,  sometimes  with  actual  superficial  ulceration.  With 
these  gastro-intestinal  s3'mptoms  there  are  associated  ansemia  and  general  wast- 
ing. It  is  very  chronic  'oith  numerous  relapses.  There  are  no  characteristic 
anatomical  changes.  There  are  usually  ulcers  in  the  colon,  and  the  French 
think  it  is  a  form  of  dysentery. 

]\Ianson  recommends  rest  and  a  milk  diet  as  curative  in  a  large  proportion 
of  the  cases.  The  monograph  by  Thin  and  the  article  by  Manson  ui  Allbutt's 
System  give  very  full  descriptions  of  the  disease. 

DiPHTHEEITIC    OE    CROUPOUS    ENTEEITIS. 

A  croupous  or  diphtheritic  inflammation  of  the  mucosa  of  the  small  and 
large  intestines  occurs  (a)  most  frequently  as  a  secondary  process  in  the 
infectious  diseases — pneumonia,  pyaemia  in  its  various  forms,  and  tA^phoid 
fever;  (&)  as  a  terminal  process  in  many  chronic  affections,  such  as  Bright' s 
disease,  cirrhosis  of  the  liver,  or  cancer;  and  (c)  as  an  effect  of  certain  poisons 
— mercury,  lead,  and  arsenic. 

There  are  three  different  anatomical  pictures.  In  one  group  of  cases  the 
mucosa  presents  on  the  top  of  the  folds  a  thin  grayish-yellow  diphtheritic 
exudate  situated  upon  a  deeply  congested  base.  In  some  cases  all  grades  may 
be  seen  between  the  thinnest  fllm  of  superficial  necrosis  and  involvement  of 
the  entire  thickness  of  the  mucosa.  In  the  colon  similar  transversely  arranged 
areas  of  necrosis  are  seen  situated  upon  h}^er8smic  patches,  and  it  may  be 
here  much  more  extensive  and  involve  a  large  portion  of  the  membrane.  There 
may  be  most  extensive  inflammation  without  any  involvement  of  the  solitary 
follicles  of  the  large  or  small  bowel. 

In  a  second  group  of  cases  the  membrane  has  rather  a  croupous  character. 
It  is  grayish-white  in  color,  more  flake-like  and  extensive,  limited,  perhaps, 
to  the  cascum  or  to  a  portion  of  the  colon;  thus,  in  several. cases  of  pneumonia 
I  found  this  flaky  adherent  false  membrane,  in  one  instance  forming  patches 
1  to  2  cm.  in  diameter,  which  in  form  were  not  unlike  rupia  crusts. 


DISEASES  OF  THE  INTESTINES.  501 

In  a  third  group  the  affection  is  really  a  follicular  enteritis^  involving  the 
solitary  glands,  which  are  swollen  and  capped  with  an  area  of  diphtheritic 
necrosis  or  are  in  a  state  of  suppuration.  Follicular  ulcers  are  common  in  this 
form.  The  disease  may  run  its  course  without  any  symptoms,  and  the  condi- 
tion is  unexpectedly  met  with  post  mortem.  In  other  instances  there  are 
diarrhoea,  pain,  but  not  often  tenesmus  or  the  passage  of  blood-stained  mucus. 
In  the  toxic  cases  the  intestinal  symptoms  may  be  very  marked,  but  in  the 
terminal  colitis  of  the  fevers  and  of  constitutional  affections  the  symptoms 
are  often  trifling. 

The  ulcerative  colitis  of  chronic  disease  may  be  only  a  terminal  event  in 
these  diphtheritic  processes. 

Phlegmonous  Enteritis. 

As  an  independent  affection  this  is  excessively  rare,  even  less  frequent 
than  its  counterpart  in  the  stomach.  It  is  seen  occasionally  in  connection 
with  intussusception,  strangulated  hernia,  and  chronic  obstruction.  Apart 
from  these  conditions  it  occurs  most  frequently  in  the  duodenum,  and  leads 
to  suppuration  in  the  submucosa  and  abscess  formation.  Except  when  asso- 
ciated with  hernia  or  intussusception  the  affection  can  not  be  diagnosed.  The 
symptoms  usually  resemble  those  of  peritonitis. 

Ulcerative  Enteritis. 

In  addition  to  the  specific  ulcers  of  tuberculosis,  syphilis,  and  typhoid 
fever,  the  following  forms  of  ulceration  occur  in  the  bowels : 

(a)  Follicular  Ulceration. — As  previously  mentioned,  this  is  met  with  very 
commonly  in  the  diarrhceal  diseases  of  children,  and  also  in  the  secondary 
or  terminal  inflammations  in  many  fevers  and  constitutional  disorders.  The 
ulcers  are  small,  punched  out,  with  sharply  cut  edges,  and  they  are  usually 
limited  to  the  follicles.  With  this  form  may  be  placed  the  catarrhal  ulcers 
of  some  writers. 

(&)  Stercoral  ulcers,  which  occur  in  long  standing  cases  of  constipation. 
Very  remarkable  indeed  are  the  cases  in  which  the  sacculi  of  the  colon  become 
filled  with  rounded  small  scybala,  some  of  which  produce  distinct  ulcers  in 
the  mucous  membrane.  The  fsecal  masses  may  have  lime  salts  deposited  in 
them,  and  thus  form  little  enteroliths. 

(c)  Simple  Ulcerative  Colitis. — This  affection,  which  clinically  is  charac- 
terized by  diarrhoea,  is  often  regarded  wrongly  as  a  form  of  dysentery.  It  is 
not  a  very  uncommon  affection,  and  is  most  frequently  met  with  in  men 
above  the  middle  period  of  life.  The  ulceration  may  be  very  extensive,  so 
that  a  large  proportion  of  the  mucosa  is  removed.  The  lumen  of  the  colon 
is  sometimes  greatly  increased,  and  the  muscular  walls  hypertrophied.  There 
are  instances  in  which  the  bowel  is  contracted.  Frequently  the  remnants  of 
the  mucosa  are  very  dark,  even  black,  and  there  may  be  polypoid  outgrowths 
between  the  ulcers. 

These  cases  rarely  come  under  observation  at  the  outset,  and  it  is  difficult 
to  speak  of  the  mode  of  origin.  They  are  characterized  by  diarrhoea  of  a 
lienteric  rather  than  of  a  dysenteric  character.  There  is  rarely  blood  or  pus 
in  the  stools.     Constipation  may  alternate  with  the  diarrhoea.     There  is  usu- 


502  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

ally  great  impairment  of  nutrition^  and  the  patients  get  weak  and  sallow. 
Perforation  occasional!}^  occurs. 

The  disease  ma}'  prove  fatal,  or  it  may  pass  on  and  become  chronic.  The 
affection  was  not  very  infrequent  at  the  Philadelphia  Hospital,  and  though 
the  disease  bears  some  resemblance  to  dysentery,  it  is  to  be  separated  from  it. 
Some  of  the  cases  which  we  have  learned  to  recognize  as  amoebic  dysentery 
resemble  this  form  very  closely.  An  excellent  description  of  it  is  given  by 
Hale  White  in  Allbutt's  System.  The  ulcerative  colitis  met  with  in  institu- 
tions, such  as  that  described  by  Gemmel,  of  the  Lancaster  Asylum,  seems  to 
be  a  true  dysentery.  Dickinson  has  described  what  he  calls  albuminuric  ulcera- 
tion of  the  bowels  in  cases  of  contracted  kidney. 

(d)  TJlceration  from  External  Perforation. — This  may  result  from  the 
erosion  of  new  growths  or,  more  commonly,  from  localized  peritonitis  with 
abscess  formation  and  perforation  of  the  bowel.  This  is  met  with  most  fre- 
quently in  tuberculous  peritonitis,  but  it  may  occur  in  the  abscess  which 
follows  perforation  of  the  appendix  or  suppurative  or  gangrenous  pancreatitis. 
Fatal  hemorrhage  may  result  from  the  perforation. 

(e)  Cancerous  TTlcers. — In  very  rare  instances  of  multiple  cancer  or  sar- 
coma the  submucous  nodules  break  down  and  ulcerate.  In  one  case  the  ileum 
contained  eight  or  ten  sarcomatous  ulcers  secondary  to  an  extensive  sarcoma 
in  the  neighborhood  of  the  shoulder-joint. 

(/)  Occasionally  a  solitary  nicer  is  met  with  in  the  caecum  or  colon,  which 
may  lead  to  perforation.  Two  instances  of  ulcer  of  the  caecum,  both  with 
perforation,  have  come  under  my  observation,  and  in  one  instance  a  simple 
ulcer  of  the  colon  perforated  and  led  to  fatal  peritonitis. 

Diagnosis  of  Intestinal  Ulcers. — As  a  rule,  diarrhoea  is  present  in  all  cases, 
but  exceptionally  there  may  be  extensive  ulceration,  particularly  in  the  small 
bowel,  without  diarrhoea.  Very  limited  ulceration  in  the  colon  may  be  asso- 
ciated with  frequent  stools.  The  character  of  the  dejections  is  of  great  im- 
portance. Pus,  shreds  of  tissue,  and  blood  are  the  most  valuable  indications. 
Pus  occurs  most  frequently  in  connection  with  ulcers  in  the  large  intestine, 
but  when  the  bowel  alone  is  involved  the  amount  is  rarely  great,  and  the 
passage  of  any  quantity  of  pure  pus  is  an  indication  that  it  has  come  from 
without,  most  commonly  from  the  rupture  of  a  pericaecal  abscess,  or  in  women 
of  an  abscess  of  the  broad  ligament.  Pus  may  also  be  present  in  cancer  of 
the  bowel,  or  it  may  be  due  to  local  disease  in  the  rectum.  A  purulent  mucus 
may  be  present  in  the  stools  in  cases  of  ulcer,  but  it  has  not  the  same  diag- 
nostic value.  The  swollen,  sago-like  masses  of  mucus  which  are  believed  by 
some  to  indicate  follicular  ulceration  are  met  with  also  in  mucous  colitis. 
Hsemorrhage  is  an  important  and  valuable  s}Tnptom  of  ulcer  of  the  bowel, 
particularly  if  profuse.  It  occurs  under  so  many  conditions  that  taken  alone 
it  may  not  be  specially  significant,  but  with  other  coexisting  circumstances 
it  may  be  the  most  important  indication  of  all. 

Fragments  of  tissue  are  occasionally  found  in  the  stools  in  ulcer,  particu- 
larly in  the  extensive  and  rapid  sloughing  in  dysenteric  processes.  Definite 
portions  of  mucosa,  shreds  of  connective  tissue,  and  even  bits  of  the  muscular 
coat  may  be  found.  Pain  occurs  in  many  cases,  either  of  a  diffuse,  colicky 
character,  or  sometimes,  in  the  ulcer  of  the  colon,  very  limited  and  well 
defined. 


DISEASES  OF  THE  INTESTINES.  503 

Perforation  is  an  accident  liable  to  happen  when  the  ulcer  extends  deeply. 
In  the  small  bowel  it  leads  to  a  localized  or  general  peritonitis.  In  the  large 
intestine,  too,  a  fatal  peritonitis  may  result,  or  if  perforation  takes  place  -in 
the  posterior  wall  of  the  ascending  or  descending  colon,  the  production  of  a 
large  abscess  cavity  in  the  retro-peritongeum.  In  a  case  at  the  University  Hos- 
pital, Philadelphia,  there  was  a  perforation  at  the  splenic  flexure  of  the  colon 
with  an  abscess  containing  air  and  pus — a  condition  of  subphrenic  pyo-pneu- 
mothorax. 

Treatment  of  the  Previous  Conditions. 

(a)  Acute  Dyspeptic  DiarrhcEa. — All  solid  food  should  be  withheld.  If 
vomiting  is  present  ice  may  be  given,  and  small  quantities  of  milk  and  soda 
water  may  be  taken.  If  the  attack  has  followed  the  eating  of  large  quanti- 
ties of  indigestible  material,  castor  oil  or  calomel  is  advisable,  but  is  not  neces- 
sary if  the  patient  has  been  freely  purged.  If  the  pain  is  severe,  20  drops 
of  laudanum  and  a  drachm  of  spirits  of  chloroform  may  be  given,  or,  if  the 
colic  is  very  intense,  a  hypodermic  of  a  quarter  of  a  grain  of  morphia.  It  is 
not  well  to  check  the  diarrhoea  unless  it  is  profuse,  as  it  usually  stops  spon- 
taneously within  forty-eight  hours.  If  persistent,  the  aromatic  chalk  powder 
or  large  doses  of  bismuth  (30  to  40  grains)  may  be  given.  A  small  enema 
of  starch  (2  ounces)  with  20  drops  of  laudanum,  every  six  hours,  is  a  most 
valuable  remedy. 

(&)  Chronic  diarrhoea,  including  chronic  catarrh  and  ulcerative  enteritis. 
It  is  important,  in  the  first  place,  to  ascertain,  if  possible,  the  cause  and 
whether  ulceration  is  present  or  not.  So  much  in  treatment  depends  upon 
the  careful  examination  of  the  stools — as  to  the  amount  of  mucus,  the  pres- 
ence of  pus,  the  occurrence  of  parasites,  and,  above  all,  the  state  of  digestion 
of  the  food — that  the  practitioner  should  pay  special  attention  to  them.  Many 
cases  simply  require  rest  in  bed  and  a  restricted  diet.  Chronic  diarrhoea  of 
many  months'  or  even  of  several  years'  duration  may  be  sometimes  cured  by 
strict  confinement  to  bed  and*  a  diet  of  boiled  milk  and  albumen  water. 

In  that  form  in  which  immediately  after  eating  there  is  a  tendency  to 
loose  evacuations  it  is  usually  found  that  some  one  article  of  diet  is  at  fault. 
The  patient  should  rest  for  an  hour  or  more  after  meals.  Sometimes  this  alone 
is  sufficient  to  prevent  the  occurrence  of  the  diarrhoea.  In  those  forms  which 
depend  upon  abnormal  conditions  in  the  small  intestine,  either  too  rapid  peris- 
talsis or  faulty  fermentative  processes,  bismuth  is  indicated.  It  must  be  given 
in  large  doses — from  half  a  drachm  to  a  drachm  three  times  a  day.  The 
smaller  doses  are  of  little  use.  Kaphthalin  preparations  here  do  much  good, 
given  in  doses  of  from  10  to  15  grains  (in  capsule)  four  or  five  times  a  day. 
Larger  doses  may  be  needed.    Salol  and  the  salicylate  of  bismuth  may  be  tried. 

An  extremely  obstinate  and  intractable  form  is  the  diarrhoea  of  hysterical 
women.  A  systematic  rest  cure  will  be  found  most  advantageous,  and  if  a 
milk  diet  is  not  well  borne  the  patient  may  be  fed  exclusively  on  egg  albumen. 
The  condition  seems  to  be  associated  in  some  cases  with  increased  peristalsis, 
and  in  such  the  bromides  may  do  good,  or  preparations  of  opium  may  be  neces- 
sary. There  are  instances  which  prove  most  obstinate  and  resist  all  forms  of 
treatment,  and  the  patient  may  be  greatly  reduced.  A  change  of  air  and 
surroundings  may  do  more  than  medicines. 


504  .DISEASES  OF   THE  DIGESTIVE  SYSTEM. 

In  a  large  group  of  the  chronic  diarrhoeas  the  mischief  is  seated  in  the 
colon  and  is  due  to  ulceration.  Medicines  hy  the  mouth  are  here  of  little  value. 
The  stools  should  be  carefully  watched  and  a  diet  arranged  which  shall  leave 
the  smallest  possible  residue.  Boiled  or  peptonized  milk  may  be  given,  but  the 
stools  should  be  examined  to  see  whether  there  is  an  excess  of  food  or  of  curds. 
Meat  is,  as  a  rule,  badly  borne  in  these  cases.  The  diarrhoea  is  best  treated 
by  enemata.  The  starch  and  laudanum  should  be  tried,  but  when  ulceration 
is  present  it  is  better  to  use  astringent  injections.  From  2  to  4  pints  of  warm 
water,  containing  from  half  a  drachm  to  a  drachm  of  nitrate  of  silver,  may 
be  used.  In  the  chronic  diarrhoea  which  follows  dysentery  this  is  particularly 
advantageous.  In  giving  large  injections  the  patient  should  be  in  the  dorsal 
position,  with  the  hips  elevated,  and  it  is  best  to  allow  the  injection  to  flow 
in  gradually  from  a  siphon  bag.  In  this  way  the  entire  colon  can  be  irrigated 
and  the  patient  can  retain  the  injection  for  som«  time.  The  silver  injections 
may  be  very  painful,  but  they  are  invaluable  in  all  forms  of  ulcerative  colitis. 
Acetate  of  lead,  boracic  acid,  sulphate  of  copper,  sulphate  of  zinc,  and  sali- 
cylic acid  may  be  used  in  l-per-cent  solutions. 

In  the  intense  forms  of  choleraic  diarrhoea  in  adults  associated  with  con- 
stant vomiting  and  frequent  watery  discharges  the  patient  should  be  given  at 
once  a  h3-podermic  of  a  quarter  of  a  grain  of  morphia,  which  should  be  re- 
peated in  an  hour  if  the  pains  return  or  the  purging  persists.  This  gives 
prompt  relief,  and  is  often  the  only  medicine  needed  in  the  attack.  The 
patient  should  be  given  stimulants,  and,  when  the  vomiting  is  allayed  by 
suitable  remedies,  small  quantities  of  milk  and  lime  water. 

II.     DIARRHGE3AL    DISEASES    IN    CHILDREN. 

Children  are  particularly  susceptible  to  disorders  of  the  alimentary  tract. 
Although  several  forms  are  recognized,  they  so  often  merge  the  one  into  the 
other  that  a  sharp  differentiation  is  impossible. 

General  Etiology. — Certain  factors  predispose  to  diarrhoea.  Age. — The 
largest  number  of  cases  occur  just  after  the  nursing  period;  the  highest  mor- 
tality is  in  the  second  half  of  the  first  year,  when  this  period  falls  in  the  hot 
weather ;  hence  the  dread  of  the  "  second  summer." 

Diet. — Diarrhoea  is  most  frequent  in  artificially  fed  babies.  Of  nineteen 
hundred  and  forty-three  fatal  cases  collected  by  Holt,  only  3  per  cent  were 
breast-fed.  The  recent  agitation  for  23ure  milk  in  the  large  cities  has  de- 
creased materially  the  number  of  diarrhoea  cases  among  bottle-fed  infants. 

Among  the  poor  the  bowel  complaint  comes  with  artificial  feeding,  and 
is  due  either  to  milk  ill  Suited  in  quantity  or  poor  in  quality  or  to  indigestible 
articles  of  diet.  Very  many  of  the  fatal  cases  have  been  fed  upon  condensed 
milk. 

Temperature. — The  relation  of  the  atmospheric  temperature  to  the  preva- 
lence of  the  disease  in  children  has  long  been  recognized.  The  mortality  curve 
begins  to  rise  in  May,  increases  in  June,  reaching  the  maximum  in  July,  and 
gradually  sinks  through  August  and  September.  The  maximum  corresponds 
closely  with  the  highest  mean  temperature,  yet  we  can  not  regard  the  heat 
itself  as  the  direct  agent,  but  only  as  one  of  several  factors.  Thus  the  mean 
temperature  of  June  is  only  four  or  five  degrees  lower  than  that  of  July,  and 


DISEASES  OF  THE  INTESTINES.  505 

yet  the  mortality  is  not  more  than  one-third.  Seibert,  who  has  carefully  ana- 
lyzed the  mortality  and  the  temperature  month  by  month  in  New  York  for 
ten  years,  fails  to  find  a  constant  relation  between  the  degrees  of  heat  and  the 
number  of  cases  of  diarrhoea.  Neither  barometric  pressure  nor  humidity 
appears  to  have  any  influence. 

Bacteeiology. — The  discovery  by  Duvall  and  Bassett,  working  at  the 
Thomas  Wilson  Sanitarium,  in  the  dejecta  of  children  suffering  from  summer 
diarrhoea,  of  a  bacillus  apparently  identical  with  the  organism  shown  by  Shiga 
to  be  the  cause  of  epidemic  dysentery  in  Japan,  has  awakened  renewed  interest 
in  the  relation  of  bacteria  to  these  disorders  in  children. 

The  Eockefeller  Institute  research  (1903)  showed  that  this  organism  was 
present  in  a  large  number  of  cases  of  so-called  "  summer  diarrhoea."  No  in- 
stances of  cholera  infantum  were  studied.  The  laboratory  studies  of  Martini 
and  Lentz,  Flexner,  Hiss,  Parke,  and  others,  indicate  that  there  is  a  group 
of  closely  allied  forms  of  bacilli  differing  slightly  from  the  original  Shiga 
bacillus  in  their  action  on  certain  sugars  and  in  agglutinating  properties. 

The  type  of  organisms  most  frequently  associated  with  the  diarrhoeas  of 
children  belongs  to  the  so-called  "  acid  type,"  and,  unlike  the  Shiga  cultures, 
ferments  mannite  with  acid  production. 

The  causal  comiection  of  this  group  of  bacteria  with  all  the  diarrhoeal  dis- 
eases of  children  has  not  been  proven.  In  the  hands  of  some  workers  they 
have  been  found  in  the  faces  of  a  large  proportion  of  all  cases  examined,  and 
also  less  frequently  in  the  sporadic  diarrhoeas  occurring  throughout  the  year. 
These  organisms  are  often  found  in  comparatively  small  numbers,  and  are 
more  easily  isolated  from  mucus  or  blood-stained  stools.  They  occur  in  the 
acute  primary  intestinal  infection  in  children,  in  subacute  infection  without 
previous  symptoms  coincident  with  or  following  other  acute  diseases  such  as 
measles,  pneumonia,  etc.,  and  in  the  terminal  intestinal  infection  following 
malnutrition  or  marasmus.  They  have  been  found  in  breast-fed  infants  as 
well  as  bottle-babies. 

The  mode  of  entrance  of  the  organism  has  not  been  determined.  Simul- 
taneous outbreaks  of  many  cases  in  remote  parts  of  a  community  where  there 
can  be  no  common  milk  supply,  and  occurrence  of  the  disease  in  breast-  and 
condensed-milk-fed  babies,  indicates  that  cow's  milk  is  not  the  only  conveyer 
of  the  infection,  and  points  to  some  common  cause,  possibly  to  the  water,  as 
a  means  of  contamination,  although  dysentery  bacilli  have  not  yet  been  iso- 
lated from  city  water. 

The  importance  of  other  organisms  must  not  be  overlooked.  The  observa- 
tions of  Escherich  showed  the  remarkable  simplicity  of  bacterial  flora  in  the 
intestines  of  healthy  milk-fed  children,  hacterium  lactis  cerogenes  being  present 
in  the  upper  portion  of  the  bowel  and  hacterium  coli  commune  in  the  lower 
bowel,  each  almost  in  pure  culture. 

When  diarrhoea  is  set  up  the  number  and  varieties  of  bacteria  are  greatly 
increased,  although  heretofore  no  forms  had  been  found  to  bear  a  constant  or 
specific  relationship  to  the  diarrhoeal  faeces. 

Certain  diarrhoeas  in  children  are  apparently  induced  by  the  lactic  acid 
organisms  in  milk,  others  by  colon  or  proteus  hacilli,  and  others,  again,  by  the 
pyogenic  cocci  and  other  forms;  all  these  bacteria  may  be  associated  with  the 
dysentery  bacilli. 
U 


506  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

There  is  considerable  evidence  to  support  the  view  that  the  destructive 
lesions  of  the  intestines  ma}^  be  produced  by  the  streptococcus  pyogenes  after 
an  initial  infection  with  a  member  of  the  dysenter}^  group. 

Morbid  Anatomy. — In  mild  cases  there  may  be  only  a  slight  catarrhal 
swelling  of  the  mucosa  of  both  small  and  large  bowel,  with  enlargement  of 
the  lymph  follicles.  The  mucous  membrane  may  be  irregularh^  congested; 
often  this  is  most  marked  at  the  summit  of  the  folds.  The  submucosa  is  usu- 
ally infiltrated  with  serum  and  small  round  cells.  In  more  severe  cases  ulcera- 
tion may  take  place.  The  loss  of  substance  begins,  usually,  in  the  mucosa, 
over  swollen  lymph  follicles.  About  the  ulcer  there  is  a  more  or  less  distinctly 
marked  inflammatory  zone.  The  destruction  of  the  tissue  is  limited  to  the 
region  of  the  follicles  and  becomes  progressive  by  the  union  of  several  adjoin- 
ing ulcers.  This  process  is  usually  confined  to  the  lower  bowel,  and  may  be 
so  extensive  as  to  leave  onh'  ribbons  of  intact  mucosa.  The  ulcers  never  per- 
forate. 

Rarel}^  there  is  a  croupous  or  pseudo-membranous  enteritis  affecting  the 
lower  ilium,  colon,  and  rectum.  The  constant  features  are  the  increased  secre- 
tion of  mucus  and  the  lymphoid  hyperplasia.  The  mesenteric  glands  are  en- 
larged. The  changes  in  the  other  organs  are  neither  numerous  nor  charac- 
teristic. 

Broncho-pneumonia  occurs  in  many  cases.  The  liver  is  often  fatty,  the 
spleen  may  be  swollen.  Brain  lesions  are  rare;  the  membranes  and  substance 
are  often  ansemic,  but  meningitis  or  thrombosis  is  very  uncommon. 

Clixical  Forms. 

Acnte  Intestinal  Indigestion. — This  form  occurs  in  children  of  all  ages, 
and  is  associated  with  improper  food.  The  symptoms  often  begin  abruptly 
with  nausea  and  vomiting,  or,  especially  in  stronger  children,  several  hours 
or  a  day  or  two  after  the  disturbing  diet.  The  local  s}Tnptoms  are  colicky 
pains,  moderate  tvnnpanites,  and  diarrhoea.  The  stools  are  four  to  ten  in 
twenty-four  hours;  at  first  faecal,  then  fluid,  with  more  or  less  mucus  and 
particles  from  undigested  material.  There  is  no  blood.  The  usual  intestinal 
bacteria  are  found.  Occasionally,  when  there  is  mucus,  dj^sentery  bacilli  are 
present.  There  is  always  fever.  It  is  rarely  very  high,  and  never  continues. 
The  pulse  may  be  rapid  and  the  prostration  marked  in  very  3^oung  or  weak 
children.  These  symptoms  usually  subside  shortly  after  the  emptying  of  the 
bowel. 

In  weakened  infants,  or  when  the  treatment  has  been  delayed  or  the  diet 
remains  unchanged,  this  disturbance  may  lead  to  more  serious  conditions. 
Attacks  of  intestinal  indigestion  tend  to  recur. 

Acute  Dyspepsia,  or  Fermentative  Diarrhoea. — This  form  is  characterized 
by  more  severe  constitutional  sjnnptoms.  It  may  begin  after  an  intestinal 
indigestion  of  several  days  in  which  the  stools  are  fluid  and  offensive,  and 
contain  undigested  food  and  curds.  In  other  cases  the  disease  sets  in 
abruptly  with  vomiting,  griping  pains,  and  fever,  which  may  rapidly  reach 
104°-105°  F. 

I^ervous  symptoms  are  usually  prominent.  The  child  is  irritable  and 
sleeps  poorly.     Convulsions  may  usher  in  the  acute  sjonptoms  or  occur  later. 


DISEASES  OF  THE  INTESTINES.  507 

An  increasing  drowsiness,  ending  in  coma,  has  been  noted  in  many  cases.  The 
stools,  which  vary  from  four  to  twenty  in  twenty-four  hours,  soon  lose  their 
fgecal  character  and  become  fluid.  Later  they  consist  largely  of  green  or 
translucent  mucus.  An  occasional  fleck  of  blood  is  noticed  in  the  mucus,  but 
this  is  never  present  in  large  amounts. 

Microscopically,  besides  the  food  residue  and  mucous  strands  are  a  mod- 
erate number  of  leucocytes  and  red  blood-corpuscles.  Epithelial  cells  are 
found  with  numerous  bacteria. 

The  acute  symptoms  generally  pass  away  in  a  few  days  with  judicious 
treatment.  Eelapses  are  frequent,  following  any  indiscretion.  The  attack 
may  be  the  beginning  of  severe  ileo-colitis. 

These  gastro-intestinal  intoxications  are  largely  confined  to  the  summer 
months  and  form  an  important  group  of  the  summer  diarrhoeas  of  children. 

Cholera  Infantum. — This  term  should  be  reserved  for  the  fulminating 
form  of  gastro-intestinal  intoxication.  The  typical  cases  are  rare  and  form 
only  a  very  small  proportion  of  the  diarrhoeal  diseases  of  infants.  The  disease 
sets  in  with  vomiting,  which  is  incessant  and  is  excited  by  an  attempt  to  take 
food  or  drink.  The  stools  are  profuse  and  frequent;  at  first  fsecal  in  charac- 
ter, brown  or  yellow  in  color,  and  finally  thin,  serous,  and  watery.  The  stools 
first  passed  are  very  offensive ;  subsequently  they  are  odorless.  The  thin,  serous 
stools  are  alkaline.  There  is  fever,  but  the  axillary  temperature  may  register 
three  or  more  degrees  below  that  of  the  rectum.  From  the  outset  there  is 
marked  prostration;  the  eyes  are  sunken,  the  features  pinched,  the  fontanelles 
depressed,  and  the  skin  has  a  peculiar  ashy  pallor.  At  first  restless  and  ex- 
cited, the  child  subsequently  becomes  heavy,  dull,  and  listless.  The  tongue 
is  coated  at  the  onset,  but  subsequently  becomes  red  and  dry.  As  in  all 
choleraic  conditions,  the  thirst  is  insatiable;  the  pulse  is  rapid  and  feeble,  and 
toward  the  end  becomes  irregular  and  imperceptible.  Death  may  occur  within 
twenty-four  hours,  with  symptoms  of  collapse  and  great  elevation  of  the  in- 
ternal temperature.  Before  the  end  the  diarrhoea  and  vomiting  may  cease. 
In  other  instances  the  intense  symptoms  subside,  but  the  child  remains  torpid 
and  semi-comatose,  with  fingers  clutched,  and  there  may  be  convulsions.  The 
head  may  be  retracted  and  the  respirations  interrupted,  irregular,  and  of  the 
Cheyne- Stokes  type.  The  child  may  remain  in  this  condition  for  some  days 
without  any  signs  of  improvement.  It  was  to  this  group  of  symptoms  in 
infantile  diarrhoea  that  Marshall  Hall  gave  the  term  "  hydrencephaloid,"  or 
spurious  hydrocephalus.  As  a  rule,  no  changes  in  the  brain  or  other  organs 
are  found.  The  condition  of  sclerema  is  described  as  a  sequel  of  cholera 
infantum.  The  skin  and  subcutaneous  tissue  becomes  hard  and  firm,  and  the 
appearance  has  been  compared  to  that  of  a  half -frozen  cadaver. 

No  constant  organism  has  been  found  in  these  cases.  Baginsky  considers 
the  disease  the  result  of  the  action  on  the  system  of  the  poisonous  products 
of  decomposition  encouraged  by  the  various  bacteria  present — a  Fdulniss  dis- 
ease. The  clinical  picture  is  that  produced  by  an  acute  bacterial  infection, 
as  in  Asiatic  cholera. 

Diagnosis. — The  diagnosis  is  readily  made.  There  is  no  other  intestinal 
affection  in  children  for  which  it  can  be  mistaken.  The  constant  vomiting, 
the  frequent  watery  discharges,  the  collapse  symptoms,  and  the  elevated  tem- 
perature make  an  unmistakable  clinical  picture.    The  outlook  in  the  majority 


508  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

of  cases  is  bad,  particularly  in  children  artificially  fed.  Hyperpyrexia,  ex- 
treme collapse,  and  incessant  vomiting  are  the  most  serious  symptoms. 

Ileo-colitis  {Entero-colitis,  Inflammatory  Diarrhcea). — In  this  form  there 
is  evidence  of  an  inflammatory  alteration  of  the  intestinal  wall,  usually  of  the 
lower  ileum  and  large  intestine.  Several  sub-varieties  are  recognized  according 
to  the  nature  and  site  of  the  lesions.  Many  of  the  cases  are  grafted  on  the 
simple  forms  above  described.  The  mucous  discharges  continue,  mingled  with 
food  residue  and  often  streaked  with  blood.  Pus  cells  are  numerous  under 
the  microscope.  The  temperature  remains  elevated  or  may  be  remittent. 
After  two  or  three  weeks  the  symptoms  gradually  subside,  the  stools  become 
fewer  in  number,  and  the  fscal  character  returns. 

In  other  instances  the  severe  involvement  of  the  intestines  seems  evident 
within  a  few  hours  of  the  onset,  with  abdominal  pain,  vomiting,  and  fever. 
Blood  and  pus  may  be  present  in  nearly  every  stool.  Tenesmus  is  frequent 
and  prolapsus  ani  is  not  uncommon.  In  severe  attacks  the  prostration  is 
marked,  the  tongue  is  dry,  the  mouth  covered  with  sordes,  and  death  may 
ensue  in  a  few  days  from  profound  sepsis,  or,  if  the  acute  stage  is  survived, 
the  case  may  continue  desperately  ill  for  weeks,  gradually  recover,  or  die  from 
asthenia. 

Haemorrhage  of  large  amounts  of  blood  is  extremely  rare.  The  appearance 
of  bright  red  stains  on  the  napkin  indicates,  usually,  ulceration  of  the  lower 
bowel  or  rectum.  When  the  blood  is  dark  brown  the  lesion  is  in  the  ileum  or 
near  the  valve.  The  extent  of  the  ulceration  can  not  be  accurately  determined 
by  the  quantity  of  the  blood  passed. 

Membranous-colitis  is  usually  only  to  be  distinguished  by  the  discovery 
of  the  membrane  in  the  rectum  through  a  speculum  or  in  prolapsus,  or  by 
the  passage  of  a  fragment  of  the  membrane  in  the  stools. 

Inflammation  of  the  colon  often  occurs  in  marantic  infants.  It  may  con- 
sist of  a  catarrhal  or  follicular  inflammation  of  the  lower  bowel  without 
destructive  lesion,  and  is  frequently  a  terminal  infection. 

Ileo-colitis  may  become  chronic  and  persist  for  months.  The  signs  of 
active  inflammation  subside;  there  is  little  pain  or  fever,  but  more  or  less 
mucus  remains  in  the  stools.  The  general  condition  of  the  child  suffers. 
There  is  a  continuous  loss  in  weight;  the  skin  is  dry  and  hangs  in  folds; 
nervous  symptoms  are  always  present.  There  may  be  stiffness  and  contrac- 
tion of  the  extremities,  with  opisthotonus.  The  progress  of  the  disease  is 
irregular,  marked  by  short  periods  of  improvement.  Death  is  often  due  to  a 
relapse,  to  asthenia,  or  to  broncho-pneumonia.  In  many  of  these  cases,  both 
acute  and  chronic,  the  dysentery  bacilli  have  been  found  in  association  with 
other  organisms. 

Prevention. — Unquestionably,  most  of  the  intestinal  disorders  of  children 
can  be  prevented.  In  many  of  our  large  cities  the  mortality  from  the  summer 
diarrhoeas  has  been  greatly  reduced  by  prophylactic  measures. 

The  infant  should  have  abundance  of  air-space  in  the  home,  with  plenty 
of  sunlight  and  fresh  air.  In  hot  weather,  it  may  be  well  for  him  to  sleep 
out  of  doors,  day  and  night.  His  clothing  must  not  be  too  heavy  in  midsum- 
mer; often  only  a  binder  and  thin  dress.  This  clothing  should  be  altered 
with  every  change  of  the  temperature.  The  greatest  cleanliness  should  sur- 
round the  life  of  the  baby,  and  the  nursing-bottles  and  nipples  are  to  be 


DISEASES  OF  THE  INTESTINES.  509 

boiled  each  day  and  kept  scrupulously  clean.  Breast-feeding  is  continued 
whenever  possible. 

Diet. — With  bottle-babies,  in  warm  weather,  the  d'iet  should  be  reduced 
in  strength — i.  e.,  weaker  milk  mixtures  used  and  more  water  given.  In  all 
crowded  communities  the  milk  should  be  sterilized  or  pasteurized  during  the 
summer  months,  and  all  the  water  given  the  baby,  either  with  or  between  the 
nourishment,  boiled.  It  is  better  that  a  child  should  be  in  the  country  during 
the  hot  weather,  but  when  this  is  impossible  the  various  parks  in  our  large 
cities  afford  much  relief. 

Treatment. — Hygienic  Management. — Even  after  the  illness  has  begun, 
much  can  be  done  by  hygienic  measures  to  diminish  the  severity.  Change  of 
air  to  seashore  or  mountain  is  often  followed  by  a  marked  improvement  in 
the  child's  condition.  The  patient  must  not  be  too  warmly  clad.  The  tem- 
perature may  be  lowered  and  nervous  symptoms  allayed  by  hydrotherapy. 
Baths,  warm  and  cool,  are  helpful.  Colon  irrigations  serve  the  double  purpose 
of  flushing  the  bowel  and  stimulating  the  nervous  system.  They  should  be 
given  cool  when  there  is  much  fever. 

Medicinal. — In  all  cases  of  diarrhoea  there  is  more  or  less  congestion  of 
the  intestinal  mucosa,  hypersecretion  of  mucus,  and  increased  peristalsis  due  in 
part  to  the  irritant  action  of  improper  food.  In  certain  forms  toxic  symptoms 
from  the  absorption  of  poisons  from  the  intestinal  tract  are  early  noticed.  In 
other  instances,  inflammatory  lesions  in  the  wall  of  the  bowel  are  present. 
The  keynote,  then,  of  the  treatment  is  promptness.  IsTature's  effort  to  remove 
the  disturbing  cause  should  be  assisted,  not  checked,  and  care  must  be  taken 
to  introduce  food  that  will  afford  the  least  pabulum  for  the  disturbing  bacteria. 

Castor-oil  and  calomel  are  to  be  preferred  as  purgatives,  especially  for 
ijifants.  A  drachm  of  the  former  repeated,  if  necessary,  will  usually  sweep 
the  intestinal  tract  and  relieve  the  irritation.  Where  there  is  much  nausea 
or  intestinal  fermentation,  calomel  is  indicated.  It  may  be  given  in  divided 
doses  at  short  intervals  until  one  or  two  grains  have  been  taken,  or  until  the 
characteristic  green  stools  appear.  Very  early  in  the  attack,  if  nausea  is  a 
marked  symptom,  nothing  relieves  so  quickly  as  gastric  lavage  with  warm 
water,  or  a  weak  soda  solution  when  there  is  much  acidity.  In  older  children, 
a  large  draught  of  boiled  water  may  be  substituted.  In  many  cases  irrigation 
of  the  lower  bowel  with  large  quantities  of  salt  solution  flushes  the  colon, 
removing  the  irritating  material,  and  diminishes  the  absorption  of  toxins.  It 
also  reduces  the  temperature  and  allays  nervous  symptoms.  The  irrigating 
fluid  should  be  cool  when  there  is  much  fever.  The  infant  is  placed  in  the 
dorsal  position  or  turned  a  little  to  the  left,  with  hips  elevated,  and  the  fluid 
from  a  fountain  syringe,  about  three  feet  above  the  patient,  is  allowed  to  flow 
into  the  rectum  through  a  large  soft  rubber  catheter.  Usually  about  a  pint 
can  be  retained  before  expulsion.  If  desired,  the  catheter  can  be  gently 
pushed  into  the  bowel  as  it  becomes  distended  with  fluid.  Two  or  three  quarts 
should  be  used  at  one  irrigation,  which  may  be  repeated  several  times  in 
twenty- four  hours  if  it  is  beneficial. 

Where  there  is  ulceration  of  the  lower  bowel,  various  astringents,  such  as 
alum,  witch  hazel  (one  or  two  teaspoonfuls  to  one  quart),  silver  nitrate, 
1-4,000,  or  a  weak  solution  of  permanganate  of  potassium,  may  be  used  as 
the  irrigating  fluid. 


510  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

When  there  is  much  loss  of  fluid  from  the  body  or  when  toxic  s}Tnptoms 
are  marked,  infusion  of  normal  salt  solution  under  the  skin  may  be  tried. 
One  to  three  hundred  cc.  of  the  solution  can  be  readily  introduced.  This 
procedure  is  not  so  permanentl}^  helpfiil  as  it  was  thought  to  be  some  years 
ago.    There  is  rarely  any  necessity  to  transfuse. 

Of  the  many  drugs  vaunted  as  intestinal  astringents  and  antiseptics,  bis- 
muth, either  as  subgallate  or  subnitrate,  has  proven  most  serviceable.  It 
should  not  be  given  until  the  disturbing  material  has  been  removed  and  the 
temperature  is  falling;  then  it  should  be  administered  in  large  doses,  5  to  10 
grains  every  hour,  until  there  is  discoloration  of  the  stools.  In  some  cases 
this  may  be  hastened  by  lac  sulphur  in  grain  doses.  Opium  should  be  very 
sparingly  used,  and  then  onl}'  for  a  specific  purpose,  to  cheek  excessive  peri- 
stalsis, violent  colic,  or  very  numerous  passages.  It  may  be  given  to  an  in- 
fant as  Dover's  powders,  ^1  gr. ;  or  paregoric,  5-10  minims  every  four 
hours;  or  morphia,  h}^odermically,  -^^--^  gr.,  when  prompt  action  is  de- 
sired. Occasionally  it  is  well  to  combine  it  with  atropia,  joW  ~  Jiro  g^. 
The  bowels  should  not  be  locked  when  the  stools  are  foul  or  the  temperature 
is  high. 

In  all  cases  where  there  is  prostration,  stimulants  are  indicated.  Alcohol, 
such  as  brandy  or  whisky,  ^  to  1  oz.  in  twenty-four  hours  in  frequent  doses, 
diluted  six  to  ten  times  with  water,  or,  where  there  is  much  nausea,  cham- 
pagne with  cracked  ice,  is  most  helpful.  Strychnine,  twt-i-wo  gr.,  or  digi- 
talin  in  similar  doses,  may  be  indicated.  Musk  and  camphor  are  also  excellent 
stimulants. 

Serum  Therapy. — Thus  far  the  results  of  serum  therapy  have  been  dis- 
appointing. Of  83  cases  collected  during  the  summer  of  1903  by  the  Eocke- 
feller  Institute,  there  were  no  cures  which  could  be  certainly  ascribed  to  the 
serum,  nor  was  the  mortality,  as  compared  with  previous  years,  appreciably 
lowered  by  serum  prepared  from  either  the  so-called  acid  or  alkaline  type  or 
organism.  In  nearly  all  instances,  however,  in  which  the  serum  was  given, 
several  days  had  elapsed  after  the  onset  of  the  illness.  It  was  only  in  the 
very  early  cases  that  any  improvement  at  all  was  noticed.  It  may  be  that 
an  earlier  trial  will  be  followed  by  better  results. 

Certainly  the  marked  reduction  in  the  mortality  in  adult  dysentery  in 
Japan,  reported  by  Shiga,  should  encourage  the  further  trial  of  this  treatment 
in  the  epidemic-diarrhoea,  as  no  ill  effects  whatever  have  been  ascribed  to  its 
use.     It  is  given  in  10-40  cc.  doses,  h}-podermically. 

Diet. — The  dietetic  management  is  of  the  utmost  importance.  In  acute 
cases  with  fever,  the  milk,  whether  breast  or  cow's  milk,  and  all  its  modifica- 
tions, must  be  stopped  at  once.  It  is  best  to  give  the  infant  nothing  but 
water  for  several  hours,  it  may  be  for  two  or  three  days,  or  until  the  acute 
symptoms  subside ;  a  cereal  water  may  then  be  substituted,  preferably  dextrin- 
ized,  to  which  may  be  added  egg  albumen,  broth,  or  beef  juice.  Preparations 
of  broth  and  beef  juice,  and  occasionally  a  weak  tea,  may  be  given.  The  time 
at  which  it  is  safe  to  return  to  a  milk  diet  varies  with  each  case,  and  no  defi- 
nite rules  can  be  laid  down.  It  is  usually  better  to  defer  milk  until  the  tem- 
perature is  nearly  normal. 

If  the  stools  are  offensive  from  proteid  decomposition,  a  diet  consisting 
largely  of  carbohydrates — i.  e.,  barley  water — is  indicated ;  whereas  proteid 


DISEASES  OF   THE  INTESTINES.  511 

diet,  such  as  beef  juice  and  egg  albumen,  is  more  helpful  when  the  stools  are 
strongly  acid. 

Experience  has  shown  that  the  ingredient  in  the  milk  that  is  not  well  borne 
is  the  fat;  hence  skimmed  milk,  diluted  or  partially  digested,  can  often  be 
safely  given  before  diluted  whole  milk.    Whey  is  often  helpful. 

In  Germany,  buttermilk  has  been  widely  used  in  convalescence  from  intes- 
tinal disturbances. 

The  various  proprietary  foods,  or  condensed  milk  mixed  with  water,  al- 
though not  to  be  given  over  long  periods,  may  be  found  serviceable  in  the 
gradual  return  of  the  child  to  a  normal  diet. 

In  children  from  three  to  seven  years  of  age  these  acute  derangements  are 
rarely  serious,  and  usually  respond  promptly  after  purgation  and  restricted 
diet,  consisting  largely  of  boiled  milk. 

It  must  be  borne  in  mind  that  injudicious  treatment,  either  in  diet  or 
medication,  may  interrupt  what  otherwise  would  be  a  prompt  recovery  and 
bring  on  the  most  serious  intestinal  lesions.  The  chronic  cases,  both  in  infants 
and  older  children,  especially  those  with  ileo-colitis  and  ulceration  in  the  gut, 
present  unusual  difficulties.  Each  case  must  be  studied  by  itself.  Food  which 
is  digested  in  the  upper  portion  of  the  intestinal  tract  is  preferable.  Milk, 
properly  modified  with  cereal  water  or  predigested,  if  intelligently  prescribed, 
offers  the  best  chance  of  success.  The  so-called  percentage  system  of  milk 
modification,  which  enables  the  physician  to  alter  at  will  the  proportion  of 
fat  or  carbohydrate  present  in  the  milk  mixture,  is  of  great  service  in  feeding 
these  long-standing  cases. 

Care  must  be  taken  not  to  over-feed,  although  occasionally  when  there  is 
persistent  anorexia,  gavage  may  be  necessary.  This  is  best  accomplished 
through  a  nasal  tube.  Some  infants  will  retain  food  given  through  a  catheter 
when  they  will  vomit  the  same  mixture  taken  from  a  bottle.  Beef  juice  or 
one  of  the  beef-peptone  preparations  is  frequently  useful.  They  should 
always  be  given  with  considerable  fluid.  In  a  large  majority  of  instances 
ulceration  is  confined  to  the  large  intestine,  and  can  be  reached  by  local 
treatment. 

Irrigations  which  flush  the  injured  surface  are  of  service.  They  should 
be  discontinued  if  much  exhaustion  follows;  this  is  rarely  the  case. 

No  very  definite  results  have  followed  the  various  astringent  preparations 
recommended.  Probably  warm  salt  or  weak  soda  solutions  are  as  useful.  Sil- 
ver nitrate  is  stimulating  and  healing  where  the  ulcerations  are  in  the  rectum. 
In  great  local  irritation  and  tenesmus,  enemata  (2  oz.)  of  flaxseed  or  starch, 
with  2  to  5  drops  of  laudanum,  are  soothing  and  beneficial. 

Treatment  of  Cholera  Infantum. — In  cholera  infantum  serious  symptoms 
may  occur  with  great  rapidity,  and  here  the  incessant  vomiting  and  frequent 
purging  render  the  administration  of  remedies  extremely  difficult.  Irrigation 
of  the  stomach  and  large  bowel  is  of  great  service,  and  when  the  fever  is  high 
ice-water  injections  may  be  used,  or  a  graduated  bath.  As  in  the  acute  chol- 
eraic diarrhoea  of  adults,  morphia  hypodermically  is  the  remedy  which  gives 
greatest  relief,  and  in  the  conditions  of  extreme  vomiting  and  purging,  with 
restlessness  and  collapse  symptoms,  this  drug  alone  commands  the  situation. 
A  child  of  one  year  may  be  given  from  t^o"  to  ^\  of  a  grain,  to  be  repeated 
in  an  hour,  and  again  if  not  better. 


512  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

In  all  eases  of  diarrhoea  convalescence  requires  very  careful  management. 
An  infant  which  has  suffered  from  a  severe  attack  should  be  especially  watched 
throughout  the  remainder  of  the  hot  weather.  During  this  time  it  is  rarely 
safe  to  return  to  a  full  diet. 

ni.    APPENDICITIS. 

Inflammation  of  the  vermiform  appendix  is  the  most  important  of  acute 
intestinal  disorders.  Formerly  the  "  iliac  phlegmon  "  was  thought  to  be  due 
to  disease  of  the  caecum — ^typhlitis — or  of  the  peritoneum  covering  it — ^peri- 
typhlitis; but  we  now  know  that  with  rare  exceptions  the  caecum  itself  is  not 
affected,  and  even  the  condition  formerly  described  as  stercoral  typhlitis  is  in 
reality  appendicitis.  The  history  is  very  fully  given  in  the  monograph  of 
Kelly  and  Hurdon.  Melier  and  Dupuytren  in  France,  Addison,  Bright,  and 
Hodgkin  in  England,  recognized  the  importance  of  the  appendix,  but  to' 
American  physicians  and  surgeons  is  largely  due  the  modern  appreciation  of 
appendicitis  as  a  common  and  serious  disease.  The  contribution  of  Fitz  in. 
1886  served  to  put  the  whole  question  on  a  rational  basis. 

Etiology. — Incidence  of  the  Disease. — In  New  York,  in  1903,  there  were 
439  deaths,  139  per  million;  in  England  and  Wales,  in  1903,  there  were  1,729' 
deaths  (Tatham),  and  in  Chicago,  140  deaths  per  million  inhabitants.  Among: 
8,043  deaths  in  the  Boston  City  Hospital  in  the  decade  ending  1901,  179 
(2.2  per  cent)  were  due  to  appendicitis,  which  may  be  taken  as  the  average 
percentage  of  death  in  America.  This  is  considerably  higher  than  the  Ger- 
man figures,  which  are  0.3  per  cent  in  Vienna  (ISTothnagel)  and  0.5  per  cent 
in  Munich  (Einhorn). 

The  exciting  causes  of  appendicitis  are  not  always  evident.  An  infection 
is  in  all  probability  the  essential  factor.  The  lumen  of  the  appendix  forms; 
a  sort  of  test-tube,  in  which  the  faeces  lodge  and  are  with  difficulty  discharged, 
so  that  the  mucosa  is  liable  to  injury  from  retention  of  the  secretions  or  from 
the  presence  of  inspissated  fasces  or  occasionally  foreign  bodies.  In  some  in- 
stances the  appendicitis  is  a  local  expression  of  a  general  infection.  Some 
have  thought  that  the  great  increase  in  the  prevalence  of  the  disease  is  due 
to  influenza.  By  some  the  poison  of  rheumatic  fever  is  believed  to  be  a  cause, 
and  just  as  it  may  excite  tonsillitis,  so  it  may  cause  inflammation  of  the  lym- 
phatic tissues  of  the  appendix.  It  is  remarkable,  too,  that  there  may  be  two 
or  three  cases  of  appendicitis  at  the  same  time  in  one  family.  The  acute  catar- 
rhal form  may  be  associated  with  pneumonia  or  typhoid  fever  or  any  of  the 
acute  infections.  Direct  injury,  as  in  straining  and  heavy  lifting,  is  an  occa- 
sional cause. 

The  bacteriology  of  the  disease  is  most  varied.  The  bacillus  coli  is  present 
in  a  large  number  of  cases,  and  the  pyogenic  organisms,  particularly  the  strep- 
tococcus pyogenes  and  the  proteus  vulgaris. 

Age. — Appendicitis  is  a  disease  of  young  persons.  According  to  Fitz's 
statistics,  more  than  50  per  cent  of  the  cases  occur  before  the  twentieth-  year ; 
according  to  Einhorn's,  60  per  cent  between  the  sixteenth  and  thirtieth  years. 
It  has  been  met  with  as  early  as  the  seventh  week,  but  it  is  rarely  seen  prior 
to  the  third  year. 

Sex. — lit  is  about  equally  common  in  males  and  in  females. 


DISEASES  OF  THE  INTESTINES.  513 

Occupation. — Persons  whose  work  necessitates  the  lifting  of  heavy  weights 
seem  more  prone  to  the  disease.  Trauma  plays  a  very  definite  role,  and  in  a 
number  of  cases  the  symptoms  have  followed  very  closely  a  fall  or  a  blow. 

Indiscretions  in  diet  are  very  prone  to  bring  on  an  attack,  particularly  in 
the  recurring  form  of  the  disease,  in  which  pain  in  the  appendix  region  not 
infrequently  follows  the  eating  of  indigestible  articles  of  food. 

Varieties. — It  is  not  easy  to  classify  the  forms  of  inflammation  of  the 
appendix.    The  following  are  the  most  important: 

Acute  catarrhal,  in  which  the  mucosa  only  is  involved  in  a  mild  infec- 
tion, causing  swelling,  a  little  oedema,  and  increased  secretion,  usually  of  a 
muco-pus.  This  form  may  give  rise  to  no  symptoms  whatever,  or  there  may 
be  occasional  colicky  pains. 

Acute  diffuse  appendicitis  is  more  common.  There  is  inflammation 
of  the  mucosa  and  thickening  of  the  entire  organ,  which  becomes  rigid  and 
tense,  and  the  peritoneal  surface  hypersemic.  There  may  be  erosions  of  the 
mucosa,  or  even  small  ulcers. 

Purulent  appendicitis  is  a  more  advanced  stage  of  the  former.  Very 
often  the  lumen  of  the  tube  is  obstructed  and  pus  is  retained,  forming  a  defi- 
nite sac,  varying  greatly  in  size. 

Gangrenous  appendicitis  is  characterized  by  necrosis,  local  or  general. 
Most  frequently  the  tip  is  involved,  but  a  large  portion  of  the  organ  may  be- 
come sphacelated,  or  in  rare  instances  the  entire  appendix  may  slough  off  from 
the  cfficum. 

In  the  acute  diffuse,  the  purulent,  or  the  gangrenous  forms  perforation 
may  take  place  in  one  or  in  several  spots.  It  leads  to  either  a  wide-spread 
peritonitis  or  a  localized  peritonitis  with  abscess  formation,  or  very  frequently, 
if  operation  is  not  performed,  to  extensive  abscess  in  the  csecal  region — sup- 
purative peri-appendicitis. 

Chronic  appendicitis  may  follow  the  acute  form,  or  the  process  may  be 
slow  and  gradual  from  the  start.  The  organ  is  firm,  slightly  enlarged,  the 
coats  thickened,  and  the  mucosa  thick  and  hypersmic.  The  lumen  may  be 
narrowed.  In  some  instances  there  are  foreign  bodies  or  concretions,  and 
there  may  be  areas  of  erosion  of  the  mucous  membrane  or  partial  obliteration 
of  the  lumen. 

Obliterative  appendicitis  is  perhaps  the  most  common  form,  as  it  seems 
to  be  a  gradual  involution  process  in  many  individuals.  The  tube  is  thick- 
ened, the  peritoneal  surface  smooth;  the  distal  portion  of  the  lumen  may  be 
entirely  obliterated,  and  gradually  the  whole  organ  becomes  sclerotic  and 
shrunken. 

Faecal  Concretions. — The  lumen  of  the  appendix  may  contain  a  mould  of 
faeces,  which  can  readily  be  squeezed  out.  Even  while  soft  the  contents  of  the 
tube  may  be  moulded  in  two  or  three  sections  with  rounded  ends.  Concretions 
— enteroliths,  coproliths — are  also  common.  Of  700  cases  of  foreign  bodies 
there  were  45  per  cent  of  iseeal  concretions  (J.  F.  Mitchell).  The  enteroliths 
often  resemble  in  shape  date-stones.  The  importance  of  these  concretions  is 
shown  by  the  great  frequency  with  which  they  are  found  in  all  acute  inflam- 
mations of  the  appendix. 

Foreign  Bodies. — Of  1,400  cases  of  appendicitis  collected  by  J.  F.  Mitchell 
these  were  present  in  7  per  cent;  in  28  cases  pins  were  found.     It  is  well  to 


514  DISEASES   OF   THE  DIGESTIVE  SYSTEM. 

bear  in  mind  that  some  of  the  concretions  bear  a  very  striking  resemblance 
to  cherry  and  date  stones. 

Remote  Effects. — The  remote  effects  of  perforative  appendicitis  are  inter- 
esting. Hemorrhage  may  occur.  In  one  of  mj'  cases  the  appendix  was  ad- 
herent to  the  promontory  of  the  sacrum,  and  the  abscess  cavity  had  perfo- 
rated in  two  places  into  the  ileum.  Death  resulted  from  profuse  hemorrhage. 
Cases  are  on  record  in  which  the  internal  iliac  artery  or  the  deep  circum- 
flex iliac  artery  has  been  opened.  Suppurative  pyleiDhlebitis  may  result  from 
inflammation  of  the  mesenteric  veins  near  the  perforated  appendix.  The 
appendix  may  perforate  in  a  hernial  sac.  Many  instances  of  this  have  been 
recorded. 

After  operation,  thrombosis  of  the  iliac  or  femoral  veins  is  not  uncommon, 
and  sudden  death  from  pulmonary  embolism  has  followed.  -  The  leg  may  be 
permanently  enlarged.  Hernia  may  occur  in  the  wound.  Strangulation  of 
the  bowel  is  an  occasional  sequence.  Eecurrence  of  the  s^miptoms  after  opera- 
tion has  been  noted,  due  in  some  cases  to  incomplete  removal. 

Symptoms. — In  a  large  proportion  of  all  cases  of  acute  appendicitis  the 
following  symptoms  are  present :  ( 1 )  Sudden  pain  in  the  abdomen,  usually 
referred  to  the  right  iliac  fossa;  (2)  fever,  often  of  moderate  grade;  (3) 
gastro-intestinal  disturbance — nausea,  vomiting,  and  frequently  consti]3ation ; 
(4)  tenderness  or  pain  on  pressure  in  the  appendix  region. 

Paix. — A  sudden,  violent  pain  in  the  abdomen  is,  according  to  Fitz,  the 
most  constant,  first,  decided  symptom  of  perforating  inflammation  of  the  ap- 
pendix, and  occurred  in  84  per  cent  of  the  cases  analyzed  b}^  him.  In  fully 
half  of  the  cases  it  is  localized  in  the  right  iliac  fossa,  but  it  may  be  central, 
diffuse,  but  usually  in  the  right  half  of  the  abdomen.  Even  in  the  cases  in 
which  the  pain  is  at  flrst  not  in  the  appendix  region,  it  is  usually  felt  here 
within  thirty-six  or  forty-eight  hours.  It  may  extend  toward  the  perinasum 
or  testicle.  It  is  sometimes  very  sharp  and  colic-like,  and  cases  have  been 
mistaken  for  nephritic  or  for  biliary  colic.  Some  patients  speak  of  it  as  a 
sharp,  intense  pain — serous-membrane  pain ;  others  as  a  dull  ache — connective- 
tissue  pain.  While  a  very  valuable  symptom,  pain  is  at  the  same  time  one 
of  the  most  misleading.  Some  of  the  forms  of  recurring  pain  in  the  appendix 
region  Talamon  has  called  appendicular  colic.  The  condition  is  believed  to 
be  due  to  partial  occlusion  of  the  lumen,  leading  to  violent  and  irregular 
peristaltic  action  of  the  circular  and  longitudinal  muscles  in  the  expulsion 
of  the  mucus. 

Fever. — Fever  is  always  present  in  the  early  stage,  even  in  the  mildest 
forms,  and  is  a  most  important  feature.  J.  B.  Murphy  states  that  he  would 
not  operate  on  a  case  in  which  he  was  confident  that  no  fever  had  been  present 
in  the  first  thirty-six  hours  of  the  disease.  An  initial  chill  is  very  rare.  The 
fever  may  be  moderate,  from  100°  to  102°;  sometimes  in  children  at  the  very 
outset  the  thermometer  may  register  above  103.5.°  The  thermometer  is  one 
of  the  most  trustworthy  guides  in  the  diagnosis  of  acute  appendicitis.  Ap- 
pendicular colic  of  great  severity-  may  occur  without  fever.  When  a  localized 
abscess  has  formed,  and  in  some  very  virulent  cases  of  general  peritonitis,  the 
temperature  may  be  normal,  but  at  this  stage  there  are  other  symptoms  which 
indicate  the  gravity  of  the  situation.  The  pulse  is  quickened  in  proportion 
to  the  fever. 


DISEASES  OF  THE  INTESTINES.  515 

Gastro-intestinal  Disturbance.— ^The  tongue  is  usually  furred  and 
moist,  seldom  dry.  Nausea  and  vomiting  are  symptoms  which  may  be  absent, 
but  which  are  commonly  present  in  the  acute  perforative  cases.  The  vomiting 
rarely  persists  beyond  the  second  day  in  favorable  cases.  Constipation  is  the 
rule,  but  the  attack  may  set  in  with  diarrhoea,  particularly  in  children. 

Local  Signs. — Inspection  of  the  abdomen  is  at  first  negative ;  there  is 
no  distention,  and  the  iliac  fossae  look  alike.  On  palpation  there  are  usually 
from  ftie  outset  two  important  signs — namely,  great  tension  of  the  right  rectus 
muscle,  and  tenderness  or  actual  pain  on  deep  pressure.  The  muscular  rigidity 
may  be  so  great  that  a  satisfactory  examination  can  not  be  made  without  an 
aneesthetic.  McBurney  has  called  attention  to  the  value  of  a  localized  point 
of  tenderness  on  deep  pressure,  which  is  situated  at  the  intersection  of  a  line 
drawn  from  the  navel  to  the  anterior  superior  spine  of '  the  ilium,  with  a 
second,  vertically  placed,  corresponding  to  the  outer  edge  of  the  right  rectus 
muscle.  Firm,  deep,  continuous  pressure  with  one  finger  at  this  spot  causes 
pain,  often  of  the  most  exquisite  character.  In  addition  to  the  tenderness, 
rigidity,  and  actual  pain  on  deep  pressure,  there  is  to  be  felt,  in  a  majority 
of  the  cases,  an  induration  or  swelling.  In  some  cases  this  is  a  boggy,  ill- 
defined  mass  in  the  situation  of  the  caecum;  more  commonly  the  swelling  is 
circumscribed  and  definite,  situated  in  the  iliac  fossa,  two  or  three  fingers' 
breadth  above  Poupart's  ligament.  Some  have  been  able  to  feel  and  roll  be- 
neath the  fingers  the  thickened  appendix.  The  later  the  case  comes  under 
observation  the  greater  the  probability  of  the  existence  of  a  well-marked  tumor 
mass.  It  is  not  to  be  forgotten  that  there  may  be  neither  tumor  mass  nor 
induration  to  be  felt  in  some  of  the  most  intensely  virulent  cases  of  perfora- 
tive appendicitis. 

In  addition  may  be  mentioned  great  irritability  of  the  bladder,  which  I 
have  known  to  lead  to  the  diagnosis  of  cystitis.  It  may  be  a  very  early  symp- 
tom. The  urine  is  scanty  and  often  contains  albumin  and  indican.  Peptonu- 
ria is  of  no  moment.  The  attitude  is  somewhat  suggestive,  the  decubitus  is 
dorsal,  and  the  right  leg  is  semi-flexed.  Examination  per  rectum  in  the  early 
stages  rarely  gives  any  information  of  value,  unless  the  appendix  lies  well 
over  the  brim  of  the  pelvis,  or  unless  there  is  a  large  abscess  cavity.  Severe 
cases  usually  show  a  leucocytosis  of  15,000  to  24,000. 

Albuminuria  is  common.  Sometimes  there  is  an  acute  nephritis,  and  Dieu- 
lafoy  has  described  an  acute  toxic  form.  He  thinks  that  the  kidneys  are  not 
infrequently  damaged  in  the  disease. 

There  are  three  possibilities  in  any  case  of  appendicitis:  (1)  Gradual  re- 
covery, (3)  the  formation  of  a  local  abscess,  and  (3)  general  peritonitis. 

Recoveet  is  the  rule.  Out  of  264  cases  at  St.  Thomas's  Hospital  with 
the  above-mentioned  clinical  characters,  190  recovered.  There  are  surgeons 
who  claim  that  the  getting  well  in  these  cases  does  not  mean  much;  that  the 
patients  have  recurrences  and  are  constantly  liable  to  the  graver  accidents  of 
the  disease.     This,  I  feel  sure,  is  an  unduly  dark  picture. 

In  a  case  which  is  proceeding  to  recovery  the  pain  lessens  at  the  end  of 
the  second  or  third  day,  the  temperature  falls,  the  tongue  becomes  cleaner, 
the  vomiting  ceases,  the  local  tenderness  is  less  marked,  and  the  bowels  are 
moved.  By  the  end  of  a  week  the  acute  symptoms  have  subsided.  An  indura- 
tion or  an  actual  small  tumor  mass  from  the  size  of  a  walnut  to  that  of  an 


516  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

egg  may  persist — a  condition  which  leaves  the  patients  very  liable  to  a  recur- 
rence. So  liable  is  the  attack  to  recur  that  a  special  variety  of  relapsing 
appendicitis  is  described. 

Local  Abscess  Formation. — As  a  result  of  ulceration  and  perforation, 
sometimes  following  the  necrosis,  rarely  as  a  sequence  of  the  diffuse  appendi- 
citis, the  patient  has  the  train  of  symptoms  above  described;  but  at  the  end 
of  the  first  week  the  local  features  persist  or  become  aggravated.  The  course 
of  the  disease  may  be  indeed  so  acute  that  by  the  end  of  the  fourth  or  fifth 
day  there  is  an  extensive  area  of  induration  in  the  right  iliac  fossa,  with  great 
tenderness,  and  operations  have  shown  that  even  at  this  very  early  date  an 
abscess  cavity  may  have  formed.  Though  as  a  rule  the  fever  becomes  aggra- 
vated with  the  onset  of  suppuration,  this  is  not  always  the  case.  The  two 
most  important  elements  in  the  diagnosis  of  abscess  formation  are  the  gradual 
increase  of  the  local  tumor  and  the  aggravation  of  the  general  s3Tiiptoms. 
Nowadays,  when  operation  is  so  frequent,  we  have  opportunities  of  seeing  the 
abscess  in  various  stages  of  development.  Quite  early  the  pus  may  lie  between 
the  caecum  and  the  coils  of  the  ileum,  with  the  general  peritongeum  shut  off 
by  fibrin,  or  there  is  a  sero-fibrinous  exudate  with  a  slight  amount  of  pus 
between  the  lower  coils  of  the  ileum.  The  abscess  cavity  may  be  small  and 
lie  on  the  psoas  muscle,  or  at  the  edge  of  the  promontory  of  the  sacrum,  and 
never  reach  a  palpable  size.  The  sac,  when  larger,  may  be  roofed  in  by  the 
small  bowel  and  present  irregular  processes  and  pockets  leading  in  different 
directions.  In  larger  collections  in  the  iliac  fossa  the  roof  is  generally  formed 
by  the  abdominal  wall.  Some  of  the  most  important  of  the  localized  abscesses 
are  those  which  are  situated  entirely  within  the  pelvis.  The  various  directions 
and  positions  into  which  the  abscess  may  pass  or  perforate  have  already  been 
referred  to  under  morbid  anatomy,  but  it  may  be  here  mentioned  again  that, 
left  alone,  it  may  discharge  externally,  or  burrow  in  various  directions,  or  be 
emptied  through  the  rectum,  vagina,  or  bladder.  Death  may  be  caused  by 
septicaemia,  by  perforation  into  an  artery  or  vein,  or  by  pylephlebitis. 

General  Peritonitis. — This  may  be  caused  by  direct  perforation  of  the 
appendix  and  general  infection  of  the  peritonaeum  before  any  delimiting  in- 
flammation is  excited.  In  a  second  group  of  cases  there  has  been  an  attempt 
at  localizing  the  infective  process,  but  it  fails,  and  the  general  peritonasum 
becomes  involved.  In  a  third  group  of  cases  a  localized  focus  of  suppuration 
exists  about  an  inflamed  appendix,  and  from  this  perforation  takes  place. 

Death  in  appendicitis  is  due  usually  to  general  peritonitis. 

The  gravity  of  appendix  disease  lies  in  the  fact  that  from  the  very  outset 
the  peritoncEum  may  he  infected;  the  initial  symptoms  of  pain,  with  nausea 
and  vomiting,  fever,  and  local  tenderness,  present  in  all  cases,  may  indicate 
a  wide-spread  infection  of  this  memhrane.  The  onset  is  usually  sudden,  the 
pain  diffuse,  not  always  localized  in  the  right  iliac  fossa,  but  it  is  not  so  much 
the  character  as  the  greater  intensity  of  the  symptoms  from  the  outset  that 
makes  one  suspicious  of  a  general  peritonitis.  Abdominal  distention,,  diffuse 
tenderness,  and  absence  of  abdominal  movements  are  the  most  trustworthy 
local  signs,  but  they  are  not  really  so  trustworthy  as  the  general  symptoms. 
The  initial  nausea  and  vomiting  persist,  the  pulse  becomes  more  rapid,  the 
tongue  is  dry,  the  urine  scanty.  In  very  acute  cases,  by  the  end  of  twenty-four 
hours  the  abdomen  may  be  distended.     By  the  third  and  fourth  days  the 


DISEASES  OF  THE  INTESTINES.  517 

classical  picture  of  a  general  peritonitis  is  well  established — a  distended  and 
motionless  abdomen,  a  rapid  pulse,  a  dry  tongue,  dorsal  decubitus  with  the 
knees  drawn  up,  and  an  anxious,  pinched,  Hippocratic  facies.  Unfortunately, 
the  leucocyte  count  gives  little  aid. 

Fever  is  an  uncertain  element.  It  is  usually  present  at  first,  but  if  the 
physician  does  not  see  the  case  until  the  third  or  fourth  day  he  should  not 
be  deceived  by  a  temperature  below  100.5°.  The  pulse  is  really  a  better  indi- 
cation than  the  temperature.  One  rarely  has  any  doubt  on  the  third  or 
fourth  day  whether  or  not  peritonitis  exists,  but  it  must  be  acknowledged  that 
there  are  exceptions  which  trouble  the  judgment  not  a  little.  While  on  the 
one  hand,  without  suggestive  symptoms,  a  laparotomy  has  disclosed  an  unex- 
pected general  peritonitis,  on  the  other,  with  severe  constitutional  symptoms 
and  apparently  characteristic  local  signs,  the  peritonaeum  has  been  found 
smooth. 

Diagnosis. — Appendicitis  is  by  far  the  most  common  inflammatory  con- 
dition, not  only  in  the  csecal  region,  but  in  the  abdomen  generally  in  persons 
under  thirty.  The  surgeons  have  taught  us  that,  almost  without  exception, 
sudden  pain  in  the  right  iliac  fossa,  with  fever  and  localized  tenderness,  with 
or  without  tumor,  means  appendix  disease.  There  are  certain  diseases  of  the 
abdominal  organs  characterized  by  pain  which  are  apt  to  be  confounded  with 
appendicitis.  Biliary  colic,  kidney  colic,  and  the  colicky  pains  at  the  men- 
strual period  in  women  have  in  some  cases  to  be  most  carefully  considered. 

Diseases  of  the  tubes  and  pelvic  peritonitis  may  simulate  appendicitis  very 
closely,  but  the  history  and  the  local  examination  under  ether  should  in  most 
cases  enable  the  practitioner  to  reach  a  diagnosis.  I  have  seen  several  cases 
supposed  to  be  recurring  appendicitis  which  proved  to  be  tubo-ovarian  disease. 

The  Dietl's  crises  in  floating  kidney  have  been  mistaken  for  appendicitis. 

Both  intussusception  and  internal  strangulation  may  present  very  similar 
symptoms,  and  if  the  patient  is  only  seen  at  the  later  stages,  when  there  is 
diffuse  peritonitis  and  great  tympany,  the  features  may  be  almost  identical. 
Fsecal  vomiting,  which  is  common  in  obstruction,  is  never  seen  in  appendicitis, 
and  in  children  the  marked  tenesmus  and  bloody  stools  are  important  signs 
of  intussusception.  It  is  not  often  difficult  to  decide  when  the  cases  are  seen 
early  and  when  the  history  is  clear,  but  mistakes  have  been  made  by  surgeons 
of  the  first  rank. 

Acute  hgemorrhagic  pancreatitis  may  also  produce  symptoms  very  like 
those  of  appendicitis  with  general  peritonitis.  The  relation  of  typhoid  fever 
and  appendicitis  is  interesting.  The  gastro-intestinal  symptoms,  particularly 
the  pain  and  the  fever,  may  at  the  onset  suggest  appendicitis.  Operations  have 
been  comparatively  frequent.  In  the  second  and  third  weeks  of  typhoid  fever 
perforation  of  the  appendix  may  occur,  and  occasionally  late  in  the  convales- 
cence perforation  of  an  unhealed  ulcer  of  the  appendix. 

There  is  a  well-marked  appendicular  hypochondriasis.  Through  the  per- 
nicious influence  of  the  daily  press,  appendicitis  has  become  a  sort  of  fad,  and 
the  physician  has  often  to  deal  with  patients  who  have  almost  a  fixed  idea 
that  they  have  the  disease.  The  worst  cases  of  this  class  which  I  have  seen 
have  been  in  members  of  our  profession,  and  I  know  of  at  least  one  instance 
in  which  a  perfectly  normal  appendix  was  removed.  The  question  really  has 
its  ludicrous  side.    A  well-known  physician  in  a  Western  city  having  one  night 


518  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

a  bellyache,  and  feeling  convinced  that  his  appendix  had  perforated,  sum- 
moned a  surgeon,  who  quickly  removed  the  supposed  offender ! 

Hysteria  may  of  course  simulate  appendicitis  very  closely,  and  it  may 
require  a  very  keen  judgment  to  make  a  diagnosis. 

Mucous  colitis  with  enteralgia  in  nervous  women  is  sometimes  mistaken 
for  appendicitis.  In  two  instances  of  the  kind  I  have  prevented  proposed 
operation,  and  I  have  heard  of  cases  in  which  the  appendix  has  been  re- 
moved. 

Perinephritic  and  pericsecal  abscess  from  perforation  of  ulcer,  either  sim- 
ple or  cancerous,  and  circumscribed  peritonitis  in  this  region  from  other 
causes,  can  rarely  be  differentiated  until  an  exploratory  incision  is  made. 

Chronic  obliterative  appendicitis  can  not  always  be  differentiated  from  the 
perforative  form,  and  in  intensity  of  pain,  severity  of  symptoms,  and,  in  rare 
instances,  even  in  the  production  of  peritonitis,  the  two  may  be  identical. 

Briefly  stated,  localized  pain  in  the  right  iliac  fossa,  with  or  without  in- 
duration or  tumor,  the  existence  of  McBurney's  tender  point,  fever,  furred 
tongue,  vomiting,  with  constipation  or  diarrhoea,  indicate  appendicitis.  The 
occurrence  of  general  peritonitis  is  suggested  by  increase  and  diffusion  of  the 
abdominal  pain,  tympanites  (as  a  rule),  marked  aggravation  of  the  constitu- 
tional symptoms,  particularly  elevation  of  fever  and  increased  rapidity  of  the 
pulse.  Obliteration  of  hepatic  dulness  is  rarely  present,  as  the  peritonaeum 
in  these  cases  does  not  often  contain  gas. 

Prognosis. — While  we  can  not  overestimate  the  gravity  of  certain  forms 
of  appendicitis,  it  is  well  to  recognize  that  a  large  proportion  of  all  cases 
recover.  It  is  the  element  of  uncertainty  in  individual  cases  which  has  given 
such  an  impetus  to  the  surgical  treatment  of  the  disease.  That  an  inflamed 
appendix  may  heal  perfectly,  even  after  perforation,  is  shown  by  instances 
(post  mortem)  of  obliterated  tubes  flrmly  imbedded  in  old  scar  tissue.  In 
1903,  in  England  and  Wales,  appendicitis  was  assigned  as  a  cause  of  1,729 
deaths,  as  compared  with  1,244  and  1,485  in  the  preceding  two  years.  The 
mortality  has  been  increasing  of  late  years  in  spite  of  the  earlier  and  better 
surgery.  Hawkins  attributes  this  to  an  increased  severity  of  the  disease.  The 
mortality  in  the  hands  of  surgeons  ranges  from  2  to  11  per  cent,  varying  with 
the  variety  and  the  stage  of  the  disease  at  which  operation  is  performed. 

Treatment. — Gradually  the  profession  has  learned  to  recognize  that  appen- 
dicitis is  a  surgical  disease.  In  hospital  practice  the  cases  should  be  admitted 
directly  to  the  surgical  wards.  Many  lives  are  lost  by  temporizing.  The 
general  practitioner  does  well  to  remember — whether  his  leanings  be  toward 
the  conservative  or  the  radical  methods  of  treatment — that  the  surgeon  is  often 
called  too  late,  never  too  early. 

There  is  no  medicinal  treatment  of  appendicitis.  There  are  remedies 
which  will  allay  the  pain,  but  there  are  none  capable  in  any  way  of  controlling 
the  course  of  the  disease.  Eest  in  bed,  a  light  diet,  measures  directed  to  allay 
the  vomiting — upon  these  all  are  agreed.  The  practice  of  giving  opium  in 
some  form  in  appendicitis  and  peritonitis  is  almost  universal  with  physicians. 
Surgeons,  on  the  other  hand,  almost  unanimously  condemn  the  practice,  as 
obscuring  the  clinical  picture  and  tending  to  give  a  false  sense  of  security ;  and 
since  they  control  the  situation,  I  think  we  should — deferring  in  this  matter 
to  their  judgment — not  give  opium,  and  trust  to  the  persistent  use  of  ice 


DISEASES  OF  THE  INTESTINES.  519 

locally  to  relieve  the  pain.  General  opinion  among  the  hest  surgeons  is,  I 
believe,  opposed  to  the  use  of  saline  purges. 

Operation  is  indicated  in  all  cases  of  acute  inflammatory  trouble  in  the 
csBcal  region,  whether  tumor  is  present  or  not,  when  the  general  symptoms 
are  severe,  and  when  at  the  end  of  forty-eight  hours,  or  even  earlier,  the 
features  of  the  case  point  to  a  progressive  lesion.  The  mortality  from  early 
operation  under  these  circumstances  is  very  slight. 

In  recurring  appendicitis,  when  the  attacks  are  of  such  severity  and  fre- 
quency as  seriously  to  interrupt  the  patient's  occupation,  the  mortality  in  the 
hands  of  capable  operators  is  very  small. 

IV.    INTESTINAL    OBSTRUCTION. 

Intestinal  obstruction  may  be  caused  by  strangulation,  intussusception, 
twists  and  knots,  strictures  and  tumors,  and  by  abnormal  contents. 

Etiology  and  Pathology. — (a)  Strangulation. — This  is  the  most  fre- 
quent cause  of  acute  obstruction,  and  occurred  in  34  per  cent  of  the  295  cases 
analyzed  by  Fitz,  and  in  35  per  cent  of  the  1,134  cases  of  Leichtenstern.  Of 
the  101  cases  of  strangulation  in  Fitz's  table,  which,  has  the  special  value  of 
having  been  carefully  selected  from  the  literature  since  1880,  the  following 
were  the  causes :  Adhesions,  63 ;  vitelline  remains,  21 ;  adherent  appendix,  6 ; 
mesenteric  and  omental  slits,  6 ;  peritoneal  pouches  and  openings,  3 ;  adherent 
tube,  1 ;  peduncular  tumor,  1.  The  bands  and  adhesions  result,  in  a  majority 
of  cases,  from  former  peritonitis.  A  number  of  instances  have  been  reported 
following  operations  upon  the  pelvic  organs  in  women.  The  strangulation 
may  be  recent  and  due  to  adhesion  of  the  bowel  to  the  abdominal  wound  or 
a  coil  may  be  caught  between  the  pedicle  of  a  tumor  and  the  pelvic  wall.  Such 
cases  are  only  too  common.  Late  occlusion  after  recovery  from  the  operation 
is  due  to  bands  and  adhesions. 

The  vitelline  remains  are  represented  by  Meckel's  diverticulum,  which 
forms  a  finger-like  projection  from  the  ileum,  usually  within  eighteen  inches 
of  the  ileo-ca3cal  valve.  It  is  a  remnant  of  the  omphalo-mesenteric  duct, 
through  which,  in  the  early  embryo,  the  intestine  communicated  with  the 
yolk-sac.  The  end,  though  commonly  free,  may  be  attached  to  the  abdominal 
wall  near  the  navel,  or  to  the  mesentery,  and  a  ring  is  thus  formed  through 
which  the  gut  may  pass. 

Seventy  per  cent  of  the  cases  of  obstruction  from  strangulation  occur  in 
males ;  40  per  cent  of  all  the  cases  occur  between  the  ages  of  fifteen  and  thirty 
years.  In  90  per  cent  of  the  cases  of  obstruction  from  these  causes  the  site 
of  the  trouble  is  in  the  small  bowel ;  the  position  of  the  strangulated  portion 
was  in  the  right  iliac  fossa  in  67  per  cent  of  the  cases,  and  in  the  lower  abdo- 
men in  83  per  cent. 

(&)  Intussusception. — In  this  condition  one  portion  of  the  intestine  slips 
into  an  adjacent  portion,  forming  an  invagination  or  intussusception.  The 
two  portions  make  a  cylindrical  tumor,  which  varies  in  length  from  a  half- 
inch  to  a  foot  or  more.  The  condition  is  always  a  descending  intussusception, 
and  as  the  process  proceeds,  the  middle  and  inner  layers  increase  at  the  ex- 
pense of  the  outer  layer.  An  intussusception  consists  of  three  layers  of  bowel : 
the  outermost,  known  as  the  intussuscipiens,  or  receiving  layer ;  a  middle  or 


520  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

returning  layer ;  and  the  innermost  or  entering  layer.  The  student  can  obtain 
a  clear  idea  of  the  arrangement  by  making  the  end  of  a  glove-finger  pass  into 
the  lower  portion.  The  actual  condition  can  be  very  clearly  studied  in  the 
post-mortem  invaginations  which  are  so  common  in  the  small  bowel  of  chil- 
dren. In  the  statistics  of  Fitz,  93  of  295  cases  of  acute  intestinal  obstruction 
were  due  to  this  cause.  Of  these,  52  were  in  males  and  27  in  females.  The 
cases  are  most  common  in  early  life,  S-i  per  cent  under  one  year  and  56  per 
cent  under  the  tenth  year.  Of  103  cases  in  children,  nearly  50  per  cent 
occurred  in  the  fourth,  fifth,  and  sixth  months  (Wiggin).  Xo  definite  causes 
could  be  assigned  in  42  of  the  cases;  in  the  others  diarrhoea  or  habitual  con- 
stipation had  existed. 

The  site  of  the  invagination  varies.  We  may  recognize  (1)  an  ileo-ccBcal, 
when  the  ileo-caecal  valve  descends  into  the  colon.  There  are  cases  in  which 
this  is  so  extensive  that  the  valve  has  been  felt  per  rectum.  This  form  oc- 
curred in  75  per  cent  of  the  cases;  in  89  per  cent  of  Wiggin's  collected  cases. 
In  the  ileo-colic  the  lower  part  of  the  ileum  passes  through  the  ileo-csecal  valve. 
(2)  The  ileal^  in  which  the  ileum  is  alone  involved.  (3)  The  colic^  in  which 
it  is  confined  to  the  large  intestine.  And  (4)  coUco-rectal,  in  which  the  colon 
and  rectum  are  involved. 

Irregular  peristalsis  is  the  essential  cause  of  intussusception.  jSTothnagel 
found  in  the  localized  peristalsis  caused  by  the  faradic  current  that  it  was 
not  the  descent  of  one  portion  into  the  other,  but  the  drawing  up  of  the 
receiving  layer  by  contraction  of  the  longitudinal  coat.  Invagination  may 
follow  any  limited,  sudden,  and  severe  peristalsis. 

In  the  post-mortem  examination,  in  a  case  of  death  from  intussusception, 
the  condition  is  very  characteristic.  Peritonitis  may  be  present  or  an  acute 
injection  of  the  serous  membrane.  When  death  occurs  early,  as  it  may  do 
from  shock,  there  is  little  to  be  seen.  The  portion  of  bowel  affected  is  large 
and  thick,  and  forms  an  elongated  tumor  with  a  curved  outline.  The  parts 
are  swollen  and  congested,  owing  to  the  constriction  of  the  mesentery  between 
the  layers.  The  entire  mass  may  be  of  a  deep  livid-red  color.  In  very  recent 
processes  there  is  only  congestion,  and  perhaps  a  thin  layer  of  lymph,  and  the 
intussusception  can  be  reduced,  but  when  it  has  lasted  for  a  few  days,  hmipb 
is  thrown  out,  the  laj-ers  are  glued  together,  and  the  entering  portion  of  the 
gut  can  not  be  withdravm. 

The  anatomical  condition  accounts  for  the  presence  of  the  tumor,  which 
exists  in  two-thirds  of  all  cases ;  and  the  engorgement,  which  results  from  the 
compression  of  the  mesenteric  vessels,  explains  the  frequent  occurrence  of 
blood  in  the  discharges,  which  has  so  important  a  diagnostic  value.  If  the 
patient  survives,  necrosis  and  sloughing  of  the  invaginated  portion  may  occur, 
and  if  union  has  taken  place  between  the  inner  and  outer  layers,  the  calibre 
of  the  gut  may  be  restored  and  a  cure  in  this  way  effected.  Many  cases  of 
the  kind  are  on  record.  In  the  Museum  of  the  Medical  Faculty  of  the  McGill 
University  are  17  inches  of  small  intestine,  which  were  passed  by  a  lad 
who  had  symptoms  of  internal  strangulation,  and  who  made  a  complete 
recovery. 

(c)  Twists  axd  Kxots. — ^^-^olvnlus  or  twist  occurred  in  42  of  the  295 
cases  (Fitz).  Sixty-eight  per  cent  were  in  males.  It  is  most  frequent  be- 
tween the  ages  of  thirty  and  forty.     In  the  great  majority  of  all  cases  the^ 


DISEASES  OF  THE  INTESTINES.  521 

twist  is  axial  and  associated  with  an  unusually  long  mesentery.  In  50  per 
cent  of  the  cases  it  was  in  the  sigmoid  flexure.  The  next  most  common  situa- 
tion is  about  the  caecum,  which  may  be  twisted  upon  its  axis  or  bent  upon 
itself.  As  a  rule,  in  volvulus  the  loop  of  bowel  is  simply  twisted  upon  its  long 
axis,  and  the  portions  at  the  end  of  the  loop  cross  each  other  and  so  cause  the 
strangulation.  It  occasionally  happens  that  one  portion  of  the  bowel  is  twisted 
about  another. 

(d)  Strictures  and  Tumors. — These  are  very  much  less  important  causes 
of  acute  obstruction,  as  may  be  judged  by  the  fact  that  there  are  only  15  in- 
stances out  of  the  295  cases,  in  14  of  which  the  obstruction  occurred  in  the 
large  intestine  ( Fitz ) .  On  the  other  hand,  they  are  common  causes  of  chronic 
obstruction. 

Lipoma  may  occur,  growing  from  the  submucosa,  and  cause  intussuscep- 
tion. In  a  number  of  cases  the  tumor  has  been  passed  per  rectum.  S.  B.  Ward 
has  collected  9  cases. 

The  obstruction  may  result  from:  (1)  Congenital  stricture.  These  are 
exceedingly  rare.  Much  more  commonly  the  condition  is  that  of  complete 
occlusion,  either  forming  the  imperforate  anus  or  the  congenital  defect  by 
which  the  duodenum  is  not  united  to  the  pylorus.  (3)  Simple  cicatricial 
stenosis,  which  results  from  ulceration,  tuberculous  or  syphilitic,  more  rarely 
from  dysentery,  and  most  rarely  of  all  from  typhoid  ulceration.  (3)  New 
growths.  The  malignant  strictures  are  due  chiefly  to  cylindrical  epithelioma, 
which  forms  an  annular  tumor,  most  commonly  met  with  in  the  large  bowel, 
about  the  sigmoid  flexure,  or  the  descending  colon.  Of  benign  growths,  papil- 
lomata,  adenomata,  lipomata,  and  fibromata  occasionally  induce  obstruction. 
(4)  Compression  and  traction.  Tumors  of  neighboring  organs,  particularly 
of  the  pelvic  viscera,  may  cause  obstruction  by  adhesion  and  traction;  more 
rarely,  a  coil,  such  as  the  sigmoid  flexure,  filled  with  fgeces,  compresses  and 
obstructs  a  neighboring  coil.  In  the  healing  of  tuberculous  peritonitis  the 
contraction  of  the  thick  exudate  may  cause  compression  and  narrowing  of 
the  coils. 

(e)  Abnormal  Contents. — Foreign  bodies,  such  as  fruit  stones,  coins, 
pins,  needles,  or  false  teeth,  are  occasionally  swallowed  accidentally,  or  by 
lunatics  on  purpose.  Eound  worms  may  become  rolled  into  a  tangled  mass 
and  cause  obstruction.  In  reality,  however,  the  majority  of  foreign  bodies, 
such  as  coins,  buttons,  and  pins,  swallowed  by  children,  cause  no  inconve- 
nience whatever,  but  in  a  day  or  two  are  found  in  the  stools.  Occasionally  such 
a  foreign  body  as  a  pin  will  pass  through  the  oesophagus  and  will  be  found 
lodged  in  some  adjacent  organ,  as  in  the  heart  (Peabody),  or  a  barley  ear 
may  reach  the  liver  (Dock). 

Medicines,  such  as  magnesia  or  bismuth,  have  been  known  to  accumulate 
in  the  bowels  and  produce  obstruction,  but  in  the  great  majority  of  the  cases 
the  condition  is  caused  by  faeces,  gall-stones,  or  enteroliths.  Of  44  cases,  in 
23  the  obstruction  was  by  gall-stones,  in  19  by  faeces,  and  in  2  by  enteroliths. 
Obstruction  by  faeces  may  happen  at  any  period  of  life.  As  mentioned  when 
speaking  of  dilatation  of  the  colon,  it  may  occur  in  young  children  and  persist 
for  weeks.  In  faecal  accumulation  the  large  bowel  may  reach  an  enormous 
size  and  the  contents  become  very  hard.  The  retained  masses  may  be  chan- 
neled, and  small  quantities  of  faecal  matter  are  passed  until  a  mass  too  large 


522  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

enters  the  lumen  and  causes  obstruction.  There  may  be  very  few  symptoms, 
as  the  condition  may  be  borne  for  weeks  or  even  for  months. 

Obstruction  by  gall-stones  is  not  very  infrequent,  as  may  be  gathered  from 
the  fact  that  23  cases  were  reported  in  the  literature  in  eight  years.  Eighteen 
of  these  were  in  women  and  5  in  men.  In  six-sevenths  of  the  cases  it  occurred 
after  the  fiftieth  year.  The  obstruction  is  usually  in  the  ileo-caecal  region, 
but  it  may  be  in  the  duodenum.  These  large  solitary  gall-stones  ulcerate 
through  the  gall-bladder,  usually  into  the  small  intestine,  occasionally  into  the 
colon.  In  the  latter  case  they  rarely  cause  obstruction.  Courvoisier  has  col- 
lected 131  cases  in  the  literature. 

Enteroliths  may  be  formed  of  masses  of  hair,  more  commonly  of  the  phos- 
phates of  lime  and  magnesia,  with  a  nucleus  formed  of  a  foreign  body  or  of 
hardened  ffeces.  jSTearly  every  museum  possesses  specimens  of  this  kind.  They 
are  not  so  common  in  men  as  in  ruminants,  and,  as  indicated  in  Fitz's  statis- 
tics, are  very  rare  causes  of  obstruction. 

Symptoms. — (a)  Acute  Obstruction". — Constipation,  pain  in  the  abdo- 
men, and  vomiting  are  the  three  important  symptoms.  Pain  sets  in  early 
and  may  come  on  abruptly  while  the  patient  is  walking  or,  more  commonly, 
during  the  performance  of  some  action.  It  is  at  first  colicky  in  character,  but 
subsequently  it  becomes  continuous  and  very  intense.  Vomiting  follows 
quickly  and  is  a  constant  and  most  distressing  symptom.  At  first  the  contents 
of  the  stomach  are  voided,  and  then  greenish,  bile-stained  material,  and  soon, 
in  cases  of  acute  and  permanent  obstruction,  the  material  vomited  is  a  brown- 
ish-black liquid,  with  a  distincth^  faecal  odor.  This  sequence  of  gastric,  bilious, 
and,  finally,  stercoraceous  vomiting  is  perhaps  the  most  important  diagnostic 
feature  of  acute  obstruction.  The  constipation  may  be  absolute,  without  the 
discharge  of  either  fjeces  or  gas.  A'^ery  often  the  contents  of  the  bowel  below 
the  stricture  are  discharged.  Distention  of  the  abdomen  usually  occurs,  and 
when  the  large  bowel  is  involved  it  is  extreme.  On  the  other  hand,  if  the 
obstruction  is  high  up  in  the  small  intestine,  there  may  be  very  slight  tympany. 
At  first  the  abdomen  is  not  painful,  but  subsequently  it  may  become  acutely 
tender. 

The  constitutional  symptoms  from  the  outset  are  severe.  The  face  is  pallid 
and  anxious,  and  finally  collapse  sjnnptoms  supervene.  The  eyes  become 
sunken,  the  features  pinched,  and  the  skin  is  covered  with  a  cold,  clammy 
sweat.  The  pulse  becomes  rapid  and  feeble.  There  may  be  no  fever;  the 
axillary  temperature  is  often  subnormal.  The  tongue  is  dry  and  parched  and 
the  thirst  is  incessant.  The  urine  is  high-colored,  scanty,  and  there  may  be 
suppression,  particularly  when  the  obstruction  is  high  up  in  the  bowel.  This 
is  probably  due  to  the  constant  vomiting  and  the  small  amount  of  liquid  which 
is  absorbed.  The  case  terminates  as  a  rule  in  from  three  to  six  days.  In  some 
instances  the  patient  dies  from  shock  or  sinks  into  coma.  A  leucocytosis  of 
75,000  or  80,000  per  c.  mm.  may  be  present. 

(h)  Symptoms  of  Chronic  Obstruction. — ^When  due  to  fsecal  impac- 
tion, there  is  a  history  of  long-standing  constipation.  There  may  have  been 
discharge  of  mucus,  or  in  some  instances  the  faecal  masses  have  been  chan- 
neled, and  so  have  allowed  the  contents  of  the  upper  portion  of  the  bowel  to 
pass  through.  In  elderly  persons  this  is  not  infrequent;  but  examination, 
either  per  rectum  or  externally,  in  the  course  of  the  colon,  will  reveal  the 


DISEASES  OF  THE  INTESTINES.  523 

presence  of  hard  scybalous  masses.  There  may  be  retention  of  fseces  for  weeks 
without  exciting  serious  symptoms.  In  other  instances  there  are  vomiting, 
pain  in  the  abdomen,  gradual  distention,  and  finally  the  ejecta  become  faecal. 
The  hardened  masses  may  excite  an  intense  colitis  or  even  peritonitis. 

In  stricture,  whether  cicatricial  or  cancerous,  the  symptoms  of  obstruction 
are  very  diverse.  Constipation  gradually  comes  on,  is  extremely  variable,  and 
it  may  be  months  or  even  years  before  there  is  complete  obstruction.  There 
are  transient  attacks,  in  which  from  some  cause  the  fseces  accumulate  above 
the  stricture,  the  intestine  becomes  greatly  distended,  and  in  the  swollen 
abdomen  the  coils  can  be  seen  in  active  peristalsis.  In  such  attacks  there  may 
be  vomiting,  but  it  is  very  rarely  of  a  faecal  character.  In  the  majority  of 
these  cases  the  general  health  is  seriously  impaired;  the  patient  gradually  be- 
comes angemic  and  emaciated,  and  finally,  in  an  attack  in  which  the  obstruc- 
tion is  complete,  death  occurs  with  all  the  features  of  acute  occlusion  or  the 
case  may  be  prolonged  for  ten  or  twelve  days. 

Diagnosis. —  (a)  The  SiTUATioisr  of  the  OBSTRUCTioisr. — Hernia  must  be 
excluded,  which  is  by  no  means  always  easy,  as  fatal  obstruction  may  occur 
from  the  involvement  of  a  very  limited  portion  of  the  gut  in  the  external  ring 
or  in  the  obturator  foramen.  Mistakes  from  both  of  these  causes  have  come 
under  my  observation;  they  were  cases  in  which  it  was  impossible  to  make  a 
diagnosis  other  than  acute  obstruction.  Timely  operation  would  have  saved 
both  lives.  A  thorough  rectal  and,  in  women,  a  vaginal  examination  should 
be  made,  which  will  give  important  information  as  to  the  condition  of  the 
pelvic  and  rectal  contents,  particularly  in  cases  of  intussusception,  in  which 
the  descending  bowel  can  sometimes  be  felt.  In  cases  of  obstruction  high  up 
the  empty  coils  sink  into  the  pelvis  and  can  there  be  detected.  Eectal  explora- 
tion with  the  entire  hand  is  of  doubtful  value.  In  the  inspection  of  the  abdo- 
men there  are  important  indications,  as  the  special  prominence  in  certain 
regions,  the  occurrence  of  well-defined  masses,  and  the  presence  of  hypertro- 
phied  coils  in  active  peristalsis.  John  Wyllie  has  called  attention  to  the  great 
value  in  diagnosis  of  the  "  patterns  of  abdominal  tumidity."  *  In  obstruction 
of  the  lower  end  of  the  large  intestine  not  only  may  the  horseshoe  of  the 
colon  stand  out  plainly,  when  the  bowel  is  in  rigid  spasm,  but  even  the  pouches 
of  the  gut  may  be  seen.  When  the  c^cum  or  lower  end  of  the  ileum  is  ob- 
structed the  tumidity  is  in  the  lower  central  region,  and  during  spasm  the 
coils  of  the  small  bowel  may  stand  out  prominently,  one  above  the  other,  either 
obliquely  or  transversely  placed — the  so-called  "  ladder  pattern."  In  obstruc- 
tion of  the  duodenum  or  jejunum  there  may  only  be  slight  distention  of  the 
upper  part  of  the  abdomen,  associated  usually  with  rapid  collapse  and  anuria. 

In  the  ileum  and  caecum  the  distention  is  more  in  the  central  portion  of 
the  abdomen;  the  vomiting  is  distinctly  faecal  and  occurs  early.  In  obstruc- 
tion of  the  colon,  tympanites  is  much  more  extensive  and  general.  Tenesmus 
is  more  common,  with  the  passage  of  mucus  and  blood.  The  course  is  not  so 
quick,  the  collapse  does  not  supervene  so  rapidly,  and  the  urinary  secretion 
is  not  so  much  reduced. 

In  obstruction  from  stricture  or  tumor  the  situation  can  in  some  cases  be 
accurately  localized,  but  in  others  it  is  very  uncertain.    Digital  examination 

*  Edinburgh  Hospital  Reports,  vol.  ii. 


524  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

of  the  rectum  should  first  bo  made.  The  rectal  tube  may  then  be  passed,  but 
it  is  impossible  to  get  be3'ond  the  sigmoid  flexure.  In  the  use  of  the  rigid  tube 
there  is  danger  of  perforation  of  the  bowel  in  the  neighborhood  of  a  stricture. 
The  quantity  of  fluid  which  can  be  passed  into  the  large  intestine  should  be 
estimated.  The  capacity  of  the  large  bowel  is  about  six  quarts.  Wiggin  ad- 
vises about  a  pint  and  a  half  from  a  height  of  three  feet  for  an  infant.  To 
thoroughly  irrigate  the  bowel  the  patient  should  be  cliloroformed  and  should 
lie  on  the  back  or  on  the  side — ^best  on  the  back,  with  the  Mps  elevated.  Treves 
suggests  that  the  CEecal  region  should  be  auscultated  during  the  passage  of  the 
fluid.  For  diagnostic  purposes  the  rectum  may  be  inflated,  either  by  the  bel- 
lows or  by  the  use  of  bicarbonate  of  soda  and  tartaric  acid.  In  certain  cases 
these  measures  give  important  indications  as  to  the  situation  of  the  obstruction 
in  the  large  bowel. 

(&)  jSTature  of  the  Obstructiox. — This  is  often  difficult,  not  infre- 
quently impossible,  to  determine.  Strangulation  is  not  common  in  very  early 
life.  In  many  instances  there  have  been  previous  attacks  of  abdominal  pain, 
or  there  are  etiological  factors  which  give  a  clew,  such  as  old  peritonitis  or 
operation  on  the  pelvic  viscera.  Xeither  the  onset  nor  the  character  of  the 
pain  gives  us  any  information.  In  rare  instances  nausea  and  vomiting  may 
be  absent.  The  vomiting  usually  becomes  faecal  from  the  third  to  the  fifth 
day.  A  tumor  is  not  common  in  strangulation,  and  was  present  in  only  one- 
fifth  of  the  cases.     Fever  is  not  of  diagnostic  value. 

Intussusception  is  an  affection  of  childhood,  and  is  of  all  forms  of  internal 
obstruction  the  one  most  readily  diagnosed.  The  presence  of  tumor,  bloody 
stools,  and  tenesmus  are  the  important  factors.  The  tumor  is  usually  sausage- 
shaped  and  felt  in  the  region  of  the  transverse  colon.  It  existed  in  66  of  93 
cases.  It  became  evident  the  first  day  in  more  than  one-third  of  the  cases, 
on  the  second  day  in  more  than  one-fourth,  and  on  the  third  day  in  more  than 
one-fifth.  Blood  ia  the  stools  occurs  in  at  least  three-fifths  of  the  cases,  either 
spontaneously  or  following  the  use  of  an  enema.  The  blood  may  be  mixed 
with  mucus.  Tenesmus  is  present  in  one-third  of  the  cases.  Faecal  vomiting 
is  not  very  common  and  was  present  in  only  12  of  the  93  instances.  Abdom- 
inal tympany  is  a  s^Tnptom  of  slight  importance,  occurring  in  only  one-third 
of  the  cases. 

Volvulus  can  rarely  be  diagnosed.  The  frequency  with  which  it  involves 
the  sigmoid  fiexure  is  to  be  borne  in  mind.  The  passage  of  a  flexible  tube 
or  injecting  fluids  might  in  these  cases  give  valuable  indications. 

In  fcBcal  obstruction  the  condition  is  usually  clear,  as  the  fgeces  can  be 
felt  per  rectum  and  also  in  the  distended  colon.  Faecal  vomiting,  tympany, 
abdominal  pain,  nausea,  and  vomiting  are  late  and  are  not  so  constant.  In 
obstruction  by  gall-stone  a  few  of  the  cases  gave  a  previous  history  of  gall- 
stone colic.  Jaundice  was  present  in  only  2  of  the  23  cases.  Pain  and  vomit- 
ing, as  a  rule,  occur  early  and  are  severe,  and  f»cal  vomiting  is  present  in 
two-thirds  of  the  cases.    A  tumor  is  rarely  evident. 

(c)  Diagnosis  feom  othee  Co^^DITIO]s^s. — Acute  enteritis  with  great  re- 
laxation of  the  intestinal  coils,  vomiting,  and  pain  may  be  mistaken  for 
obstruction.  In  an  autopsy  on  a  case  of  this  kind  the  small  and  large  bowels 
were  intensely  inflamed,  relaxed,  sodden,  and  enormously  distended.  The 
symptoms  were  those  of  acute  obstruction,  but  the  intestine  was  free  from 


DISEASES  OF  THE  INTESTINES.  525 

duodenum  to  rectum.  Of  late  years  many  instances  have  been  reported  in 
which  peritonitis  following  disease  of  the  appendix  has  been  mistaken  for 
acute  obstruction.  The  intense  vomiting,  the  general  tympany  and  abdominal 
tenderness,  and  in  some  instances  the  suddenness  of  the  onset  are  very  decep- 
tive, and  in  two  cases  which  have  come  under  my  notice  the  symptoms  pointed 
very  strongly  to  internal  strangulation.  In  appen^dix  disease  the  temperature 
is  more  frequently  elevated,  the  vomiting  is  never  fgecal,  and  in  many  cases 
there  is  a  history  of  previous  attacks  in  the  csecal  region.  Acute  hgemorrhalgic 
pancreatitis  may  produce  symptoms  which  simulate  closely  intestinal  obstruc- 
tion. A  boy  was  admitted  to  the  Johns  Hopkins  Hospital  with  a  history  of 
obstinate  vomiting,  intense  abdominal  pain,  gradually  increasing  tympany, 
and  no  passage  for  several  days.  His  condition  seemed  serious  and  he  was 
transferred  at  once  to  the  surgical  wards.  At  the  operation  the  coils  were 
found  uniformly  distended  and  covered  in  places  with  the  thinnest  film  of 
lymph.  No  obstruction  existed,  but  there  was  a  tumor-like  mass  surrounding 
the  pancreas,  firm,  hard,  and  deeply  infiltrated  with  blood.  The  patient 
improved  after  the  operation  and  recovered  completely. 

Treatment. — Purgatives  should  not  be  given.  For  the  pain  hypodermic 
injections  of  morphia  are  indicated.  To  allay  the  distressing  vomiting,  the 
stomach  should  be  washed  out.  ISTot  only  is  this  directly  beneficial,  but  Kuss- 
maul  claims  that  the  abdominal  distention  is  relieved,  the  pressure  in  the 
bowel  above  the  seat  of  obstruction  is  lessened,  and  the  violent  peristalsis  is 
diminished.  It  may  be  practised  three  or  four  times  a  day,  and  in  some  in- 
stances has  proved  beneficial;  in  others  curative.  Thorough  irrigation  of  the 
large  bowel  with  injections  should  be  pract-ised,  the  warm  fluid  being  allowed 
to  flow  in  from  a  fountain  syringe,  and  the  amount  carefully  estimated. 

Inflation  may  also  be  tried,  by  forcing  the  air  into  the  rectum  with  the 
bellows  or  with  a  Davidson's  syringe.  It  is  a  measure  not  without  risk,  as 
instances  of  rupture  of  the  bowel  have  been  reported.  Of  39  cases  in  children 
treated  by  inflation  or  enemata  16  recovered  (Wiggin).  In  cases  of  acute 
obstruction,  surgical  measures  should  be  resorted  to  early. 

For  the  tympanites  turpentine  stupes  and  hot  applications  may  be  ap- 
plied ;  if  extreme,  the  bowel  may  be  punctured  with  a  small  aspirator  needle. 
In  cases  of  chronic  obstruction  the  diet  must  be  carefully  regulated,  and  opium 
and  belladonna  are  useful  for  the  paroxysmal  pains.  Enemata  should  be  em- 
ployed, and  if  the  obstruction  becomes  complete,  resort  must  be  had  to  surgical 
measures. 

V.    CONSTIPATION    (Costiveness). 

Definition. — Eetention  of  faeces  from  any  cause. 

Constipation  in  Adults. — The  causes  are  varied  and  may  be  classed  as 
general  and  local. 

General  Causes. —  (a)  Constitutional  peculiarities:  Torpidity  of  the  bow- 
els is  often  a  family  complaint  and  is  found  more  often  in  dark  than  in  fair 
persons.  (&)  Sedentary  habits,  particularly  in  persons  who  eat  too  much  and 
neglect  the  calls  of  nature,  (c)  Certain  diseases,  such  as  ansemia,  neuras- 
thenia and  hysteria,  chronic  aifections  of  the  liver,  stomach,  and  intestines, 
and  the  acute  fevers.     Under  this  heading  may  appropriately  be  placed  that 


526  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

most  injuiious  of  all  habits,  drug-taking,  (d)  Either  a  coarse  diet,  which 
leaves  too  much  residue,  or  a  diet  wliich  leaves  too  little. 

Local  Causes. — Weakness  of  the  abdominal  muscles  in  obesity  or  from 
overdistention  in  repeated  pregnancies.  Atony  of  the  large  bowel  from  chronic 
disease  of  the  mucosa;  the  presence  of  tumors,  physiological  or  pathological, 
pressing  upon  the  bowel;  enteritis;  foreign  bodies,  large  masses  of  scybala, 
and  strictures  of  all  kinds.  An  important  local  cause  is  atony  of  the  colon, 
particularly  of  the  muscles  of  the  sigmoid  flexure  by  which  the  fseces  are 
propelled  into  the  rectum.  By  far  the  most  obstinate  form  is  that  associated 
with  a  contracted  state  of  the  bowel,  which  is  sometimes  spoken  of  as  spas- 
modic constipation.  This  may  be  met  with  in  three  conditions:  First,  as  a 
sequence  of  chronic  dysentery  or  ulcerative  colitis;  secondly,  in  protracted 
cases  of  hysteria  and  neurasthenia  in  women,  particularly  in  association  with 
uterine  disease;  and,  thirdly,  in  very  old  persons  often  without  any  definite 
cause.  It  may  be  that  the  sigmoid  flexure  and  lower  colon  are  in  a  condition 
of  contraction  and  spasm,  while  the  transverse  and  ascending  parts  are  in  a 
state  of  atony  and  dilatation.  The  most  characteristic  sign  of  this  variety 
is  the  presence  of  hard,  globular  masses,  or  more  rarely  small  and  sausage- 
like fffices.  For  interesting  studies,  with  the  X-rays,  of  the  phenomena  of 
constipation  see  the  articles  by  Hertz  in  the  Lancet,  1908. 

Symptoms. — The  most  persistent  constipation  for  weeks  or  even  months 
may  exist  with  fair  health.  All  kinds  of  evils  have  been  attributed  to  poison- 
ing by  the  resorption  of  noxious  matters  from  the  retained  faces — copramia. 
Chlorosis,  which  Sir  Andrew  Clark  attributed  to  fsecal  poisoning,  is  not  always 
associated  with  constipation,  and  if  due  to  this  cause  should  be  in  men,  women, 
and  children  the  most  common  of  all  disorders.  Debility,  lassitude,  and  a 
mental  depression  are  frequent  s}'niptoms  in  constipation,  particularly  in  per- 
sons of  a  nervous  temperament.  Headache,  loss  of  appetite,  and  a  furred 
tongue  may  also  occur.  Individuals  difEer  extraordinarily  in  this  matter: 
one  feels  wretched  all  day  without  the  accustomed  evacuation ;  another  is  com- 
fortable all  the  week  except  on  the  day  on  which  by  purge  or  enema  the  bowels 
are  relieved. 

When  persistent,  the  accumulation  of  faeces  leads  to  unpleasant,  some- 
times serious  symptoms,  such  as  piles,  ulceration  of  the  colon,  distention  of 
the  sacculi,  perforation,  enteritis,  and  occlusion.  In  women,  pressure  may 
cause  pain  at  the  time  of  menstruation  and  a  sensation  of  fulness  and  dis- 
tention in  the  pelvic  organs.  Xeuralgia  of  the  sacral  nerves  may  be  caused 
by  an  overloaded  sigmoid  flexure.  The  faeces  collect  chiefly  in  the  colon. 
Even  in.  extreme  grades  of  constipation  it  is  rare  to  find  dry  faeces  in  the 
caecum.  The  fa?ces  may  form  large  tumors  at  the  hepatic  or  splenic  flexures, 
or  a  sausage-like,  doughy  mass  above  the  navel,  or  an  irregular  lumpy  tumor 
in  the  left  inguinal  region.  In  old  persons  the  sacculi  of  the  colon  become 
distended  and  the  scybala  may  remain  in  them  and  undergo  calciflcation, 
forming  enteroliths. 

In  cases  with  prolonged  retention  the  faecal  masses  become  channeled  and 
diarrhoea  may  occur  for  days  before  the  true  condition  is  discovered  by  rectal 
or  external  examination.  In  women  who  have  been  habitually  constipated, 
attacks  of  diarrhoea  with  nausea  and  vomiting  should  excite  suspicion  and 
lead  to  a  thorough  examination  of  the  large  bowel.    Fever  may  occur  in  these 


DISEASES  OF  THE  INTESTINES.  527 

cases,  and  Meigs  has  reported  an  instance  in  which  the  condition  simulated 
typhoid  fever. 

Constipation  in  infants  is  a  common  and  troublesome  disorder.  The 
causes  are  congenital,  dietetic,  and  local.  There  are  instances  in  which  the 
child  is  constipated  from  birth  and  may  not  have  a  natural  movement  for 
years  and  yet  thrive  and  develop.  There  are  cases  of  enormous  dilatation  of 
the  large  bowel  with  persistent  constipation.  The  condition  appears  sometinaes 
to  be  a  congenital  defect.  In  some  of  these  patients  there  may  be  constricting 
bands,  or,  as  in  a  case  of  Cheever's,  a  congenital  stricture. 

Dietetic  causes  are  more  common.  In  sucklings  it  often  arises  from  an 
unnatural  dryness  of  the  small  residue  which  passes  into  the  colon,  and  it 
may  be  very  difficult  to  decide  whether  the  fault  is  in  the  mother's  milk  or  in 
the  digestion  of  the  child.  Most  probably  it  is  in  the  latter,  as  some  babies 
may  be  persistently  costive  on  natural  or  artificial  foods.  Deficiency  of  fat 
in  the  milk  is  believed  by  some  writers  to  be  the  cause.  In  older  children 
it  is  of  the  greatest  importance  that  regular  habits  should  be  enjoined.  Care- 
lessness on  the  part  of  the  mother  in  this  matter  often  lays  the  foundation  of 
troublesome  constipation  in  after  life.  Impairment  of  the  contractility  of  the 
intestinal  wall  in  consequence  of  inflammation,  disturbance  in  the  normal 
intestinal  secretions,  and  mechanical  obstruction  by  tumors,  twists,  and  intus- 
susception are  the  chief  local  causes. 

Treatment. — Much  may  be  done  by  systematic  habits,  particularly  in  the 
young.  The  desire  to  go  to  stool  should  always  be  granted.  Exercise  in 
moderation  is  helpful.  In  stout  persons  and  in  women  with  pendulous  abdo- 
mens the  muscles  should  have  the  support  of  a  bandage.  Friction  or  regu- 
larly applied  massage  is  invaluable  in  the  more  chronic  cases.  A  good  substi- 
tute is  a  metal  ball  weighing  from  four  to  six  pounds,  which  may  be  rolled 
over  the  abdomen  every  morning  for  five  or  ten  minutes.  The  diet  should  be 
light,  with  plenty  of  fruit  and  vegetables,  particularly  salads  and  tomatoes. 
Oatmeal  is  usually  laxative,  though  not  to  all;  brown  bread  is  better  than 
that  made  from  fine  white  flour.  Of  liquids,  water  and  aerated  mineral  waters 
may  be  taken  freely.  A  tumblerful  of  cold  water  on  rising,  taken  slowly,  is 
efficacious  in  many  cases.  A  glass  of  hot  water  at  night  may  also  be  tried 
alone.  A  pipe  or  a  cigar  after  breakfast  is  with  many  men  an  infallible 
remedy. 

When  the  condition  is  not  very  obstinate  it  is  well  to  try  to  relieve  it  by 
hygienic  and  dietetic  measures.  If  drugs  must  be  used  they  should  be  the 
milder  saline  laxatives  or  the  compound  liquorice  powder.  Enemata  are  often 
necessary,  and  it  is  much  preferable  to  employ  them  early  than  to  constantly 
use  purgative  pills.  Glycerine  either  in  the  form  of  suppository  or  as  a  small 
injection  is  very  valuable.  Half  a  drachm  of  boric  acid  placed  within  the 
rectum  is  sometimes  efficacious.  The  injections  of  tepid  water,  with  or  with- 
out soap,  may  be  used  for  a  prolonged  period  with  good  effect  and  without 
damage.  The  patient  should  be  in  the  dorsal  position  with  the  hips  elevated, 
and  it  is  best  to  let  the  fluid  flow  in  slowly  from  a  fountain  syringe. 

The  usual  remedies  employed  are  often  useless  in  the  constipation  asso- 
ciated with  contracted  bowel.  A  very  satisfactory  measure  is  the  olive-oil 
injection  as  recommended  by  Kussmaul.  The  patient  lies  on  the  back  with 
the  hips  elevated^  and  with  a  cannula  and  tube  from  15  to  30  ounces  of  pure 


528  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

oil  are  alloAved  to  flow  slowly  (or  are  injected)  into  the  bowel.  The  opera- 
tion should  take  at  least  fifteen  minutes.  This  may  be  repeated  every  day 
until  the  intestine  is  cleared,  and  subsequently  a  smaller  injection  every  few 
days  will  suffice. 

There  are  various  drugs  which  are  of  special  service,  particularly  the  com- 
bination of  ipecacuanha,  nux  vomica,  or  belladonna,  with  aloes,  rhubarb,  colo- 
cyntli,  or  podophyllin.  Meigs  recommends  particularly  the  combination  of 
extract  of  belladonna  (gr.  y-j)?  extract  of  nux  vomica  (gr.  ^),  and  extract  of 
coloc}Tith  (gr.  ij),  one  pill  to  be  taken  three  times  a  day.  In  anaemia  and 
chlorosis,  a  sulphur  confection  taken  in  the  morning,  and  a  pill  of  iron,  rhu- 
barb, and  aloes  throughout  the  day,  are  very  serviceable. 

In  children  the  indications  should  be  met,  as  far  as  possible,  by  hygienic 
and  dietetic  measures.  In  the  constipation  of  sucklings  a  change  in  the  diet 
of  the  mother  may  be  tried,  or  from  one  to  three  teaspoonfuls  of  cream  may 
be  given  before  each  nursing.  In  artificially  fed  children  the  top  milk  with 
the  cream  should  be  used.  Drinking  of  water,  barley  water,  or  oatmeal  water 
will  sometimes  obviate  the  difficulty.  If  laxatives  are  required,  simple  syrup, 
manna,  or  olive  oil  may  be  sufficient.  The  conical  piece  of  soap,  so  often  seen 
in  nurseries,  is  sometimes  efficacious.  Massage  along  the  colon  may  be  tried. 
Small  injections  of  cold  water  may  be  used.  Large  injections  should  be 
avoided,  if  possible.  If  it  is  necessary  to  give  a  laxative  by  the  mouth,  castor 
oil  or  the  fluid  magnesia  is  the  best.  The  saline  purgatives  appear  to  act  by 
increasing  the  muscular  and  glandular  activit}^  of  the  bowel.  If  there  are 
signs  of  gastro-intestinal  irritation,  rhubarb  and  soda  or  gray  powder  may 
be  given.    In  older  children  the  diet  should  be  carefully  regulated. 

VI.    ENTEROPTOSIS    (Glenard's    Disease). 

Definition. — "  Dropping  of  the  viscera,"  visceroptosis,  is  not  a  disease,  but 
a  symptom  group  characterized  by  looseness  of  the  mesenteric  and  peritoneal 
attachments,  so  that  the  stomach,  the  intestines,  particularly  the  transverse 
colon,  the  liver,  the  kidneys,  and  the  spleen  occupy  an  abnormally  low  position 
in  the  abdominal  cavit}'. 

Symptoms  and  Physical  Signs. — It  is  important  to  recognize  two  groups 
of  cases.  In  one  the  splanclinoptosis  follows  the  loss  of  normal  support  of 
the  abdominal  wall  in  consequence  of  repeated  pregnancies  or  recurring  ascites. 
The  condition  may  be  extreme  without  the  slightest  distress  on  the  part  of 
the  patient. 

The  second  and  more  important  group  occurs  usually  in  young  persons, 
who  present,  with  splanclinoptosis,  the  features  of  more  or  less  marked  neu- 
rasthenia. 

In  the  first  group  inspection  of  the  abdomen  shows  a  very  relaxed  abdom- 
inal wall,  and  as  a  rule  the  linese  albicantes  of  recurring  pregnancies.  Peri- 
stalsis of  the  intestines  may  be  seen,  and  in  extreme  cases  the  outlines  of  the 
stomach  itself  with  its  waves  of  peristalsis.  On  inflating  the  stomach  with 
carbonic-acid  gas  the  organ  stands  out  with' great  prominence,  and  the  lesser 
and  greater  curvatures  are  seen,  the  latter  extending  perhaps  a  hand's  breadth 
below  the  level  of  the  navel.  The  waves  of  peristalsis  are  feeble  and  without 
the  vigor  and  force  of  those  seen  in  the  stomach  dilated  from  stricture  of  the 


DISEASES  OF  THE  INTESTINES.  529 

pylorus.  The  condition  of  descensus  ventriculi  with  atony  is  ])est  studied  in 
this  group  of  cases.  An  important  point  to  remember  is  that  it  may  exist  in 
an  extreme  grade  without  symptoms. 

In  the  other  group  is  embraced  a  somewhat  motley  series  of  cases,  in  which, 
with  a  pronounced  nervous,  or,  as  we  call  it  now,  neurasthenic  basis,  there  are 
displacements  of  the  viscera  with  symptoms.  The  patients  are  usually  young, 
more  frequently  women  than  men,  and  of  spare  habit.  The  condition  may 
follow  an  acute  illness  with  wasting.  They  complain,  as  a  rule,  of  dyspepsia, 
throbbing  in  the  abdomen,  and  dragging  pains  or  weakness  in  the  back,  and 
inability  to  perform  the  usual  duties  of  life.  A  very  considerable  proportion 
of  all  the  cases  of  neurasthenia  present  the  local  features  of  enteroptosis. 
When  preparing  for  the  examination  one  notices  usually  an  erythematous 
flushing  of  the  skin ;  the  scratch  of  the  nail  is  followed  instantly  by  a  line  of 
hyperemia,  less  often  of  marked  pallor.  The  pulsation  of  the  abdominal 
aorta  is  readily  seen. 

On  examination  of  the  viscera  one  finds  the  following:  The  stomach  is 
below  the  normal  level,  and  in  women  who  have  laced  it  may  be  vertically 
placed.  The  splashing  of  clapotage  is  unusually  distinct.  After  inflation 
with  carbonic-acid  gas  the  outlines  of  the  stomach  are  seen  through  the  thin 
abdominal  walls.  In  extreme  cases  there  may  be  great  dilatation  of  the  stom- 
ach, in  consequence  of  obstruction  of  the  pylorus  by  pressure  of  the  displaced 
right  kidney. 

Nephroptosis,  or  displacement  of  the  kidney,  is  one  of  the  most  constant 
phenomena  in  enteroptosis.  It  is  well,  perhaps,  to  distinguish  between  the 
kidney  which  one  can  just  touch  on  deep  inspiration — palpable  kidney,  one 
which  is  freely  movable,  and  which  on  deep  inspiration  descends  so  that  one 
can  put  the  fingers  of  the  palpating  hand  above  it  and  hold  it  down,  and, 
thirdly,  a  fioating  kidney,  which  is  entirely  outside  the  costal  arch,  is  easily 
grasped  in  the  hand,  readily  moved  to  the  middle  line,  and  low  down  toward 
the  right  iliac  fossa.  It  is  held  by  some  that  the  designation  floating  kidney 
should  be  restricted  to  the  cases  in  which  there  is  a  meso-nepliron,  but  this 
is  excessively  rare,  while  extreme  grades  of  renal  mobility  are  common.  Some 
of  the  more  serious  sequences  of  movable  kidney,  namely,  Dietl's  crises  and 
intermittent  hydronephrosis,  will  be  considered  with  diseases  of  the  kidney. 

Displacement  of  the  liver  is  very  much  less  common.  In  thin  women 
who  have  laced  the  organ  is  often  tilted  forward,  so  that  a  very  large  sur- 
face of  the  lobes  comes  in  contact  with  the  abdominal  wall;  it  is  a  very  com- 
mon mistake  under  these  circumstances  to  think  that  the  organ  is  enlarged. 
Dislocation  of  the  liver  itself  will  be  considered  later. 

Mobility  of  the  spleen  is  sometimes  very  marked  in  enteroptosis.  In  an 
extreme  grade  it  may  be  found  in  almost  any  region  of  the  abdomen.  It  is 
very  frequently  mistaken  for  a  fibroid  or  ovarian  tumor.  A  considerable  pro- 
portion of  the  cases  come  first  under  the  care  of  the  gynecologist. 

There  is  usually  much  relaxation  of  the  mesentery  and  of  the  peritoneal 
folds  which  support  the  intestines.  The  colon  is  displaced  downward  (colop- 
tosis),  with  consequent  kinking  at  the  flexures.  The  descent  may  be  so  low 
that  the  transverse  colon  is  at  the  brim  of  the  pelvis.  It  may  indeed  be  fixed 
or  bent  in  the  form  of  a  V.  It  is  frequently  to  be  felt,  as  Glenard  states, 
as  a  firm  cord  crossing  the  abdomen  at  or  below  the  level  of  the  navel.  This 
35 


530  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

kinking  may  take  place  not  only  in  the  colon,  but  at  the  pj'lorus,  where  the 
duodenum  passes  into  the  jejunum,  and  where  the  ileum  enters  the  csecum. 

The  explanation  of  the  phenomena  accompanying  enteroptosis  is  by  no 
means  easy.  It  has  been  suggested  by  Glenard  and  others  that  overfilling  of 
the  splanchnic  vessels  in  consequence  of  displacements  and  kinking  accounts 
for  the  feelings  of  exhaustion  and  general  nervousness.  In  a  large  proportion 
of  the  cases,  however,  no  symptoms  occur  until  after  an  illness  or  some  pro- 
tracted nervous  strain. 

Treatment. — In  a  majority  of  all  cases  four  indications  are  present:  To 
treat  the  existing  neurasthenia,  to  relieve  the  nervous  dyspepsia,  to  overcome 
the  constipation,  and  to  afford  mechanical  support  to  the  organs.  Three  of 
these  are  considered  under  their  appropriate  sections.  In  cases  in  which  the 
enteroptosis  has  followed  loss  in  weight  after  an  acute  illness  or  worries  and 
cares,  an  important  indication  is  to  fatten  the  patient. 

A  well-adapted  abdominal  bandage  is  one  of  the  most  important  measures 
in  enteroptosis.  In  many  of  the  milder  grades  it  alone  suffices.  I  know  of 
no  single  simple  measure  which  affords  relief  to  distressing  symptoms  in  so 
many  cases  as  the  abdominal  bandage.  It  is  best  made  of  linen,  should  fit 
snugly,  and  should  be  arranged  with  straps  so  that  it  can  not  ride  up  over  the 
hips.  A  special  form  must  be  used,  as  will  be  mentioned  later,  for  movable 
kidney.  Some  of  the  more  aggravated  types  of  enteroptosis  are  combined 
with  such  features  of  neurasthenia  that  a  rigid  Weir  Mitchell  treatment  is 
indicated.  In  a  few  very  refractory  cases  surgical  interference  may  be  called 
for.  Treves,  in  Allbutt's  System,  records  two  cases,  one  in  which  laparotomy 
was  resorted  to  as  a  medical  measure  with  perfect  results.  In  the  other  the 
liver  was  stitched  in  place,  and  complete  recovery  followed. 

And  lastly,  the  physician  must  be  careful  in  dealing  with  the  subjects 
of  enteroptosis  not  to  lay  too  much  stress  on  the  disorder.  It  is  well  never 
to  tell  the  patient  that  a  kidney  is  movable;  the  symptoms  may  date  from 
a  knowledge  of  the  existence  of  the  condition. 

VII.     MISCELLANEOUS  AFFECTIONS. 

I.  Mucous  Colitis. 

Known  by  various  names,  such  as  membranous  enteritis,  tubular  diarrhoea, 
mucous  colic,  and  myxoneurosis  intestinalis,  this  remarkable  disease  has  been 
recognized  for  several  centuries.  An  exhaustive  description  of  it  is  given  by 
Woodward  in  vol.  ii  of  the  Medical  and  Surgical  Reports  of  the  Civil  War. 
The  passage  of  mucus  in  large  quantities  from  the  bowel  is  met  with,  first, 
in  catarrh  of  the  intestine,  due  to  various  causes.  It  is  not  uncommon  in  chil- 
dren, and  may  be  associated  with  disturbances  of  digestion  and  slight  colic. 
Secondly,  in  local  disease  or  irritation  of  the  bowel,  in  cancer  of  the  colon 
and  of  the  rectum.  In  tubo-ovarian  disease  much  mucus  and  slime  may  be 
passed.  Thirdly,  true  mucous  colitis,  a  secretion  neurosis  of  the  large  intes- 
tine met  with  particularly  in  nervous  and  hysterical  patients.  It  is  more  com- 
mon in  women  than  in  men.  There  is  an  abnormal  secretion  of  a  tenacious 
mucus,  which  may  be  slimy  and  gelatinous,  like  frog-spawn,  or  it  is  passed  in 
strings  or  strips,  more  rarely  as  a  continuous  tubular  membrane. .   I  have 


DISEASES  OF  THE  INTESTINES.  531 

twice  seen  this  membrane  in  situ,  closely  adherent  to  the  mucosa,  but  capable 
of  separation  without  any  lesion  of  the  surface.  Microscopically  the  casts  are 
mucoid,  of  a  uniform  granular  ground  substance  through  which  there  are  rem- 
nants of  cells,  some  of  which  have  undergone  a  definite  hyaline  transformation. 
Triple  phosphate,  cholesterin,  and  fatty  crystals  are  present,  and  occasionally 
fine,  sand-like  concretions.     The  epithelium  of  the  mucosa  seems  to  be  intact. 

Symptoms. — In  a  large  proportion  of  all  the  cases  the  subjects  are  nervous 
in  greater  or  less  degree.  Some  cases  have  had  hysterical  outbreaks,  and  there 
may  be  hypochondriasis  or  melancholia.  The  patients  are  self-centred  and 
often  much  worried  about  the  mucous  stools.  Some  of  the  cases  are  among 
the  most  distressing  with  which  we  have  to  deal,  invalids  of  from  ten  to  twenty 
years'  standing,  neurasthenic  to  an  extreme  degree,  with  recurring  attacks  of 
pain  and  the  passage  of  large  quantities  of  mucus  or  even  of  intestinal  casts. 

In  many  cases  the  attacks  may  come  on  in  paroxysms,  associated  with 
colicky  pains,  or  occasionally  crises  of  the  greatest  severity,  so  that  appendicitis 
may  be  suspected.  Emotional  disturbances,  worry  of  all  sorts,  or  an  error 
in  diet  may  bring  on  an  attack.  Constipation  is  a  special  feature  in  many 
cases.     Sometimes  there  are  attacks  of  nervous  diarrhoea. 

While  the  disease  is  obstinate  and  distressing,  it  is  rarely  serious,  though 
Herringham  states  that  he  knew  of  three  cases  of  mucous  colitis  in  which 
death  occurred  suddenly,  in  all  with  great  pain  in  the  left  side  of  the  abdomen. 
The  abdomen  itself  is  rarely  distended.  There  is  often  a  very  painful  spot 
just  between  the  navel  and  the  left  costal  border,  tender  on  pressure,  and  some- 
times the  paroxysms  of  pain  seem  centred  in  this  region. 

Diagnosis. — The  diagnosis  is  rarely  doubtful,  but  it  is  important  not  to 
mistake  the  membranes  for  other  substances;  thus,  the  external  cuticle  of 
asparagus  and  undigested  portions  of  meat  or  sausage-skins  sometimes  assume 
forms  not  unlike  mucous  casts,  but  the  microscopical  examination  will  quickly 
differentiate  them.  Mucous  colitis  with  severe  pain  may  be  mistaken  for 
appendicitis. 

Treatment. — Drugs  are  of  little  value.  It  is  quite  useless  to  give  bismuth 
and  so-called  intestinal  remedies.  First  the  basic  neurasthenic  state  is  to  be 
dealt  with,  and  this  may  suffice  for  a  cure.  Secondly,  daily  irrigations  of  the 
colon  through  a  long  tube — one  to  two  pints  of  warm  alkaline  fluid.  At 
Plombieres,  Harrogate,  and  other  spas  this  treatment  is  most  successfully 
carried  out.  Thirdly,  the  coarser  sorts  of  food  should  be  eaten  which  leave 
a  large  residue;  and,  lastly,  should  these  measures  fail,  the  question  of  open- 
ing the  colon  or  irrigating  through  the  appendix  may  be  considered. 

II.  Dilatation  of  the  Colon. 

Hale  White,  in  Allbutt's  System,  recognizes  four  groups  of  cases.  In  the 
first  the  distention  is  entirely  gaseous,  and  occurs  not  infrequently  as  a  tran- 
sient condition.  In  many  cases  it  has  an  important  influence,  inasmuch  as 
it  may  be  extreme,  pushing  up  the  diaphragm  and  seriously  impairing  the 
action  of  the  heart  and  lungs.  H.  Fenwick  has  called  attention  to  this  as 
occasionally  a  cause  of  sudden  heart-failure. 

In  the  second  group  are  the  cases  in  which  the  distention  of  the  colon  is 
caused  by  solid  substances,  as  faecal  matter,  occasionally  by  foreign  bodies 
introduced  from  without,  and  more  rarely  by  gall-stones. 


532  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

"When,  tliirdl}',  the  dilatation  is  due  to  an  organic  obstruction  in  front 
of  the  dilated  gut,  the  colon  may  reach  a  very  large  size.  These  cases  are 
common  enough  in  malignant  tumors  and  sometimes  in  volvulus.  Dilata- 
tion of  the  sigmoid  flexure  occurs  particularly  when  this  portion  of  the  bowel 
is  congenitally  very  long.  In  such  cases  the  bowel  may  be  so  distended  that 
it  occupies  the  greater  part  of  the  abdomen,  pusliing  up  the  liver  and  the  dia- 
phragm.   An  acute  condition  is  sometimes  caused  by  a  twist  in  the  meso-colon. 

Fourthly,  there  are  the  cases  of  so-called  ideopathic  dilatation  of  the  colon, 
which  occurs  most  commonly  in  children.  Aarchow  called  it  "  giant  growth 
of  the  colon."  While,  as  a  rule,  there  is  no  obstruction  or  narrowing,  there  may 
be,  as  Treves  has  pointed  out,  stricture  of  the  sigmoid  flexure.  In  the  idio- 
pathic chronic  form  the  gut  reaches  an  enormous  size.  The  coats  may  be  hyper- 
trophied  without  evidence  of  any  special  organic  change  in  the  mucosa.  The 
most  remarkable  instance  has  been  reported  by  Formad.  The  patient,  known 
as  the  "balloon-man,"  aged  twenty-three  years  at  the  time  of  his  death,  had 
had  a  distended  abdomen  from  infancy.  Post  mortem  the  colon  was  found 
as  large  as  that  of  an  ox,  the  circumference  ranging  from  15  to  30  inches. 
The  weight  with  the  contents  was  47  pounds.  In  children  the  symptoms  are 
very  definite — constipation,  as  a  rule,  often  protracted  and  leading  to  great 
distention,  the  coils  of  the  bowels  forming  patterns.  This  may  be  followed  by 
periods  of  diarrhoea.  In  several  of  my  cases  the  child  had  never  had  a  natural 
movement.  The  abdomen  is  protuberant,  particularly  in  the  upper  segment, 
soft,  and  on  inspection  peristalsis  may  be  visible.  The  condition  is,  as  a  rule, 
incurable  without  surgical  interference.  In  one  of  my  cases  good  results  fol- 
lowed the  establishment  of  an  artificial  anus,  but  the  most  brilliant  case  is  that 
reported  by  Treves,  who  excised  the  greater  part  of  the  colon,  with  recovery. 

III.  IxTESTixAL  Sand. 

"  Sable  Intestinal." — There  are  two  groups  of  cases  in  which  sand-like 
material  is  passed  with  the  stools.  The  false,  in  which  it  is  made  up  of  the 
remains  of  vegetable  food  and  fruits  which  have  resisted  digestion  or  which 
have  become  encrusted  with  earthy  salts.  True  intestinal  sand  of  animal 
origin,  gritty  fine  particles,  usually  gray  or  colorless,  sometimes  dark.  It  is 
formed  in  the  bowel  and  is  made  up  largely  of  lime  salts.  In  mucous  colitis 
this  material  may  be  passed  at  intervals  for  months. 

IV.  Diverticulitis — Perisigmoiditis. 

In  the  lower  part  of  the  descending  colon  and  in  the  sigmoid  flexure 
diverticula  occur,  sometimes  congenital,  sometimes  acquired,  most  commonly 
in  women  and  in  association  with  constipation.  Of  81  cases  collected  by  Tell- 
ing, 53  were  in  males.  They  are  prone  to  form  at  the  site  of  the  appendices 
epiploicee.  Intestinal  obstruction,  acute  gangrene,  perforation  with  the  for- 
mation of  abscess,  peritonitis,  vesico-colic  fistula,  and  metastatic  suppuration 
are  occasional  complications.  In  acute  cases  left-sided  appendicitis  is  diag- 
nosed, while  in  the  chronic  cases  the  mimicry  of  cancer  is  very  close.  The 
cases  are  more  common  than  we  have  heretofore  supposed.  Eesection  of  the 
affected  portion  of  the  colon  has  been  successfully  performed. 


DISEASES  OF  THE  INTESTINES.  533 

V.  Affections  of  the  Mesentery, 

(1)  Haemorrhage  (hcematoma). — Instances  in  which  the  bleeding  is  confined 
to  the  mesenteric  tissues  are  rare;  more  commonly  the  condition  is  associated 
with  hsemorrhagic  infiltration  of  the  pancreas  and  with  retroperitoneal  hsemor- 
rhage.  It  occurs  in  rupture  of  aneurisms,  either  of  the  abdominal  aorta  or  of 
the  superior  mesenteric  arter}^,  in  malignant  forms  of  the  infectious  fevers,  as 
small-pox,  and,  lastly,  in  individuals  in  whom  no  predisposing  conditions  exist. 

(3)  Affections  of  the  Mesenteric  Vessels. — (a)  Aneurism  (see  under 
Arteries). 

(&)  Embolism  and  Thrombosis. — Infarction  of  the  Bowel. — When  the 
mesenteric  vessels  are  blocked  by  emboli  or  thrombi  the  condition  of  infarc- 
tion follows  in  the  territory  supplied,  which  may  pass  on  to  gangrene  or  to 
perforation  and  peritonitis.  Probably  the  occlusion  of  small  vessels  does  not 
produce  any  symptoms,  and  the  circulation  may  be  re-established.  If  the  supe- 
rior mesenteric  artery  is  blocked  the  result  is  fatal.  Endocarditis,  arterio- 
sclerosis, and  aneurism  of  the  aorta  are  the  important  factors  in  occlusion  of 
the  arteries.  In  the  veins  the  thrombosis  may  be  primary,  following  infective 
processes  in  the  intestines,  particularly  about  the  appendix,  or  it  occurs  in 
cachectic  states.  Secondary  thrombosis  is  met  with  in  cirrhosis  of  the  liver, 
syphilis,  and  pylephlebitis,  or  may  result  from  the  stasis  caused  by  arterial 
emboli.  Jackson,  Porter,  and  Quimby  have  made  an  exhaustive  study  of  30 
Boston  cases,  and  have  collected  314  cases.  They  recognize  two  groups — acute 
and  chronic.  In  the  former  the  onset  is  sudden,  with  colic,  nausea,  vomiting, 
and  a  bloody  diarrhoea,  so  that  the  picture  is  one  of  acute  obstruction.  The 
abdomen  becomes  distended  and  death  occurs  in  collapse  within  a  few  days. 
In  the  chronic  cases  the  onset  is  insidious,  and  there  may  be  no  symptoms 
referable  to  the  abdomen.  Of  the  314  cases,  64  per  cent  were  in  men.  The 
diagnosis  is  extremely  difficult,  and  the  acute  cases  are  usually  regarded  as 
obstruction.  Exploratory  operation  has  been  made  in  47  cases,  4  of  which 
have  recovered.  In  J.  W.  Elliot's  successful  case  48  inches  of  the  bowel  were 
resected.  In  the  horse,  infarction  of  the  intestine  is  extremely  common  in  con- 
nection with  the  verminous  aneurisms  of  the  mesenteric  arteries,  and  is  the 
usual  cause  of  colic  in  this  animal. 

(3)  Diseases  of  the  Mesenteric  Veins. — Dilatation  and  sclerosis  occur  in 
cirrhosis  of  the  liver.  In  instances  of  prolonged  obstruction  there  may  be 
large  saccular  dilatations  with  calcification  of  the  intima,  as  in  a  case  of  oblit- 
eration of  the  vena  portse  described  by  me.  Suppuration  of  the  mesenteric 
veins  is  not  rare,  and  occurs  usually  in  connection  with  pylephlebitis.  The 
mesentery  may  be  much  swollen  and  is  like  a  bag  of  pus,  and  it  is  only  on 
careful  dissection  that  one  sees  that  the  pus  is  really  within  channels  repre- 
senting extremely  dilated  mesenteric  veins.  Two  of  the  three  cases  I  have 
seen  were  in  connection  with  local  appendix  abscess. 

(4)  Disorders  of  the  Chyle  Vessels. — Varicose,  cavernous,  and  cystic  chy- 
langiomata  are  met  with  in  the  mucosa  and  submucosa  of  the  small  intestine, 
occasionally  of  the  stomach.  Extravasation  of  chyle  into  the  mesenteric  tissue 
is  sometimes  seen.  Chylous  cysts  are  found.  I  saw  one  the  size  of  an  egg  at 
the  root  of  the  mesentery.  Bramann  records  a  case  in  a  man  aged  sixty-three, 
in  which  a  cyst  of  this  kind  the  size  of  a  child's  head  was  healed  by  operation. 


534  DISEASES  OF   THE  DIGESTIVE  SYSTEM. 

There  is  an  instance  on  record  of  a  congenital  malformation  of  the  thoracic 
duct,  in  which  the  receptaculmn  formed  a  flattened  cyst  which  discharged  into 
the  peritonaeum,  and  a  chylous  ascitic  fluid  was  withdrawn  on  several  occasions. 
Homans,  of  Boston,  reports  an  extraordinary  case  of  a  girl,  who  from  the  third 
to  the  thirteenth  year  had  an  enlarged  abdomen.  Laparotomy  showed  a  series 
of  cysts  containing  clear  fluid.  They  were  supposed  to  be  dilated  lymph  ves- 
sels connected  with  the  intestines. 

(5)  Cysts  of  the  Mesentery. — Much  attention  has  been  directed  of  late 
years  to  the  occurrence  of  mesenteric  cysts,  and  the  literature  which  is  fully 
given  by  Dowd  (Annals  of  Surgery,  vol.  xxxii)  is  already  extensive.  They 
may  be  either  dermoid,  hydatid,  serous,  sanguineous,  or  ch3dous.  They 
occur  at  any  portion  of  the  mesentery,  and  range  from  a  few  inches  in  diam- 
eter to  large  masses  occup3ing  the  entire  abdomen.  They  are  frequently 
adherent  to  the  neighboring  organs,  to  the  liver,  spleen,  uterus,  and  sigmoid 
flexure. 

The  symptoms  usually  are  those  of  a  progressively  enlarging  tumor  in  the 
abdomen.  Sometimes  a  mass  develops  rapidly,  particularly  in  the  heemor- 
rhagic  forms.  Colic  and  constipation  are  present  in  some  cases.  The  general 
health,  as  a  rule,  is  well  maintained  in  spite  of  the  progressive  enlargement  of 
the  abdomen,  which  is  most  prominent  in  the  umbilical  region.  Mesenteric 
cysts  may  persist  for  many  years,  even  ten  or  twenty. 

The  diagnosis  is  extremely  uncertain,  and  no  single  feature  is  in  any  way 
distinctive,  xlugagneur  gives  three  important  signs :  the  great  mobility,  the 
situation  in  the  middle  line,  and  the  zone  of  tympany  in  front  of  the  tumor. 
Of  these,  the  second  is  the  only  one  which  is  at  all  constant,  as  when  the 
tumors  are  large  the  mobility  disappears,  and  at  this  stage  the  intestines,  too, 
are  pushed  to  one  side.  It  is  most  frequently  mistaken  for  ovarian  tumor. 
Movable  kidney,  hydronephrosis,  and  cysts  of  the  omentum  have  also  been 
confused  with  it.  In  certain  instances  puncture  may  be  made  for  diagnostic 
purposes,  but  it  is  better  to  advise  laparotomy  for  the  purpose  of  drainage, 
or,  if  possible,  enucleation  may  be  practised. 


H.    DISEASES   OF  THE  LIVER. 

I.    JAUNDICE    (Icterus). 

Definition. — Jaundice  or  icterus  is  a  condition  characterized  by  coloration 
of  the  skin,  mucous  membranes,  and  fluids  of  the  body  by  the  bile-pigment. 

Like  albuminuria,  jaundice  is  a  symptom  and  not  a  disease,  and  is  met 
with  in  a  variety  of  conditions. 

For  a  full  consideration  of  the  theories  of  jaundice  the  reader  is  referred 
to  William  Hunter's  article  in  Allbutt's  System  of  Medicine.  The  cases  with 
icterus  may  be  divided  into  three  great  groups. 

1.  Obstructive  Jaundice, 

The  following  classification  of  the  causes  of  obstructive  jaundice  is  given 
by  Murchison:   (1)   Obstruction  by  foreign  bodies  within  the  ducts,  as  gall- 


DISEASES  OF   THE  LIVER.  535 

stones  and  parasites;  (2)  by  inflammatory  tumefaction  of  the  duodanum  or 
of  the  lining  membrane  of  the  duct;  (3)  by  stricture  or  obliteration  of  the 
duct;  (4)  by  tumors  closing  the  orifice  of  the  duct  or  growing  in  its  interior; 
(5)  by  pressure  on  the  duct  from  without,  as  by  tumors  of  the  liver  itself,  of 
the  stomach,  pancreas,  kidney,  or  omentum;  by  pressure  of  enlarged  glands 
in  the  fissures  of  the  liver,  and,  more  rarely,  of  abdominal  aneurism,  faecal 
accumulation,  or  the  pregnant  uterus. 

According  to  Eolleston,  in  these  cases  of  extra-hepatic  or  obstructive  jaun- 
dice the  pressure  within  the  biliary  capillaries,  usually  low,  becomes  increased 
"and  the  bile  is  absorbed  by  the  lymphatics  of  the  liver  and  not  by  the  blood 
capillaries. 

To  these  causes  some  add  lowering  of  the  blood  pressure  in  the  portal  sys- 
tem so  that  the  tension  in  the  smaller  bile-ducts  is  greater  than  in  the  blood- 
vessels. For  this  view,  however,  there  is  no  positive  evidence.  In  this  class 
may  perhaps  be  placed  the  cases  of  jaundice  from  mental  shock  or  depressed 
emotions,  which  "  may  conceivably  cause  spasm  and  reversed  peristalsis  of  the 
bile-duct"  (W.  Hunter). 

General  Symptoms  of  Obstructive  Jaundice. — ^(1)  Icterus,  or  tinting 
of  the  skin  and  conjunctives.  The  color  ranges  from  a  lemon-yellow  in  catar- 
rhal jaundice  to  a  deep  olive-green  or  bronzed  hue  in  permanent  obstruction. 
In  some  instances  the  color  of  the  skin  is  greenish  black,  the  so-called  "  black 
jaundice."    Except  the  central  nervous  system,  the  tissues  are  all  stained. 

(2)  In  the  more  chronic  forms  pruritus  is  a  most  distressing  symptom. 
There  is  a  curious  preicteric  itching,  which  Eiessman  thinks  is  suggestive  of 
cancer,  but  I  have  seen  it  most  marked  in  gall-stone  cases.  Sweating  is  com- 
mon, and  may  be  curiously  localized  to  the  abdomen  or  to  the  palms  of  the 
hands.  Lichen,  urticaria,  and  boils  may  occur.  Xanthoma  multiplex  is  rare. 
Only  two  cases  have  occurred  under  my  observation.  Usually  in  the  flat  form, 
rarely  nodular,  they  are  most  common  in  the  eyelids  and  on  the  hands  and 
feet.  They  may  be  very  numerous  over  the  whole  body.  Occasionally  the 
tumors  are  found  in  the  bile  duct.  After  persisting  for  years  they  may  dis- 
appear. In  very  chronic  cases  telangiectases  develop  in  the  skin,  sometimes 
in  large  numbers  over  the  body  and  face,  occasionally  on  the  mucous  mem- 
brane of  the  tongue  and  lips,  forming  patches  of  a  bright  red  color  from 
1  to  2  cm.  in  breadth. 

(3)  The  secretions  are  colored  with  bile-pigment.  The  sweat  tinges  the 
linen;  the  tears  and  saliva  and  milk  are  rarely  stained.  The  expectoration 
is  not  often  tinted  unless  there  is  inflammation,  as  when  pneumonia  coexists 
with  jaundice.  The  urine  may  contain  the  pigment  before  it  is  apparent  in 
the  skin  or  conjunctiva.  The  color  varies  from  light  greenish  yellow  to  a 
deep  black-green.  Gmelin's  test  is  made  by  allowing  five  or  six  drops  of  urine 
and  a  similar  amount  of  common  nitric  acid  to  flow  together  slowly  on  the 
flat  surface  of  a  white  plate.  A  play  of  colors  is  produced — various  shades 
of  green,  yellow,  violet,  and  red.  In  cases  of  jaundice  of  long  standing  or 
great  intensity  the  urine  usually  contains  albumin  and  always  bile-stained 
tube-casts. 

(4)  No  bile  passes  into  the  intestine.  The  stools  therefore  are  of  a  pale 
drab  or  slate-gray  color,  and  usually  very  fetid  and  pasty.  The  "  clay-color  " 
of  the  stools  is  also  in  part  due  to  the  presence  of  undigested  fat  which, 


536  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

according  to  Miiller,  may  be  increased  from  7  to  10  per  cent,  which  is  normal, 
to  55  or  78.5  per  cent.  There  may  be  constipation;  in  many  instances,  owing 
to  decomposition,  there  is  diarrhoea. 

(5)  Slow  pulse.  The  heart's  action  may  fall  to  40,  30,  or  even  to  20  per 
minute.  It  is  particularly  noticeable  in  the  cases  of  catarrhal  and  recent  jaun- 
dice, and  is  not  as  a  rule  an  unfavorable  symptom.  This  bradycardia  has  been 
ascribed  to  the  inhibitory  action  of  the  bile  salts  on  the  cardiac  ganglia.  It 
occurs  only  in  the  early  stages  of  jaundice.  At  this  time  bile  acids  pass  into 
the  blood,  but  are  produced  in  very  small  quantities  when  jaundice  is  estab- 
lished. The  respirations  may  fall  to  10  or  even  to  7  per  minute.  Xanthopsia, 
or  yellow  vision,  may  occur. 

(6)  Hemorrhage.  The  tendency  to  bleeding  in  chronic  icterus  is  a  serious 
feature  in  some  cases.  It  has  been  shown  that  the  blood-coagulation  time  may 
be  much  retarded,  and  instead  of  from  three  minutes  and  a  half  to  four  min- 
utes and  a  half  we  have  found  it  in  some  cases  as  late  as  eleven  or  twelve  min- 
utes. This  is  a  point  which  should  be  taken  account  of  by  surgeons,  inasmuch 
as  incontrollable  hgemorrhage  is  a  well-recognized  accident  in  operating  upon 
patients  with  chronic  obstructive  jaundice.  Purpura,  large  subcutaneous 
extravasations,  more  rarely  haemorrhages  from  the  mucous  membranes,  occur 
in  protracted  jaundice,  and  in  the  more  severe  forms. 

(7)  Cerebral  symptoms.  Irritability,  great  depression  of  spirits,  or  even 
melancholia  may  be  present.  In  any  case  of  persistent  jaundice  special  nerv- 
ous phenomena  may  develop  and  rapidly  prove  fatal — such  as  sudden  coma, 
acute  delirium,  or  con\Tilsions.  Usually  the  patient  has  a  rapid  pulse,  slight 
fever,  and  a  dry  tongue,  and  he  passes  into  the  so-called  "  typhoid  state." 
These  features  are  not  nearly  so  common  in  obstructive  as  in  febrile  jaundice, 
but  they  not  infrequently  terminate  a  chronic  icterus  in  whatever  way  pro- 
duced. The  group  of  symptoms  has  been  termed  cholcemia  or,  on  the  supposi- 
tion that  cholesterin  is  the  poison,  cholestermmia ;  but  its  true  nature  has  not 
yet  been  determined.  In  some  of  the  cases  the  symptoms  may  be  due  to 
uragmia. 

2.  Toxemic  and  Hemolytic  Jaundice. 

The  term  hsematogenous  jaundice  was  formerly  applied  to  this  group  in 
contradistinction  to  the  hepatogenous  jaundice,  associated  with  manifest  ob- 
structive changes  in  the  bile-passages.  The  toxic  jaundice  cases  are  essentially 
obstructive  in  origin,  and  it  is  doubtful  whether  there  are  any  true  non-obstruc- 
tive cases.  The  manner  in  which  the  jaundice  is  produced  in  these  cases  has 
been  experimentally  worked  out  by  Stadelmann  and  Afanassiew.  The  obstruc- 
tion is  due  to  the  extreme  visciditv  of  the  bile  associated  with  a  mild  angio- 
colitis.  The  sequence  of  events  is  as  follows :  Destruction  of  blood  by  hemoly- 
sis; liberation  of  haemoglobin  with  increased  formation  and  excretion  of  bile 
pigments  (polychromia)  ;  increased  viscidity  of  the  bile,  which,  at  the  low  pres- 
sure at  which  the  bile  is  excreted,  .causes  a  temporary  obstruction,  with  reab- 
sorption  of  the  bile  and  jaundice;  finally,  as  the  drug  exhausts  itself,  the  bile 
loses  its  viscid  character,  the  flow  is  re-established,  and  the  jaundice  disappears. 
Stadelmann  found  that  a  similar  explanation  applies  to  other  varieties  of  jaun- 
dice associated  with  increased  blood  destruction.  To  show  that  the  blood  and 
liver  both  play  a  part  in  the  production  of  the  jaundice,  Afanassiew  has  sug- 


DISEASES  OF  THE  LIVER.  537 

gested  the  name  '^  hremoliepatogenoiis  "  jaundice.  Rolleston  refers  to  them 
as  cases  of  "  intrahepatic  "  jaundice.  Hunter  groups  the  causes  as  follows : 
1.  Jaundice  produced  by  the  action  of  poisons,  such  as  toluylendiamin,  phos- 
phorus, arsenic,  snake-venom.  2.  Jaundice  met  with  in  various  specific  fevers 
and  conditions,  such  as  yellow  fever,  malaria  (remittent  and  intermittent), 
pyemia,  relapsing  fever,  typhus,  enteric  fever,  scarlatina.  3.  Jaundice  met 
with  in  various  conditions  of  unknown  but  more  or  less  obscure  infective 
nature,  and  variously  designated  as  epidemic,  infectious,  febrile,  malignant 
jaundice,  icterus  gravis,  Weil's  disease,  acute  yellow  atrophy. 

The  symptoms  are  not  nearly  so  striking  as  in  the  obstructive  variety. 
The  bile  is  present  in  the  stools.  The  skin  has  in  many  cases  only  a  light 
lemon  tint.  The  urine  may  contain  no  bile-pigment,  but  the  urinary  pig- 
ments are  considerably  increased.  In  the  severer  forms,  as  in  acute  yellow 
atrophy,  the  color  may  be  more  in-tense,  but  in  malaria  and  pernicious  angemia 
the  tint  is  usually  light.  The  constitutional  disturbance  may  be  very  pro- 
found, with  high  fever,  delirium,  convulsions,  suppression  of  urine,  black 
vomit,  and  cutaneous  hemorrhages.  In  certain  cases  of  haemolytic  jaundice 
the  fragility  of  the  red  corpuscles  is  greatly  increased  and  they  may  be  smaller 
than  normal  (Widal,  Chautfard)  and  show  granular  degeneration.  This  is 
particularly  the  case  in  the  group  of  congenital  icterus  with  enlarged  spleen. 


3.  Hereditaey  Icterus. 

A  family  form  of  icterus  has  long  been  known.  We  must  recognize,  indeed, 
several  groups.  First,  icterus  neonatorum,  the  remarkable  instance  described 
by  Glaister  (Lancet,  March,  1879),.  in  which  a  woman  had  eight  children,  six 
of  whom  died  of  jaundice  shortly  after  birth;  one  of  the  cases  had  stenosis  of 
the  common  duct,  which,  as  Jolm  Thomson  has  shown,  is,  with  angiocholitis, 
a  common  lesion  in  this  affection.  Still  more  remarkable  is  it  that  the  mother 
of  the  woman  had  twelve  children,  all  of  whom  were  icteric  after  birth,  but 
the  jaundice  gradually  disappeared.  A  brother  of  the  woman  had  several  chil- 
dren who  also  were  jaundiced  at  birth.  Glaister  states  that  all  of  the  children 
of  Morgagni,  fifteen  in  number,  had  icterus  neonatorum.  Secondly,  the  con- 
genital acholuric  icterus.  Minkowski  reported  eight  cases  in  three  genera- 
tions. The  jaundice  is  slight,  the  stools  are  not  clay  colored,  the  urine  has  no 
bile  pigment  but  contains  urobilin,  the  general  health  is  little  if  at  all  dis- 
turbed. Splenic  enlargement  is  a  marked  feature.  Many  cases  have  now  been 
reported  of  this  Minkowski  type,  nearly  all  in  family  groups,  but  Chauffard 
has  met  with  a  case  without  hereditary  basis  and  I  have  seen  at  least  one  case 
of  the  kind.  In  the  only  autopsy  so  far  reported  no  special  changes  were 
found  in  the  liver  or  bile  passages.  Thirdly,  a  group  of  cases  with  enlarge- 
ment of  the  spleen  and  liver  and  marked  constitutional  disturbances,  dwarfing 
of  stature,  infantilism,  slight  jaundice,  cases  which  have  been  described  as 
Hanot's  cirrhosis,  have  occurred  in  two  or  three  members  of  a  family,  and  the 
jaundice  has  dated  from  early  childhood. 

In  connection  with  the  various  fevers,  malaria,  yellow  fever,  and  Weil's 
disease  jaundice  has  been  described.    Two  special  affections  may  here  receive 
consideration,  the  icterus  of  the  new-born  and  acute  yellow  atrophy. 
36 


538  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


II.     ICTERUS    NEONATORUM. 

Xew-born  infants  are  liable  to  jaundice^  which  in  some  instances  rapidly 
proves  fatal.     A  mild  and  a  severe  form  may  be  recognized. 

The  mild  or  physiological  icterus  of  the  new-born  is  a  common  disease 
in  foundling  hospitals,  and  is  not  very  infrequent  in  private  practice.  In  900 
consecutive  births  at  the  Sloane  Maternity,  icterus  was  noted  in  300  cases 
(Holt).  The  discoloration  appears  early,  usually  on  the  first  or  second  day, 
and  is  of  moderate  intensity.  The  urine  may  be  bile-stained  and  the  faeces 
colorless.  The  nutrition  of  the  child  is  not  usually  distijrbed,  and  in  the 
majority  of  cases  the  jaundice  disappears  within  two  weeks.  This  form  is 
never  fatal.  The  cause  of  this  jaundice  is  not  at  all  clear.  Some  have  attrib- 
uted it  to  stasis  in  the  smaller  bile-ducts,  jvhich  are  compressed  by  the  dis- 
tended radicals  of  the  portal  vein.  Others  hold  that  the  jaundice  is  due  to 
the  destruction  of  a  large  number  of  red  blood-corpuscles  during  the  first 
few  days  after  birth. 

The  severe  form  of  icterus  in  the  new-born  may  dejDend  upon  (a)  con- 
genital absence  of  the  common  or  hepatic  duct,  of  which  there  are  several 
instances  on  record;  (&)  congenital  s}"philitic  hepatitis;  and  (c)  septic  poi- 
soning, associated  with  phlebitis  of  the  umbilical  vein.  This  is  a  severe  and 
fatal  form,  in  which  also  hemorrhage  from  the  cord  may  occur. 

Curiously  enough,  in  contradistinction  to  other  forms,  the  brain  and  cord 
may  be  stained  yellow  in  icterus  neonatorum,  sometimes  diffusely,  more  rarely 
in  definite  foci  corresponding  to  the  ganglion  cells  which  have  become  deeply 
stained  (Schmorl). 

III.     ACUTE    YELLOW    ATROPHY. 

(Malignant  Jaundice;  Icterus  Gravis.) 

Definition. — Jaundice  associated  with  marked  cerebral  symptoms  and  char- 
acterized anatomically  b}^  extensive  necrosis  of  the  liver-cells  with  reduction 
in  volume  of  the  organ. 

Etiology. — This  is  a  rare  disease.  The  first  authentic  description  of  a 
case  was  by  Ballonius,  who  died  in  1616.  Bright  in  1836  described  the  con- 
dition, and  gave  a  good  colored  drawing  of  the  liver.  Of  18,000  medical 
patients  admitted  to  the  Johns  Hopkins  Hospital  in  nearly  sixteen  years 
there  were  only  2  cases,  one  white  and  one  colored.  Hunter  has  collected  only 
50  cases  between  1880  and  1891:  (inclusive),  which  brings  up  the  total  number 
of  recorded  cases  to  about  250.  On  the  other  hand,  a  physician  may  see  sev- 
eral cases  within  a  few  years,  or  even  within  a  few  months,  as  happened  to 
Eeiss,  who  saw  five  cases  within  three  months  at  the  Charite,  in  Berlin.  The 
disease  seems  to  be  rare  in  the  United  States.  It  is  more  common  in  women 
than  in  men.  Of  the  100  cases  collected  by  Legg,  69  were  in  females ;  and  of 
Thierfelder's  143  cases,  88  were  in  women.  There  is  a  remarkable  associa- 
tion between  the  disease  and  pregnancy,  which  was  present  in  25  of  the  69 
women  in  Legg's  statistics,  and  in  33  of  the  88  women  in  Thierfelder's  collec- 
tion. This  fact  probably  explains  its  prevalence  in  women.  It  is  most  com- 
mon between  the  ages  of  twenty  and  thirty,  but  has  been  met  with  as  early  as 


DISEASES  OF  THE  LIVER.  539 

the  fourth  da}^  and  the  tenth  month.  Rolleston  has  collected  22  cases  occurring 
in  the  first  decade.  It  has  followed  fright  or  profound  mental  emotion.  In 
hypertrophic  cirrhosis  the  symptoms  of  a  profound  icterus  gravis  may  develop, 
with  all  the  clinical  features  of  acute  yellow  atrophy,  including  the  presence 
of  leucin  and  tyrosin  in  the  urine,  and  convulsions.  Though  the  symptoms 
produced  hy  phosphorus  poisoning  closely  simulate  those  of  acute  yellow 
atrophy,  the  two  conditions  are  not  identical.  Acute  yellow  atrophy  occa- 
sionally occurs  in  syphilis.  This  happens  of tener  in  women  than  in  men. 
The  disease  has  followed  a  drinking  bout.  Various  organisms,  most  fre- 
quently the  colon  bacillus,  have  been  found  in  the  liver,  but  possess  no  causal 
relationship  to  the  disease. 

Morbid  Anatomy. — The  liver  is  greatly  reduced  in  size,  looks  thin  and 
flattened,  and  sometimes  does  not  reach  more  than  one-half  or  even  one-third 
of  its  normal  weight.  It  is  flabby  and  the  capsule  is  wrinkled.  Externally 
the  organ  has  a  greenish-yellow  color.  On  section  the  color  may  be  yellowish- 
brown,  yellowish-red,  or  mottled,  and  the  outlines  of  the  lobules  are  indistinct. 
The  yellow  and  dark-red  portions  represent  different  stages  of  the  same 
process — the  yellow  an  earlier,  the  red  a  more  advanced  stage.  The  organ 
may  cut  with  considerable  firmness.  Microscopically  the  liver-cells  are  seen 
in  all  stages  of  necrosis,  and  in  spots  appear  to  have  undergone  complete 
destruction,  leaving  a  fatty,  granular  debris  with  pigment  grains  and  crystals 
of  leucin  and  tyrosin.  Haemorrhages  occur  between  the  liver-cells.  There  is 
a  cholangitis  of  the  smaller  bile-ducts.  Marchand,  MacCallum,  and  others  have 
described  regenerative  changes  in  the  cases  which  do  not  run  an  acute  course. 
Eegeneration  occurs  in  two  ways :  ( 1 )  From  hyperplasia  of  pre-existing 
liver-cells.  Mitotic  figures  may  be  seen  and  the  regeneration  of  the  liver- 
cells  leads  to  the  production  of  hyperplastic  or  "  oedematous  "  nodules  in  the 
liver,  which  project  above  the  surface  of  the  surrounding  parts.  (2)  From 
hyperplasia  of  the  interlobular  bile-ducts  by  means  of  which  cells  approaching 
liver-cells  are  produced.  The  bile- ducts  and  gall-bladder  are  empty.  Hunter 
concludes  that  it  is  a  toxgemic  catarrh  of  the  finer  bile-ducts,  similar  to  that 
which  is  found  after  poisoning  by  toluylendiamin  or  phosphorus. 

The  other  organs  show  extensive  bile-staining,  and  there  are  numerous 
hsemorrhages.  The  kidneys  may  show  marked  granular  degeneration  of  the 
epithelium,  and  usuall}''  there  is  fatty  degeneration  of  the  heart.  In  a  major- 
ity of  the  cases  the  spleen  is  enlarged. 

Symptoms. — In  the  initial  stage  there  is  a  gastro-duodenal  catarrh,  and 
at  first  the  jaundice  is  thought  to  be  of  a  simple  nature.  In  some  instances 
this  lasts  only  a  few  days,  in  others  two  or  three  weeks.  Then,  severe  symp- 
toms set  in — ^headache,  delirium,  trembling  of  the  muscles,  and,  in  some 
instances,  convulsions.  Vomiting  is  a  constant  symptom,  and  blood  may  be 
brought  up.  Haemorrhages  occur  into  the  skin  or  from  the  mucous  surfaces ; 
in  pregnant  women  abortion  may  occur.  With  the  development  of  the  head 
symptoms  the  jaundice  usually  increases.  Coma  sets  in  and  gradually  deepens 
until  death.  The  body  temperature  is  variable ;  in  a  majority  of  the  cases  the 
disease  runs  an  afebrile  course,  though  sometimes  just  before  death  there  is 
an  elevation.  In  some  instances,  however,  there  has  been  marked  pyrexia. 
The  pulse  is  usually  rapid,  the  tongue  coated  and  dry,  and  the  patient  is  in 
3,  "  typhoid  state."     There  may  be  an  entire  obliteration  of  the  liver  dulness. 


540  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

This  is  due  to  the  flabb}^  organ  falling  away  from  the  abdominal  walls  and 
allowing  the  intestinal  coils  to  take  its  place. 

The  urine  is  bile-stained  and  often  contains  tube-casts.  Frequently  albu- 
minuria and  occasionally  albumosuria  occur.  Urea  is  markedly  diminished. 
There  is  a  corresponding  increase  in  the  percentage  of  nitrogen  present  as 
ammonia.  Herter  finds  it  may  be  increased  from  the  normal  2  to  5  per  cent 
up  to  17  per  cent.  The  diminution  in  urea  is  probably  partly  due  to  the  liver- 
cells  failing  to  manufacture  urea  from  ammonia,  but  it  may  also  be  in  part 
due  to  organic  acids  seizing  on  the  ammonia,  and  thus  preventing  the  forma- 
tion of  urea  out  of  the  basic  ammonia.  Leucin  and  tyrosin  are  not  constantly 
present;  of  23  cases  collected  by  Hunter,  in  9  neither  was  found;  in  10  both 
were  present ;  in  3  tyrosin  only ;  in  1  leucin  only.  The  leucin  occurs  as  rounded 
disks,  the  tyrosin  in  needle-shaped  crystals,  arranged  either  in  bundles  or  in 
groups.  The  tyrosin  may  sometimes  be  seen  in  the  urine  sediment,  but  it  is 
best  first  to  evaporate  a  few  drops  of  urine  on  a  cover-glass.  The  present  view 
is  that  the  leucin  and  tyrosin  are  derived  from  the  liver-cells  themselves  as  a 
result  of  their  extensive  destruction.  In  the  majority  of  cases  no  bile  enters 
the  intestines,  and  the  stools  are  clay-colored.  The  disease  is  almost  invariably 
fatal.  In  a  few  instances  recovery  has  been  noted.  I  saw  in  Leube's  clinic, 
at  Wiirzburg,  a  case  which  was  convalescent.  In  1897  Legg  gave  a  list  of  28 
cases  of  reputed  recoveries. 

Diagnosis. — Jaundice  with  vomiting,  diminution  of  the  liver  volume,  de- 
lirium, and  the  presence  of  leucin  and  tyrosin  in  the  urine,  form  a  character- 
istic and  unmistakable  group  of  symptoms.  Leucin  and  tyrosin  are  not, 
however,  distinctive.  They  may  be  present  in  cases  of  afebrile  jaundice  with 
slight  enlargement  of  the  liver. 

It  is  not  to  be  forgotten  that  any  severe  jaundice  may  be  associated  with 
intense  cerebral  symptoms.  The  clinical  features  in  certain  cases  of  hyper- 
trophic cirrhosis  are  almost  identical,  but  the  enlargement  of  the  liver,  the 
more  constant  occurrence  of  fever,  and  the  absence  of  leucin  and  tyrosin  are 
distinguishing  signs.  Phosphorus  poisoning  may  closely  simulate  acute  yellow 
atrophy,  particularly  in  the  heemorrhages,  jaundice,  and  the  diminution  in  the 
liver  volume,  but  the  gastric  symptoms  are  usually  more  marked,  and  leucin 
and  tyrosin  are  stated  not  to  occur  in  the  urine. 

Treatment. — No  known  remedies  liave  any  infiuence  on  the  course  of  the 
disease.  Theoretically,  efforts  should  be  made  to  eliminate  the  toxins  before 
they  produce  their  degenerative  effects  by  free  purgation  and  the  use  of  sub- 
cutaneous and  intravenous  saline  injections.  Gastric  sedatives  may  be  used 
to  allay  the  distressing  vomiting. 

IV.    AFFECTIONS    OF    THE    BLOOD-VESSELS    OF    THE 

LIVER. 

(1)  Anaemia. — On  the  post-mortem  table,  when  the  liver  looks  anaemic, 
as  in  the  fatty  or  amyloid  organ,  the  blood-vessels,  which  during  life  were  prob- 
ably well  filled,  can  be  readily  injected.  There  are  no  symptoms  indicative  of 
this  condition. 

(2)  Hyperaemia. — This  occurs  in  two  forms,  (a)  Active  hyperemia. 
After  each  meal  the  rapid  absorption  by  the  portal  vessels  induces  transient 


DISEASES  OF  THE  LIVER.  541 

congestion  of  the  organ,  which,  however,  is  entirely  physiological';  but  it  is 
quite  possible  that  in  persons  who  persistently  eat  and  drink  too  much  this 
active  hypersemia  may  lead  to  functional  disturbance  or,  in  the  case  of  drink- 
ing too  freely  of  alcohol,  to  organic  change.  In  the  acute  fevers  an  acute 
hypersemia  may  be  present. 

The  symptoms  of  active  hyperaemia  are  indefinite.  Possibly  the  sense 
of  distress  or  fulness  in  the  right  hypochondrium,  so  often  mentioned  by 
dyspeptics  and  by  those  who  eat  and  drink  freely,  may  be  due  to  this  cause. 
There  are  probably  diurnal  variations  in  the  volume  of  the  liver.  In  cir- 
rhosis with  enlargement  the  rapid  reduction  in  volume  after  a  copious  haem- 
orrhage indicates  the  important  part  which  hypersemia  plays  even  in  organic 
troubles.  It  is  stated  that  suppression  of  the  menses  or  suppression  of  a 
hasmorrhoidal  flow  is  followed  by  hypersemia  of  the  liver.  Andrew  H.  Smith 
has  described  a  case  of  periodical  enlargement  of  the  liver. 

(&)  Passive  Congestion. — This  is  much  more  common  and  results  from 
an  increase  of  pressure  in  the  efferent  vessels  or  sub-lobular  branches  of  the 
hepatic  veins.  Every  condition  leading  to  venous  stasis  in  the  right  heart 
at  once  affects  these  veins. 

In  chronic  valvular  disease,  in  emphysema,  cirrhosis  of  the  lung,  and  in 
intrathoracic  tumors  mechanical  congestion  occurs  and  finally  leads  to  very 
definite  changes.  The  liver  is  enlarged,  firm,  and  of  a  deep-red  color;  the 
hepatic  vessels  are  greatly  engorged,  particularly  the  central  vein  in  each  lob- 
ule and  its  adjacent  capillaries.  On  section  the  organ  presents  a  peculiar 
mottled  appearance,  owing  to  the  deeply  congested  hepatic  and  the  ansemic 
portal  territories ;  hence  the  term  nutmeg  which  has  been  given  to  this  condi- 
tion. Gradually  the  distention  of  the  central  capillaries  reaches  such  a  grade 
that  atrophy  of  the  intervening  liver-cells  is  induced.  Brown  pigment  is 
deposited  about  the  centre  of  the  lobules  and  the  connective  tissue  is  greatly 
increased.  In  this  cyanotic  induration  or  cardiac  liver  the  organ  is  large  in 
the  early  stage,  but  later  it  may  become  contracted.  Occasionally  in  this  form 
the  connective  tissue  is  increased  about  the  lobules  as  well,  but  the  process 
usually  extends  from  the  sub-lobular  and  central  veins. 

The  symptoms  of  this  form  are  not  always  to  be  separated  from  those 
of  the  associated  conditions,  Gastro-intestinal  catarrh  is  usually  priesent  and 
hsematemesis  may  occur.  The  portal  obstruction  in  advanced  cases  leads  to 
ascites,  which  may  precede  the  development  of  general  dropsy.  There  is  often 
slight  jaundice,  the  stools  may  be  clay-colored,  and  the  urine  contains  bile- 
pigment. 

On  examination  the  organ  is  found  to  be  increased  in  size.  It  may  be  a 
full  hand's  breadth  below  the  costal  margin  and  tender  on  pressure.  It  is  in 
this  condition  particularly  that  we  meet  with  pulsation  of  the  liver.  We  must 
distinguish  the  communicated  throbbing  of  the  heart,  which  is  very  common, 
from  the  heaving,  diffuse  impulse  due  to  regurgitation  into  the  hepatic  veins, 
in  which,  when  one  hand  is  upon  the  ensiform  cartilage  and  the  other  upon 
the  right  side  at  the  margin  of  the  ribs,  the  whole  liver  can  be  felt  to  dilate 
with  each  impulse. 

The  indications  for  treatment  in  passive  hyperemia  are  to  restore  the 
balance  of  the  circulation  and  to  unload  the  engorged  portal  vessels.  In  cases 
of  intense  hyperaemia  18  or  20  ounces  of  blood  may  be  directly  aspirated  from 


542  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

the  liver,  as  advised  hy  George  Harley  and  practised  by  many  Anglo-Indian 
physicians.  Good  results  sometimes  follow  this  hepato-phlebotomy.  The 
prompt  relief  and  marked  reduction  in  the  volume  of  the  organ  which  follow 
an  attack  of  hsematemesis  or  bleeding  from  piles  suggests  this  practice.  Salts 
administered  by  Matthew  Hay's  method  deplete  the  portal  system  freely  and 
thoroughly.  As  a  rule,  the  treatment  must  be  that  of  the  condition  with  which 
it  is  associated. 

(3)  Diseases  of  the  Portal  Vein. —  (a)  Thrombosis';  Adhesive  Pyle- 
phlebitis.— Coagulation  of  blood  in  the  portal  vein  is  met  with  in  cirrhosis, 
in  syphilis  of  the  liver,  invasion  of  the  vein  by  cancer,  proliferative  perito- 
nitis involving  the  gastro-hepatic  omentum,  perforation  of  the  vein  by  gall- 
stones, and  occasionally  follows  sclerosis  of  the  walls  of  the  portal  vein  or 
of  its  branches  (Borrmann).  In  rare  instances  a  complete  collateral  circula- 
tion is  established,  the  thrombus  undergoes  the  usual  changes,  and  ultimately 
the  vein  is  represented  by  a  fibrous  cord,  a  condition  which  has  been  called 
pyleplileiitis  adliesiva.  In  a  case  of  this  kind  which  I  dissected  the  portal  vein 
was  represented  by  a  narrow  fibrous  cord ;  the  collateral  circulation,  which  must 
have  been  completely  established  for  years,  ultimately  failed,  ascites  and 
hgematemesis  supervened  and  rapidly  proved  fatal.  The  diagnosis  of  obstruc- 
tion of  the  portal  vein  can  rarely  be  made.  A  suggestive  symptom,  however, 
is  a  sudden  onset  of  the  most  intense  engorgement  of  the  branches  of  the 
portal  system,  leading  to  ha?matemesis,  melaena,  ascites,  and  swelling  of  the 
spleen. 

Infarcts  are  not  common  in  the  liver  and  may  be  either  anaemic  or  hsemor- 
rhagic.  They  are  met  with  in  obstruction  of  the  portal  vessels,  or  of  the  portal 
and  hepatic  veins  at  the  same  time,  occasionally  in  disease  of  the  hepatic  artery. 

(&)  Suppurative  pylephlebitis  will  be  considered  in  the  section  on 
abscess. 

(4)  Affections  of  the  hepatic  vein  are  extremely  rare.  Dilatation  occurs 
in  cases  of  chronic  enlargement  of  the  right  heart,  from  whatever  cause  pro- 
duced. Emboli  occasionally  pass  from  the  right  auricle  into  the  hepatic  veins. 
A  rare  and  unusual  event  is  stenosis  of  the  orifices  of  the  hepatic  veins,  which 
I  met  in  a  case  of  fibroid  obliteration  of  the  inferior  vena  cava  and  wliich  was 
associated  with  a  greatly  enlarged  and  indurated  liver. 

(5)  Hepatic  Artery. — Enlargement  of  this  vessel  is  seen  in  cases  of  cir- 
rhosis of  the  liver.  It  may  be  the  seat  of  extensive  sclerosis.  Aneurism  of 
the  hepatic  artery  is  rare,  but  instances  are  on  record,  and  will  be  referred 
to  in  the  section  on  arteries. 

V.    DISEASES    OF    THE   BILE-PASSAGES    AND 
GALL-BLADDER. 

I.  Acute  Catarrh  of  the  Bile-ducts  {Catarrhal  Jaundice). 

Definition. — Jaundice  due  to  swelling  and  obstruction  of  the  terminal  por- 
tion of  the  common  duct. 

Etiology. — General  catarrhal  inflammation  of  the  bile-ducts  is  usually  asso- 
ciated with  gall-stones.  The  catarrhal  process  now  under  consideration  is 
probably  always  an  extension  of  a  gastro-duodenal  catarrh,  and  the  process  is 


DISEASES  OF  THE  LIVER.  543 

most  intense  in  the  pars  intestinalis  of  the  duct,  which  projects  into  the  duo- 
denum. The  mucous  membrane  is  swollen,  and  a  plug  of  inspissated  mucus 
fills  the  diverticulum  of  Vater,  and  the  narrower  portion  just  at  the  orifice, 
completely  obstructing  the  outflow  of  bile.  It  is  not  known  how  wide-spread 
this  catarrh  is  in  the  bile-passages,  and  whether  it  really  passes  up  the  ducts. 
It  would,  of  course,  be  possible  to  have  a  catarrh  of  the  finer  ducts  within  the 
liver,  which  some  French  writers  think  may  initiate  the  attack,  but  the  evi- 
dence for  this  is  not  strong,  and  it  seems  more  likely  that  the  terminal  por- 
tion of  the  duct  is  always  first  involved.  In  the  only  instance  which  I  have 
had  an  opportunity  to  examine  post  mortem  the  orifice  was  plugged  with  in- 
spissated mucus,  the  common  and  hepatic  ducts  were  slightly  distended  and 
contained  a  bile-tinged,  not  a  clear,  mucus,  and  there  were  no  observable 
changes  in  the  mucosa  of  the  ducts. 

This  catarrhal  or  simple  jaundice  results  from  the  following  causes: 
(1)  Duodenal  catarrh,  in  whatever  way  produced,  most  commonly  following 
an  attack  of  indigestion.  It  is  most  frequently  met  with  in  young  persons, 
but  may  occur  at  any  age,  and  may  follow  not  only  errors  in  diet,  but  also 
cold,  exposure,  and  malaria,  as  well  as  the  conditions  associated  with  portal 
obstruction,  chronic  heart-disease,  and  Bright's  disease.  (2)  Emotional  dis- 
turbances may  be  followed  by  jaundice,  which  is  believed  to  be  due  to  catar- 
rhal swelling.  Cases  of  this  kind  are  rare  and  the  anatomical  condition  is 
unknown.  (3)  Simple  or  catarrhal  jaundice  may  occur  in  epidemic  form. 
(4)  Catarrhal  jaundice  is  occasionally  seen  in  the  infectious  fevers,  such  as 
pneumonia,  and  typhoid  fever.  The  nature  of  acute  catarrhal  jaundice  is 
still  unknown.  It  may  possibly  be  an  acute  infection.  In  favor  of  this 
view  are  the  occurrence  in  epidemic  form  and  the  presence  of  slight  fever. 
The  spleen,  however,  is  not  often  enlarged.  In  only  4  out  of  23  cases  was  it 
palpable. 

Symptoms. — There  may  be  neither  pain  nor  distress,  and  the  patient's 
friends  may  first  notice  the  yellow  tint,  or  the  patient  himself  may  observe  it 
in  the  looking-glass.  In  other  instances  there  are  dyspeptic  symptoms  and 
uneasy  sensations  in  the  hepatic  region  or  pains  in  the  back  and  limbs.  In  the 
epidemic  form,  the  onset  may  be  more  severe,  with  headache,  chill,  and  vom- 
iting. Fever  is  rarely  present,  though  the  temperature  may  reach  101°,  some- 
times 102°.  All  the  signs  of  obstructive  jaundice  already  mentioned  are  pres- 
ent, the  stools  are  clay-colored,  and  the  urine  contains  bile-pigment.  The  skin 
has  a  bright-yellow  tint ;  the  greenish,  bronzed  color  is  never  seen  in  the  simple 
form.  I  have  once  seen  spider  angiomata  on  the  face  in  catarrhal  jaundice. 
They  disappeared  in  a  few  months.  The  pulse  may  be  normal,  but  occasion- 
ally it  is  remarkably  slow,  and  may  fall  to  40  or  30  beats  in  the  minute,  and 
the  respirations  to  as  low  as  8  per  minute.  Sleepiness,  too,  may  be  present. 
The  liver  may  be  normal  in  size,  but  is  usually  slightly  enlarged,  and  the  edge 
can  be  felt  below  the  costal  margin.  Occasionally  the  enlargement  is  more 
marked.  As  a  rule  the  gall-bladder  can  not  be  felt.  The  spleen  may  be  in- 
creased in  size.  The  duration  of  the  disease  is  from  four  to  eight  weeks. 
There  are  mild  cases  in  which  the  jaundice  disappears  within  two  weeks;  on 
the  other  hand,  it  may  persist  for  three  months  or  even  longer.  The  stools 
should  be  carefully  watched,  for  they  give  the  first  intimation  of  removal  of 
the  obstruction. 


544  DISEASES  OF   THE  DIGESTIVE  SYSTEM. 

Diagnosis. — The  diagnosis  is  rarely  difficult.  The  onset  in  young,  com- 
jDaratively  healthy  persons,  the  moderate  grade  of  icterus,  the  absence  of  ema- 
ciation or  of  evidences  of  cirrhosis  or  cancer,  usually  make  the  diagnosis  easy. 
Cases  which  persist  for  two  or  three  months  cause  uneasiness,  as  the  suspicion 
is  aroused  that  it  may  be  more  than  simple  catarrh.  The  absence  of  pain,  the 
negative  character  of  the  physical  examination,  and  the  maintenance  of  the 
general  nutrition  are  the  points  in  favor  of  simple  jaundice.  There  are 
instances  in  which  time  alone  can  determine  the  true  nature  of  the  case.  The 
possibility  of  Weil's  disease  must  be  borne  in  mind  in  anomalous  tj'pes. 

Treatment. — As  a  rule  the  patient  can  keep  on  his  feet  from  the  outset. 
Measures  should  be  used  to  allay  the  gastric  catarrh,  if  it  is  present.  A  dose 
of  calomel  may  be  given,  and  the  bowels  kept  open  subsequently  by  salines. 
The  patient  should  not  be  violently  purged.  Bismuth  and  bicarbonate  of  soda 
may  be  given,  and  the  patient  should  drink  freely  of  the  alkaline  mineral 
waters,  of  which  Yichy  is  the  best.  Irrigation  of  the  large  bowel  with  cold 
water  may  be  practised.  The  cold  is  supposed  to  excite  peristalsis  of  the  gall- 
bladder and  ducts,  and  thus  aid  in  the  expulsion  of  the  mucus. 

II.  Cheoxic  Cataeehal  Axgiocholitis. 

This  may  possibly  occur  also  as  a  sequel  of  the  acute  catarrh.  I  have  never 
met  with  an  instance,  however,  in  which  a  chronic,  persistent  jaundice  could 
be  attributed  to  this  cause.  A  chronic  catarrh  always  accompanies  obstruc- 
tion in  the  common  duct,  whether  by  gall-stones,  malignant  disease,  stricture, 
or  external  pressure.     There  are  two  groups  of  cases : 

(1)  With  Complete  Obsteuctiox  of  the  Commox  Duct. — In  this  form 
the  bile-passages  are  greatly  dilated,  the  common  duct  may  reach  the  size  of 
the  thumb  or  larger,  there  is  usually  dilatation  of  the  gall-bladder  and  of  the 
ducts  within  the  liver.  The  contents  of  the  ducts  and  of  the  gaU-bladder  are 
a  clear,  colorless  mucus.  The  mucosa  may  be  everywhere  smooth  and  not 
swollen.  The  clear  mucus  is  usually  sterile.  The  patients  are  the  subjects 
of  chronic  jaundice,  usually  without  fever. 

( 2  )  With  Incomplete  Obstbuctiox  of  the  Duct. — There  is  pressure 
on  the  duct  or  there  are  gall-stones,  single  or  multiple,  in  the  common  duct  or 
in  the  diverticulum  of  Yater.  The  bile-passages  are  not  so  much  dilated,  and 
the  contents  are  a  bile-stained,  turbid  mucus.  The  gall-bladder  is  rarely  much 
dilated.     In  a  majority'  of  all  cases  stones  are  found  in  it. 

The  symptoms  of  this  type  of  catarrhal  angiocholitis  are  sometimes  very 
distinctive.  With  it  is  associated  most  frequently  the  so-called  hepatic  inter- 
mittent fever,  recurring  attacks  of  chills,  fever,  and  sweats.  We  need  still 
further  information  about  the  bacteriology  of  these  cases.  In  aU  probability 
the  febrile  attacks  are  due  distinctly  to  infection.  I  can  not  too  strongly  em- 
phasize the  point  that  the  recmriug  attacks  of  intermittent  fever  do  not  neces- 
sarily mean  suppurative  angiocholitis.  The  question  will  be  referred  to  again 
under  gall-stones. 

III.  Suppurative  axd  Ulcerative  Angiocholitis. 

The  condition  is  a  diffuse,  purulent  angiocholitis  involving  the  larger  and 
smaller  ducts.  In  a. large  proportion  of  all  cases  there  is  associated  suppura- 
tive disease  of  the  gall-bladder. 


DISEASES  OF  THE  LIVER.  545 

Etiology. — It  is  the  most  serious  of  the  sequels  of  gall-stones.  Occa- 
sionally a  diffuse  suppurative  angiocholitis  follows  the  acute  infectious  chole- 
cystitis; this,  however,  is  rare,  since  fortunately  in  the  latter  condition  the 
cystic  duct  is  usually  occluded.  Cancer  of  the  duct,  foreign  bodies,  such  as 
lumbricoids  or  fish  bones,  are  occasional  causes.  There  may  be  extension  from 
a  suppurative  pylephlebitis.  In  rare  instances  suppurative  cholangitis  occurs 
in  the  acute  infections,  as  pneumonia  and  influenza. 

The  common  duct  is  greatly  dilated  and  may  reach  the  size  of  the  index 
finger  or  the  thumb ;  the  walls  are  thickened,  and  there  may  be  fistulous  com- 
munications with  the  stomach,  colon,  or  duodenum.  The  hepatic  ducts  and 
their  extensions  in  the  liver  are  dilated  and  contain  pus  mixed  with  bile.  On 
section  of  the  liver  small  abscesses  are  seen,  which  correspond  to  the  dilated 
suppurating  ducts.  The  gall-bladder  is  usually  distended,  full  of  pus,  and 
with  adhesions  to  the  neighboring  parts,  or  it  may  have  perforated. 

Symptoms. — The  symptoms  of  suppurative  cholangitis  are  usually  very 
severe.  A  previous  history  of  gall-stones,  the  development  of  a  septic  fever,  the 
swelling  and  tenderness  of  the  liver,  the  enlargement  of  the  gall-bladder,  and 
the  leucocytosis  are  suggestive  features.  Jaundice  is  always  present,  but  is 
variable.  In  some  cases  it  is. very  intense,  in  others  it  is  slight.  There  may 
be  very  little  pain.  There  is  progressive  emaciation  and  loss  of  strength.  In 
a  recent  case  parotitis  developed  on  the  left  side,  which  subsided  without  sup- 
puration. 

Ulceration,  stricture,  perforation,  and  fistulse  of  the  bile-passages  will  be 
considered  with  gall-stones. 

IV.  Acute  Infectious  Cholecystitis. 

Etiology. — Acute  inflammation  of  the  gall-bladder  is  usually  due  to  bac- 
terial invasion,  with  or  without  the  presence  of  gall-stones.  Three  varieties  or 
grades  may  be  recognized:  The  catarrhal,  the  suppurative,  and  the  phlegmo- 
nous. The  condition  is  very  serious,  difficult  to  diagnose,  often  fatal,  and  may 
require  for  its  relief  prompt  surgical  intervention.  The  cases  associated  with 
gall-stones  have  of  course  long  been  recognized,  but  we  now  know  that  an 
acute  infection  of  the  gall-bladder  leading  to  suppuration,  gangrene,  or  per- 
foration is  by  no  means  infrequent. 

Acute  non-calculous  cholecystitis  is  a  result  of  bacterial  invasion.  The 
colon  bacillus,  the  typhoid  bacillus,  the  pneumococcus  and  staphylococci  and 
streptococci  have  been  the  organisms  most  often  found.  The  frequency  of 
gall-bladder  infection  in  the  fevers  is  a  point  already  referred  to,  particularly 
in  typhoid  fever. 

Condition  of  the  Gall-bladder. — The  organ  is  usually  distended  and  the 
walls  tense.  Adhesions  may  have  formed  with  the  colon  or  the  omentum.  In 
other  instances  perforation  has  taken  place  and  there  is  a  localized  abscess, 
or  in  the  more  fulminant  forms  general  peritonitis.  The  contents  of  the 
organ  are  usually  dark  in  color,  muco-purulent,  purulent,  or  hemorrhagic. 
In  the  cases  with  acute  phlegmonous  inflammation  there  may  be  a  very  foul 
odor.  As  Eichardson  remarks,  the  cystic  duct  is  often  found  closed  even  when 
no  stone,  is  impacted.  It  should  be  borne  in  mind  that  in  the  acutely  dis- 
tended gall-bladder  the  elongation  and  enlargement  may  take  place  chiefly 
upward  and  inward,  toward  the  foramen  of  Winslow. 


546  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

Symptoms. — Severe  paroxysmal  pain  is,  as  a  rule,  the  first  indication,  most 
commonly  in  the  right  side  of  the  abdomen  in  the  region  of  the  liver.  It 
may  be  in  the  epigastrium  or  low  down  in  the  region  of  the  appendix. 
"  Xausea,  vomiting,  rise  of  pulse  and  temperature,  prostration,  distention  of 
the  abdomen,  rigidity,  general  tenderness  becoming  localized"  usually  follow 
(Eichardson) .  In  this  form,  without  gall-stones,  jaundice  is  not  often  pres- 
ent. The  local  tenderness  is  extreme,  but  it  may  be  deceptive  in  its  situation. 
Associated  probably  with  the  adhesion  and  inflammatory  processes  between 
the  gall-bladder  and  the  bowel  are  the  intestinal  s}Tnptoms,  and  there  may  be 
complete  stoppage  of  gas  and  fseces;  indeed,  the  operation  for  acute  obstruc- 
tion has  been  performed  in  several  cases.  The  distended  gall-bladder  may 
sometimes  be  felt.    As  sequels  there  may  be  serious  distention  or  empyema. 

Diagnosis. — The  diagnosis  is  by  no  means  easy.  The  s}Taptoms  may  not 
indicate  the  section  of  the  abdomen  involved.  In  two  of  our  cases  and  in  three 
of  Eichardson's  appendicitis  was  diagnosed;  in  two  of  his  cases  acute  intes- 
tinal obstruction  was  suspected.  This  was  the  diagnosis  in  a  case  of  acute 
phlegmonous  cholecystitis  which  I  reported  in  1881.  The  history  of  the  cases 
is  often  a  valuable  guide.  Occurring  during  the  convalescence  from  t}^hoid 
fever,  after  pneumonia,  or  in  a  patient  with  previous  cholecystitis,  such  a 
group  of  symptoms  as  mentioned  would  be  highly  suggestive.  The  differen- 
tiation of  the  variety  of  the  cholecystitis  can  not  be  made.  In  the  acute  sup- 
purative and  phlegmonous  forms  the  s}Tnptoms  are  usually  more  severe,  per- 
foration is  very  apt  to  occur,  with  local  or  general  peritonitis,  and  unless 
operative  measures  are  undertaken  death  ensues. 

There  is  an  acute  cholecystitis,  probably  an  infective  form,  in  which  the 
patient  has  recurring  attacks  of  pain  in  the  region  of  the  gall-bladder.  The 
diagnosis  of  gall-stones  is  made,  but  an  operation  shows  simply  an  enlarged 
gall-bladder  filled  with  mucus  and  bile,  and  the  mucous  membrane  perhaps 
swollen  and  inflamed.  In  some  of  these  cases  gall-stones  may  have  been  pres- 
ent and  have  passed  before  the  operation. 

V.  Caxcee  of  the  Bile-passages. 

Females  suffer  in  the  proportion  of  3  to  1  (Musser),  or  4  to  1  (Ames). 
In  cases  of  primary  cancer  of  the  bile-duct,  on  the  other  hand,  men  and  women 
appear  to  be  about  equally  affected.  In  Musser's  series  65  per  cent  of  the 
cases  occurred  between  the  ages  of  forty  and  seventy.  The  association  of 
malignant  disease  of  the  gall-bladder  with  gall-stones  has  long  been  recog- 
nized. The  fact  is  well  put  by  Kehmack  as  follows :  "  While  gall-stones  are 
found  in  from  6  to  12  per  cent  of  all  general  cases  (that  is,  coming  to  autopsy), 
they  occur  in  association  with  cancer  of  the  gall-bladder  in  from  90  to  100 
per  cent."    In  Futterer's  series  calculi  were  present  in  70  per  cent. 

The  exact  nature  of  the  association  is  not  very  clear,  but  it  is  usually  re- 
garded as  an  effect  of  the  chronic  irritation.  On  the  other  hand,  it  is  urged 
that  the  presence  of  the  malignant  disease  may  itself  favor  the  production  of 
gall-stones.  Histologically.  "  carcinoma  of  the  gall-bladder  varies  much,  both 
in  the  form  of  the  cells  and  in  their  structural  arrangement ;  it  may  be  either 
columnar  or  spheroidal-celled"  (Eolleston).  The  fundus  is  usually  first 
involved  in  the  gall-bladder,  and  in  the  ducts  the  ductus  communis  choledochus. 


DISEASES  OF   THE  LIVER.  547 

When  the  disease  involves  the  gall-Madder,  a  tumor  can  be  detected  ex- 
tending diagonally  downward  and  inward  toward  the  navel,  variable  in  size, 
occasionally  very  large,  due  either  to  great  distention  of  the  gall-bladder  or 
to  involvement  of  contiguous  parts.     It  is  usually  very  firm  and  hard. 

Among  the  important  symptoms  are  jaundice,  which  was  present  in  69 
per  cent  of  Musser's  cases;  pain,  often  of  great  severity  and  paroxysmal  in 
character.  The  pain  and  tenderness  on  pressure  persist  in  the  intervals  be- 
tween the  paroxysmal  attacks.  In  one  of  my  three  cases,  which  Ames  reported, 
there  was  a  very  profound  anaemia,  but  an  absence  of  jaundice  throughout. 
Gall-stones  were  present  in  two  of  the  cases,  and  a  history  of  gall-stone  attacks 
was  obtained  from  the  third.  When  the  liver  becomes  involved  the  picture  is 
that  of  carcinoma  of  the  organ. 

Primary  malignant  disease  in  the  tile-ducts  is  less  common,  and  rarely 
forms  tumors  that  can  be  felt  externally.  The  tumor  is  usually  in  the  com- 
mon duct,  57  of  80  cases  collected  by  Rolleston.  Kelynack  gives  very  fully 
a  number-  of  important  points  in  the  differential  diagnosis  between  tumors 
in  the  duct  and  tumors  in  the  gall-bladder.  There  is  usually  an  early,  intense, 
and  persistent  jaundice.  The  dilated  gall-bladder  may  rupture.  At  best  the 
diagnosis  is  very  doubtful,  unless  cleared  up  by  an  exploratory  operation.  A 
very  interesting  form  of  malignant  disease  of  the  ducts  is  that  which  involves 
the  diverticulum  of  Vater.  Eolleston  has  collected  16  cases.  An  elderly 
woman  was  admitted  under  my  care  with  jaundice  of  some  months'  duration, 
without  pain,  with  progressive  emaciation,  and  a  greatly  enlarged  gall-bladder. 
My  colleague,  Halsted,  operated  and  found  obstruction  at  the  orifice  of  the 
common  duct.  He  opened  the  duodenum,  removed  a  cylindrical-celled  epi- 
thelioma of  the  ampulla  of  Vater,  and  stitched  the  common  duct  to  another 
portion  of  the  duodenum.  The  patient  made  an  uninterrupted  recovery,  and, 
fourteen  weeks  after  the  operation,  had  gained  twenty-five  pounds  in  weight 
and  passed  bile  with  the  faeces.  A  year  later  death  occurred  from  secondary 
disease  of  the  head  of  the  pancreas. 

VI.  Stenosis  and  Obstruction  of  the  Bile-ducts. 

Stenosis. — Stenosis  or  complete  occlusion  may  follow  ulceration,  most  com- 
monly after  the  passage  of  a  gall-stone.  In  these  instances  the  obstruction  is 
usually  situated  low  down  in  the  common  duct.  Instances  are  extremely  rare. 
Foreign  bodies,  such  as  the  seeds  of  various  fruits,  may  enter  the  duct,  and 
occasionally  round  worms  crawl  into  it.  Liver-flukes  and  echinococci  are  rare 
causes  of  obstruction  in  man. 

Obstruction. — Obstruction  by  pressure  from  without  is  more  frequent. 
Cancer  of  the  head  of  the  pancreas,  less  often  a  chronic  interstitial  inflamma- 
tion, may  compress  the  terminal  portion  of  the  duct;  rarely,  cancer  of  the 
pylorus.  Secondary  involvement  of  the  lymph-glands  of  the  liver  is  a  common 
cause  of  occlusion  of  the  duct,  and  is  met  with  in  many  cases  of  cancer  of  the 
stomach  and  other  abdominal  organs.  Rare  causes  of  obstruction  are  aneu- 
rism of  a  branch  of  the  coeliac  axis  of  the  aorta,  and  pressure  of  very  large 
abdominal  tumors. 

Symptoms. — The  symptoms  produced  are  those  of  chronic  obstructive  jaun- 
dice.   At  first,  the  liver  is  usually  enlarged,  but  in  chronic  cases  it  may  be 


548  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

reduced  in  size,  and  be  found  of  a  deepl}^  bronzed  color.  The  hepatic  inter- 
mittent fever  is  not  often  associated  with  complete  occlusion  of  the  duct  from 
any  cause,  but  it  is  most  frequently  met  with  in  chronic  obstruction  by  gall- 
stones. Permanent  occlusion  of  the  duct  terminates  in  death.  In  a  majority 
of  the  cases  the  conditions  which  lead  to  the  obstruction  are  in  themselves  fatal. 
The  liver,  which  is  not  necessarily  enlarged,  presents  a  moderate  grade  of  cir- 
rhosis. Cases  of  cicatricial  occlusion  may  last  for  years.  A  patient  under  my 
care,  who  was  permanently  jaundiced  for  nearly  three  years,  had  a  filiroid 
occlusion  of  the  duct. 

Diagnosis. — The  diagnosis  of  the  nature  of  the  occlusion  is  often  very  diffi- 
cult. A  history  of  colic,  jaundice  of  varying  intensity,  paroxysms  of  pain,  and 
intermittent  fever  points  to  gall-stones.  In  cancerous  obstruction  the  tumor 
mass  can  sometimes  be  felt  in  the  epigastric  region.  In  cases  in  which  the 
lymph-glands  in  the  transverse  fissure  are  cancerous,  the  primary  disease  may 
be  in  the  pelvic  organs  or  the  rectum,  or  there  may  be  a  limited  cancer  of  the 
stomach,  which  has  not  given  any  s}Tnptoms.  In  these  cases  the  examination 
of  the  other  l}Tnphatic  glands  may  be  of  value.  In  a  man  who  came  under 
observation  with  a  jaundice  of  seven  weeks'  duration,  believed  to  be  catarrhal 
(as  the  patient's  general  condition  was  good  and  he  was  not  said  to  have  lost 
flesh),  a  small  nodular  mass  was  detected  at  the  navel,  which  on  removal 
proved  to  be  scirrhus.  Involvement  of  the  clavicular  groups  of  l}Tnph-glands 
may  also  be  serviceable  in  diagnosis.  The  gall-bladder  is  usually  enlarged  in 
obstruction  of  the  common  duct,  except  in  the  cases  of  gall-stones  (Courvoi- 
sier's  law).  Great  and  progressive  enlargement  of  the  liver  with  jaundice 
and  moderate  continued  fever  is  more  commonly  met  with  in  cancer. 

Congenital  obliteration  of  the  ducts  is  an  interesting  condition,  of  which 
there  are  some  60  or  70  cases  on  record.  It  may  occur  in  several  members 
of  one  family.  Spontaneous  haemorrhages  are  frequent,  particularly  from  the 
navel.  The  subjects  may  live  for  three  or  even  eight  weeks.  The  liver  is  usu- 
ally cirrhotic  and  the  spleen  is  enlarged.  Eolleston  suggests  that  the  disease 
is  primarily  a  congenital  cirrhosis  with  consecutive  involvement  of  the  ducts. 
For  a  recent  careful  consideration  of  the  subject,  see  John  Thomson's  article 
in  AUbutt's  System  of  Medicine. 

VI.     CHOLELITHIASIS. 

No  chapter  in  medicine  is  more  interesting  than  that  wMeh  deals  with  the 
question  of  gall-stones.  Few  afEections  present  so  many  points  for  study — 
chemical,  bacteriological,  pathological,  and  clinical.  The  past  few  years  have 
seen  a  great  advance  in  our  knowledge  in  two  directions:  First,  as  to  the  mode 
of  formation  of  the  stones,  and,  secondly,  as  to  the  surgical  treatment  of  the 
cases.  The  recent  study  of  the  origin  of  stones  dates  from  ISTaumTi's  work  in 
1891.  Marion  Sims's  suggestion  that  gall-stones  came  within  the  sphere  of 
the  surgeon  has  been  most  fruitful. 

Origin  of  Gall-stones. — Two  important  points  with  reference  to  the  for- 
mation of  calculi  in  the  bile-passages  were  brought  out  by  Xaumm:  (a)  The 
origin  of  the  cholesterin  of  the  bile,  as  well  as  of  the  lime  salts  from  the  mu- 
cous membrane  of  the  biliary  passages,  particularly  when  inflamed ;  and  ( & ) 
the  remarkable  association  of  micro-organisms  with  gall-stones.     It  is  stated 


DISEASES  OF  THE  LIVER.  549 

that  Bristowe  first  noticed  the  origin  of  cholesterin  in  the  gall-bladder  itself, 
but  Naunyn's  observations  showed  that  both  the  cholesterin  and  the  lime  were 
in  great  part  a  production  of  the  mucosa  of  the  gall-bladder  and  of  the  bile- 
ducts,  particularly  when  in  a  condition  of  catarrhal  inflammation  excited  by 
the  presence  of  microbes.  According  to  the  views  of  this  author,  the  lithoge- 
nous  catarrh  (which,  by  the  way,  is  quite  an  old  idea)  modifies  materially  the 
chemical  constitution  of  the  bile  and  favors  the  deposition  about  epithelial 
debris  and  bacteria  of  the  insoluble  salts  of  lime  in  combination  with  the  bili- 
rubin, Welch  and  others  have  demonstrated  the  presence  of  micro-organisms 
in  the  centre  of  gall-stones.  Three  additional  points  of  interest  may  be  re- 
ferred to : 

First,  the  demonstration  that  the  gall-bladder  is  a  peculiarly  favorable 
habitat  for  micro-organisms.  The  colon  bacilli,  staphylococci,  streptococci, 
pneumococci,  and  the  typhoid  bacilli  have  all  been  found  here  under  varying 
conditions  of  the  bile.  A  remarkable  fact  is  the  length  of  time  that  they  may 
live  in  the  gall-bladder,  as  was  first  demonstrated  by  Blachstein  in  Welch's 
laboratory.  The  typhoid  bacillus  has  been  isolated  in  pure  culture  seven  years 
after  an  attack. 

Secondly,  the  experimental  production  of  gall-stones  has  been  successfully 
accomplished  by  Gilbert  and  Fournier  by  injecting  micro-organisms  into  the 
gall-bladder  of  animals. 

Thirdly,  the  association  of  gall-stones  with  the  specific  fevers.  Bernheim, 
in  1889,  first  called  attention  to  the  frequency  of  gall-stone  attacks  after 
typhoid.  Since  that  time  Dufort  has  collected  a  series  of  cases,  and  Chiari, 
Mason,  and  Camac  have  called  attention  to  the  great  frequency  of  gall-bladder 
complications  during  and  after  this  disease. 

While  it  is  probable  that  a  lithogenous  catarrh,  induced  by  micro-organ- 
isms, is  the  most  important  single  factor,  there  are  other  accessory  causes  of 
great  moment. 

Country. — Gall-stones  are  less  frequent  in  the  United  States  than  in  Ger- 
many, 6.94  to  13  per  cent  (Mosher).  They  are  less  common  in  England  than 
on  the  Continent.     Cholelithiasis  is  found  in  India. 

Age. — Nearly  50  per  cent  of  all  the  cases  occur  in  persons  above  forty 
years  of  age.  They  are  rare  under  twenty-five.  They  have  been  met  with  in 
the  new-born,  and  in  infants  (John  Thomson). 

Sex. — Three-fourths  of  the  cases  occur  in  women.  Pregnancy  has  an  im- 
portant influence.  Naunyri  states  that  90  per  cent  of  women  with  gall-stones 
have  borne  children. 

All  conditions  which  favor  stagnation  of  bile  in  the  gall-bladder  predispose 
to  the  formation  of  stones.  Among  these  may  be  mentioned  corset-wearing, 
enteroptosis,  nephroptosis,  and  occupations  requiring  a  "  leaning  forward " 
position.  Lack  of  exercise,  sedentary  occupations,  particularly  when  com- 
bined with  over-indulgence  in  food,  constipation,  depressing  mental  emotions 
are  also  to  be  regarded  as  favoring  circumstances.  The  belief  prevailed  for- 
merly that  there  was  a  lithiac  diathesis  closely  allied  to  that  of  gout. 

Physical  Characters  of  Gall-stones. — They  may  be  single,  in  which  case 
the  stone  is  usually  ovoid  and  may  attain  a  very  large  size.  Instances  are  on 
record  of  gall-stones  measuring  more  than  5  inches  in  length.  They  may  be 
extremely  numerous,  ranging  from  a  score  to  several  hundreds  or  even  several 


550  DISEASES  OF   THE  DIGESTIVE  SYSTEM. 

thousands,  in  which  case  the  stones  are  very  small.  When  moderately  numer- 
ous, they  show  signs  of  mutual  pressure  and  have  a  polygonal  form,  with 
smooth  facets;  occasionally,  however,  five  or  six  gall-stones  of  medium  size 
are  met  with  in  the  bladder  which  are  round  or  ovoid  and  without  facets. 
They  are  sometimes  mulberry-shaped  and  very  dark,  consisting  largely  of  bile- 
pigments.  Again  there  are  small,  black  calculi,  rough  and  irregular  in  shape, 
and  varying  in  size  from  grains  of  sand  to  small  shot.  These  are  sometmies 
known  as  gall-sand.  On  section,  a  calculus  contains  a  nucleus,  which  consists 
of  bile-pigment,  rarely  a  foreign  body.  The  greater  portion  of  the  stone  is 
made  up  of  cholesterin,  which  may  form  the  entire  calculus  and  is  arranged 
in  concentric  laminae  showing  also  radiating  lines.  Salts  of  lime  and  mag- 
nesia, bile  acids,  fattv'  acids,  and  traces  of  iron  and  copper  are  also  found  in 
them.  Host  gall-stones  consist  of  from  70  to  80  per  cent  of  cholesterin,  in 
either  the  amorjDhous  or  the  crystalline  form.  As  above  stated,  it  is  sometimes 
jDure,  but  more  commonly  it  is  mixed  with  the  bile-pigment.  The  outer  layer 
of  the  stone  is  usually  harder  and  brownish  in  color. 

The  Seat  of  Formation. — "Within  the  liver  itself  calculi  are  occasionally 
found,  but  are  here  usually  small  and  not  abundant,  and  in  the  form  of  ovoid, 
greenish-black  grains.  A  large  majority  of  all  calculi  are  formed  within  the 
gall-bladder.  The  stones  in  the  larger  ducts  have  usually  had  their  origin  in 
the  gall-bladder. 

Symptoms. — In  a  majority  of  the  cases,  gall-stones  cause  no  s}-mptoms. 
The  gall-bladder  will  tolerate  the  presence  of  large  numbers  for  an  indefinite 
period  of  time,  and  post-mortem  examinations  show  that  they  are  present  in 
25  per  cent  of  all  women  over  sixty  years  of  age  (Xaumm).  Moynihan  claims 
that  in  most  cases  there  are  early  spnj^foms — a  sense  of  fulness,  weight,  and 
oppression  in  the  epigastrium;  a  catch  in  the  breath,  a  feeling  of  faintness 
or  nausea,  and  a  chilliness  after  eating.  Attacks  of  indigestion  are  common. 
I  have  seen  two  cases  with  obstinate  attacks  of  urticaria.  I  have  had  many 
cases  in  which  the  most  careful  inquiry  failed  to  elicit  the  existence  of  any 
s^mjjtoms  prior  to  the  attack  of  colic. 

The  French  writers  have  suggested  a  useful  division,  dealing  with  the  main 
symptoms  of  cholelithiasis,  into  (1)  the  aseptic,  mechanical  accidents  in  con- 
sequence of  migration  of  the  stone  or  of  obstruction,  either  in  the  ducts  or  in 
the  intestines;  (2)  the  septic,  infectious  accidents,  either  local  (the  angio- 
cholitis  and  cholecystitis  with  empyema  of  the  gall-bladder,  and  the  fistulse 
and  abscess  of  the  liver  and  infection  of  the  neighboring  parts)  or  general, 
the  biliary  fever  and  the  secondary  visceral  lesions. 

1.  Biliary  Colic. — Gall-stones  may  become  engaged  in  the  cystic  or  the 
common  duct  without  producing  pain  or  severe  s}inptoms.  More  commonly 
the  passage  of  a  stone  excites  the  violent  s}inptoms  known  as  biliary  colic.  The 
attack  sets  in  abruptly  with  agonizing  pain  in  the  right  hypochondriac  region, 
which  radiates  to  the  shoulder,  or  is  very  intense  in  the  epigastric  and  in  the 
lower  thoracic  regions.  It  is  often  associated  with  a  rigor  and  a  rise  in  tem- 
perature from  102°  to  103°.  The  pain  is  usually  so  intense  that  the  patient 
rolls  about  in  agony.  There  are  vomiting,  profuse  sweating,  and  great  depres- 
sion of  the  circulation.  There  may  be  marked  tenderness  in  the  region  of  the 
liver,  which  may  be  enlarged,  and  the  gall-bladder  may  become  palpable  and 
very  tender.    In  other  cases  the  fever  is  more  marked.    The  spleen  is  enlarged 


DISEASES  OF  THE  LIVER.  551 

(Naunyn)  and  the  urine  contains  albumin  with  red  blood-corpuscles.  Ortner 
holds  that  cholecystitis  acuta,  occurring  in  connection  with  gall-stones,  is  a 
septic  (bacterial)  infection  of  the  bile-passages.  The  symptoms  of  acute  infec- 
tious cholecystitis  and  those  of  what  we  call  gall-stone  colic  are  very  similar, 
and  surgeons  have  frequently  performed  cholecystotomy  for  the  former  condi- 
tion, believing  calculi  were  present.  In  a  large  number  of  the  cases  jaundice 
occurs,  but  it  is  not  a  necessary  symptom.  Of  course  it  does  not  happen  dur- 
ing the  passage  of  the  stone  through  the  cystic  duct,  but  only  when  it  becomes 
lodged  in  the  common  duct.  The  pain  is  due  (a)  to  the  slow  progress  in  the 
cystic  duct,  in  which  the  stone  takes  a  rotary  course  owing  to  the  arrangement 
of  the  Heisterian  valve;  the  cystic  duct  is  poor  in  muscle  fibres  but  rich  in 
nerves  and  ganglia;  (&)  to  the  acute  inflammation  which  usually  accompanies 
an  attack;  (c)  to  the  stretching  and  distention  of  the  gall-bladder  by  retained 
secretions. 

The  attack  varies  in  duration.  It  may  last  for  a  few  hours,  several  days, 
or  even  a  week  or  more.  If  the  stone  becomes  impacted  in  the  orifice  of  the 
common  duct,  the  jaundice  becomes  intense;  much  more  commonly  it  is  a 
slight  transient  icterus.  The  attack  of  colic  may  be  repeated  at  intervals  for 
some  time,  but  finally  the  stone  passes  and  the  symptoms  disappear. 

Occasionally  accidents  occur,  such  as  rupture  of  the  duct  with  fatal  peri- 
tonitis. Fatal  syncope  during  an  attack,  and  the  occurrence  of  repeated  con- 
vulsive seizures  have  come  under  my  observation.  These  are,  however,  rare 
events.  Palpitation  and  distress  about  the  heart  may  be  present,  and  occa- 
sionally a  mitral  murmur  occurs  during  the  paroxysm,  but  the  cardiac  condi- 
tions described  by  some  writers  as  coming  on  acutely  in  biliary  colic  are  possi- 
bly pre-existent  in  these  patients. 

The  diagnosis  of  acute  hepatic  colic  is  generally  easy.  The  pain  is  in  the 
upper  abdominal  and  thoracic  regions,  whereas  the  pain  in  nephritic  colic  is 
in  the  lower  abdomen.  A  chill,  with  fever,  is  much  more  frequent  in  biliary 
colic  than  in  gastralgia,  with  which  it  is  liable,  at  times,  to  be  confounded. 
A  history  of  previous  attacks  is  an  important  guide,  and  the  occurrence  of 
jaundice,  however  slight,  determines  the  diagnosis.  To  look  for  the  gall-stones, 
the  stools  should  be  thoroughly  mixed  with  water  and  carefully  filtered  through 
a  narrow-meshed  sieve.  Pseudo-biliary  colic  is  not  infrequently  met  with  in 
nervous  women,  and  the  diagnosis  of  gall-stones  made.  This  nervous  hepatic 
colic  may  be  periodical ;  the  pain  may  be  in  the  right  side  and  radiating ;  some- 
times associated  with  other  nervous  phenomena,  often  excited  by  emotion,  tire, 
or  excesses.  The  liver  may  be  tender,  but  there  are  neither  icterus  nor  inflam- 
matory conditions.  The  combination  of  colic  and  jaundice,  so  distinctive  of 
gall-stones,  is  not  always  present.  The  pains  may  be  not  colicky,  but  more 
constant  and  dragging  in  character.  Of  50  cases  operated  upon  by  Eiedel,  10 
had  not  had  colic,  only  14  presented  a  gall-bladder  tumor,  while  a  majority 
had  not  had  jaundice.  A  remarkable  xanthoma  of  the  bile-passages  has  been 
found  in  association  with  hepatic  colic.  I  have  already  spoken  of  the  diagno- 
sis of  acute  cholecystitis  from  appendicitis  and  obstruction  of  the  bowels.  Ee- 
eurring  attacks  of  pain  in  the  region  of  the  liver  may  follow  adhesions  between 
the  gall-bladder  and  adjacent  parts. 

2.  Obstruction  of  the  Cystic  Duct. — The  effects  may  be  thus  enumer- 
ated : 


552  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

(a)  Dilatation  of  the  gall-ljladder — hydrops  vesicae  felles.  In  acute  ob- 
struction the  contents  are  bile  mixed  with  much  mucus  or  muco-purulent  mate- 
rial. In  chronic  obstruction  the  bile  is  replaced  by  a  clear  fluid  mucus.  This 
is  an  important  point  in  diagnosis,  jjarticularly  as  a  dropsical  gall-bladder  may 
form  a  very  large  tumor.  The  reaction  is  not  always  constant.  It  is  either 
alkaline  or  neutral;  the  consistence  is  thin  and  mucoid.  Albumin  is  usually 
present.  A  dilated  gall-bladder  may  reach  an  enormous  size,  and  in  one  in- 
stance Tait  found  it  occupying  the  greater  part  of  the  abdomen.  In  such 
eases,  as  is  not  unnatural,  it  has  been  mistaken  for  an  ovarian  tumor.  I  have 
described  a  case  in  which  it  was  attached  to  the  right  broad  ligament.  The 
dilated  gall-bladder  can  usually  be  felt  below  the  edge  of  the  liver,  and  in  many 
instances  it  has  a  characteristic  outline  like  a  gourd.  An  enlarged  and  relaxed 
organ  may  not  be  palpable,  and  in  acute  cases  the  distention  may  be  upward 
toward  the  hilus  of  the  liver.  The  dilated  gall-bladder  usually  projects  directly 
downward,  rarely  to  one  side  or  the  other,  though  occasionally  toward  the  mid- 
dle line.  It  may  reach  below  the  navel,  and  in  persons  with  thin  walls  the 
outline  can  be  accurately  defined.  Eiedel  has  called  attention  to  a  tongue-like 
projection  of  the  anterior  margin  of  the  right  lobe  in  connection  with  enlarged 
gall-bladder.  It  is  to  be  remembered  that  distention  of  the  gall-bladder  may 
occur  without  jaundice;  indeed,  the  greatest  enlargement  has  been  met  with 
in  such  cases. 

Gall-stone  crepitus  may  be  felt  when  the  bladder  is  very  full  of  stones  and 
its  walls  not  very  tense.  It  is  rarely  well  felt  unless  the  abdominal  walls  are 
much  relaxed.  It  may  be  found  in  patients  who  have  never  had  any  symptoms 
of  cholelithiasis. 

(&)  Acute  cholecystitis.  The  simple  form  is  common,  and  to  it  are  due 
probably  very  many  of  the  symptoms  of  the  gall-stone  attack.  Phlegmonous 
cholecystitis  is  rare;  only  seven  instances  are  found  in  the  enormous  statis- 
tics of  Courvoisier.  It  is,  however,  much  more  common  than  these  figures 
indicate.    Perforation  may  occur  with  fatal  peritonitis. 

(c)  Suppurative  cholecystitis,  empyema  of  the  gall-bladder,  is  much  more 
common,  and  in  the  great  majority  of  cases  is  associated  with  gall-stones — 41 
m  55  cases  (Courvoisier).  There  may  be  enormous  dilatation,  and  over  a  litre 
of  pus  has  been  found.  Perforation  and  the  formation  of  abscesses  in  the 
neighborhood  are  not  uncommon. 

(d)  Calcification  of  the  gall-bladder  is  commonly  a  termination  of  the 
previous  condition.  There  are  two  separate  forms :  incrustation  of  the  mucosa 
with  lime  salts  and  the  true  infiltration  of  the  wall  with  lime,  the  so-called 
ossification. 

(e)  Atrophy  of  the  gall-bladder.  This  is  by  no  means  uncommon.  The 
organ  shrinks  into  a  small  fibroid  mass,  not  larger,  perhaps,  than  a  good-sized 
pea  or  walnut,  or  even  has  the  form  of  a  narrow  fibrous  string ;  more  com- 
monly the  gall-bladder  tightly  embraces  a  stone.  This  condition  is  usually 
preceded  by  hydrops  of  the  bladder. 

Occasionally  the  gall-bladder  presents  diverticula^  which  may  be  cut  ofE 
from  the  main  portion,  and  usually  contain  calculi. 

(3)  Obstruction  of  the  Common  Duct. — There  may  be  a  single  stone 
tightly  wedged  in  the  duct  in  any  part  of  its  course,  or  a  series  of  stones, 
sometimes  extending  into  both  hepatic  and  cystic  ducts,  or  a  stone  lies  in 


DISEASES  OF  THE  LIVER.  553 

the  diverticulum  of  Vater.  There  are  three  groups  of  cases:  (ft)  In  rare  in- 
stances a  stone  tightly  corks  the  common  duct,  causing  permanent  occlusion; 
or  it  may  partly  rest  in  the  cystic  duct,  and  may  have  caused  thickening  of 
the  junction  of  the  ducts;  or  a  big  stone  may  compress  the  hepatic  or  upper 
part  of  the  common  duct.  The  jaundice  is  deep  and  enduring,  and  there  are 
no  septic  features.  The  pains,  the  previous  attacks  of  colic,  and  the  absence 
of  enlarged  gall-bladder  help  to  separate  the  condition  from  obstruction  by 
new  growths,  although  it  can  not  be  differentiated  with  certainty.  The  ducts 
are  usually  much  dilated  and  everywhere  contain  a  clear  mucoid  fluid. 

(&)  Incomplete  obstruction,  with  infective  cholangitis.  There  may  be  a 
series  of  stones  in  the  common  duct,  a  single  stone  which  is  freely  movable, 
or  a  stone  (ball- valve  stone)  in  the  diverticulum  of  Vater.  These  conditions 
may  be  met  with  at  autopsy,  without  the  subjects  having  had  symptoms  point- 
ing to  gall-stones;  but  in  a  majority  of  cases  there  are  very  characteristic 
features. 

The  common  duct  may  be  as  large  as  the  thumb;  the  hepatic  duct  and 
its  branches  through  the  liver  may  be  greatly  dilated,  and  the  distention  may 
be  even  apparent  beneath  the  liver  capsule.  Great  enlargement  of  the  gall- 
bladder is  rarer.  The  mucous  membrane  of  the  ducts  is  usually  smooth  and 
clear,  and  the  contents  consist  of  a  thin,  slightly  turbid  bile-stained  mucus. 

Naunyn  has  given  the  following  as  the  distinguishing  signs  of  stone  in 
the  common  duct:  "  (1)  The  continuous  or  occasional  presence  of  bile  in 
the  fseces;  (2)  distinct  variations  in  the  intensity  of  the  jaundice;  (3)  normal 
size  or  only  slight  enlargement  of  the  liver;  (4)  absence  of  distention  of  the 
gall-bladder;  (5)  enlargement  of  the  spleen;  (6)  absence  of  ascites;  (7)  pres- 
ence of  febrile  disturbance;  and  (8)  duration  of  the  jaundice  for  more  than 
a  year." 

In  connection  with  the  ball-valve  stone,  which  is  most  commonly  found 
in  the  diverticulum  of  Vater,  though  it  may  be  in  the  common  duct  itself, 
there  is  a  special  symptom  group:  (a)  Ague-like  paroxysms,  chills,  fever,  and 
sweating;  the  hepatic  intermittent  fever  of  Charcot;  (&)  jaundice  of  varying 
intensity,  which  persists  for  months  or  even  years,  and  deepens  after  each  par- 
oxysm; (c)  at  the  time  of  the  paroxysm,  pains  in  the  region  of  the  liver  with 
gastric  disturbance.  These  symptoms  may  continue  on  and  off  for  three  or 
four  years,  without  the  development  of  suppurative  cholangitis.  In  one  of 
my  cases  the  jaundice  and  recurring  hepatic  intermittent  fever  existed  from 
July,  1879,  until  August,  1882;  the  patient  recovered  and  still  lives.  The 
condition  has  lasted  from  eight  months  to  three  years.  The  rigors  are 
of  intense  severity,  and  the  temperature  rises  to  103°  or  105°.  The  chills 
may  recur  daily  for  weeks,  and  present  a  tertian  or  quartan  type,  so  that 
they  are  often  attributed  to  malaria,  with  which,  however,  they  have  no  con- 
nection. The  jaundice  is  variable,  and  deepens  after  each  paroxysm.  The 
itching  may  be  most  intense.  Pain,  which  is  sometimes  severe  and  colicky, 
does  not  always  occur.  There  may  be  marked  vomiting  and  nausea.  As  a 
rule  there  is  no  progressive  deterioration  of  health.  In  the  intervals  between 
the  attacks  the  temperature  is  normal. 

The  clinical  history  and  the  post-mortem  examinations  in  my  cases  show 
conclusively  that  this  condition  may  persist  for  years  without  a  trace  of  sup- 
puration within  the  ducts,    There  must,  however,  be  an  infection,  such  as  may 


554  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

exist  for  years  in  the  gall-bladder,  without  causing  suppuration.  It  is  prob- 
able that  the  toxic  symptoms  develop  only  when  a  certain  grade  of  tension 
is  reached. 

An  interesting  and  valuable  diagnostic  point  is  the  absence  of  dilatation 
of  the  gall-bladder  in  cases  of  obstruction  from  stone — Courvoisier's  rule. 
Ecklin,  who  has  recently  reviewed  this  j)oint,  finds  that  of  172  cases  of  obstruc- 
tion of  the  common  duct  by  calculus  in  34  the  gall-bladder  was  normal,  in  110 
it  was  contracted,  and  in  38  it  was  dilated.  Of  139  cases  of  occlusion  of  the 
common  duct  from  other  causes  the  gall-bladder  was  normal  in  9,  shrunken 
in  9,  and  dilated  in  121. 

(c)  Incomplete  obstruction^  with  suppurative  cholangitis.  When  suppu- 
rative cholangitis  exists  the  mucosa  is  thickened,  often  eroded  or  ulcerated; 
there  may  be  extensive  suppuration  in  the  ducts  throughout  the  liver,  and  even 
empyema  of  the  gall-bladder.  Occasionally  the  suppuration  extends  beyond 
the  ducts,  and  there  is  localized  liver  abscess,  or  there  is  perforation  of  the 
gall-bladder  with  the  formation  of  abscess  between  the  liver  and  stomach. 

Clinically  it  is  characterized  by  a  fever  which  may  be  intermittent,  but 
more  commonly  is  remittent  and  without  prolonged  intervals  of  apyrexia. 
The  jaundice  is  rarely  so  intense,  nor  do  we  see  the  deepening  of  the  color 
after  the  paroxysms.  There  is  usually  greater  enlargement  of  the  liver,  and 
tenderness  and  more  definite  signs  of  septicaemia.  The  cases  run  a  shorter 
course,  and  recovery  never  takes  place. 

(4)  The  Moee  Eemote  Effects  of  Gall-stones. — (a)  Biliary  Fistulce. 
These  are  not  uncommon.  There  may,  for  instance,  be  abnormal  communica- 
tion between  the  gall-bladder  and  the  hepatic  duct  or  the  gall-bladder  and  a 
cavity  in  the  liver  itself.  More  rarely  perforation  occurs  between  the  common 
duct  and  the  portal  vein.  Of  this  there  are  at  least  four  instances  on  record, 
among  them  the  celebrated  case  of  Ignatius  Loyola.  Perforation  into  the 
abdominal  cavity  is  not  uncommon;  119  cases  exist  in  the  literature  (Cour- 
voisier),  in  70  of  which  the  rupture  occurred  directly  into  the  peritoneal  cav- 
ity; in  49  there  was  an  encapsulated  abscess.  Perforation  may  take  place 
from  an  intrahepatic  branch  or  from  the  hepatic,  common,  or  cystic  ducts. 
Perforation  from  the  gall-bladder  is  the  most  common. 

Fistulous  communications  between  the  bile-passages  and  the  gastro-intes- 
tinal  canal  are  frequent.  Openings  into  the  stomach  are  rare.  Between  the 
duodenum  and  bile-passages  they  are  much  more  common.  Courvoisier  has 
collected  10  instances  of  communication  between  the  ductus  communis  and 
the  duodenum,  and  73  cases  between  the  gall-bladder  and  the  duodenum. 
Communication  with  the  ileum  and  jejunum  is  extremely  rare.  Of  fistulous 
opening  into  the  colon  39  cases  are  on  record.  These  communications  can 
rarely  be  diagnosed;  they  may  be  present  without  any  symptoms  whatever. 
It  is  probably  by  ulceration  into  the  duodenum  or  colon  that  the  large  gall- 
stones escape. 

Occasionally  the  urinary  passages  may  be  opened  into  and  the  stones  may 
be  found  in  the  bladder.  Many  instances  are  on  record  of  fistulae  between 
the  bile-passages  and  the  lungs.  Courvoisier  has  collected  24  cases,  to  which 
list  J.  E.  Graham  has  added  10,  including  2  cases  of  his  own.  (Trans,  of 
Assoc,  of  Am.  Physicians,  xiii.)  Bile  may  be  coughed  up  with  the  expec- 
toration, sometimes  in  considerable  quantities. 


DISEASES  OF  THE  LIVER.  555 

Of  all  fistulous  communications  the  external  or  cutaneous  is  the  most  com- 
mon. Courvoisier's  statistics  number  184  cases,  in  50  per  cent  of  which  the 
perforation  took  place  in  the  right  hypochondrium ;  in  39  per  cent  in  the 
region  of  the  navel.  The  number  of  stones  discharged  varied  from  one  or 
two  to  many  hundreds.  Eecovery  took  place  in  78  cases;  some  with,  some 
without  operation. 

(h)  Obstruction  of  the  Bowel  ly  Gall-stones. — Reference  has  already  been 
made  to  this;  its  frequency  appears  from  the  fact  that  of  295  cases  of  obstruc- 
tion, occurring  during  eight  years,  analyzed  by  Fitz,  23  were  by  gall-stone. 
Courvoisier's  statistics  give  a  total  number  of  131  cases,  in  6  of  which  the 
calculi  had  a  peculiar  situation,  as  in  a  diverticulum  or  in  the  appendix.  Of 
the  remaining  125  cases,  in  70  the  stone  was  spontaneously  passed,  usually 
with  severe  symptoms.  The  post-mortem  reports  show  that  in  some  of  these 
cases  even  very  large  stones  have  passed  per  viam  naturalem,  as  the  gall-duct 
has  been  enormously  distended,  its  orifice  admitting  the  finger  freely.  This, 
however,  is  extremely  rare.  The  stones  have  been  found  most  commonly  in 
the  ileum. 

Treatment  of  Gall-stones  and  their  Effects. — In  an  attack  of  biliary  colic 
the  patient  should  be  kept  under  morphia,  given  hypodermically,  in  quarter- 
grain  doses.  In  an  agonizing  paroxysm  it  is  well  to  give  a  whiff  or  two  of  chlo- 
roform until  the  morphia  has  had  time  to  act.  Great  relief  is  experienced 
from  the  hot  bath  and  from  fomentations  in  the  region  of  the  liver.  The 
patient  should  be  given  laxatives  and  should  drink  copiously  of  alkaline 
mineral  waters.  Olive  oil  has  proved  useless  in  my  hands.  When  taken  in 
large  quantities,  fatty  concretions  are  passed  with  the  stools,  which  have  been 
regarded  as  calculi;  and  concretions  due  to  eating  pears  have  been  also  mis- 
taken, particularly  when  associated  with  colic  attacks.  Since  the  days  of 
Durande,  whose  mixture  of  ether  and  turpentine  is  still  largely  used  in  France, 
various  remedies  have  been  advised  to  dissolve  the  stones  within  the  gall-blad- 
der, none  of  which  are  efficacious. 

The  diet  should  be  regulated,  the  patient  should  take  regular  exercise  and 
avoid,  as  much  as  possible,  the  starchy  and  saccharine  foods.  The  soda  salts 
recommended  by  Prout  are  believed  to  prevent  the  concentration  of  the  bile 
and  the  formation  of  gall-stones.  Either  the  sulphate  or  the  phosphate  may 
be  taken  in  doses  of  from  1  to  2  drachms  daily.  For  the  intolerable  itching 
McCall  Anderson's  dusting  powder  may  be  used :  starch,  an  ounce ;  camphor, 
a  drachm  and  a  half;  and  oxide  of  zinc,  half  an  ounce.  Some  of  this  should 
be  finely  dusted  over  the  skin  with  a  powder-puff.  Powdering  with  starch, 
strong  alkaline  baths  (hot),  pilocarpin  hypodermically  (gr.  i— g),  and  anti- 
pyrin  (gr.  viij),  may  be  tried.  Ichthyol  and  lanolin  ointment  sometimes  gives 
relief. 

Exploratory  pimcture,  as  practised  by  the  elder  Pepper,  in  1857,  in  a  ease  of 
empyema  of  the  gall-bladder,  and  by  Bartholow  in  1878  is  not  now  often  done. 
Aspiration  is  usually  a  safe  procedure,  though  a  fatal  result  has  followed. 

The  surgical  treatment  of  gall-stones  has  of  late  years  made  rapid  prog- 
ress. The  operation  of  cholecystotomy,  or  opening  the  gall-bladder  and  remov- 
ing the  stones,  which  was  advised  by  Sims,  has  been  remarkably  successful. 
The  removal  of  the  gall-bladder,  cholecystectomy,  has  also  been  practised  with 
success.     The  indications  for  operation  are :  (a)  Repeated  attacks  of  gall-stone 


556  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

colic.  The  operation  is  now  attended  with  such  slight  risk  that  the  patient 
is  much  safer  in  the  hands  of  a  surgeon  than  when  left  to  Xature,  with  the 
feeble  assistance  of  drugs  and  mineral  waters.  (&)  The  presence  of  a  dis- 
tended gall-bladder,  associated  with  attacks  of  pain  or  with  fever,  (c)  When 
a  gall-stone  is  permanently  lodged  in  the  common  duct,  and  the  group  of 
symptoms  above  described  are  present,  the  question,  then,  of  advising  opera- 
tion depends  largely  upon  the  personal  methods  and  success  of  the  surgeon 
who  is  available. 

In  1,000  consecutive  operations  for  gall-stone  disease  the  brothers  Mayo, 
of  Eochester,  Minn.,  had  50  deaths,  5  per  cent.  In  673  cases  of  cholecystot- 
omy  the  mortality  was  only  2.4  per  cent.  In  186  cholecystectomies  the  mor- 
tality was  4.3  per  cent.  In  137  operations  for  stone  in  the  common  duct  the 
mortality  was  11  per  cent. 

Vn.     THE    CIRRHOSES    OF    THE   LIVER. 

General  Considerations. — The  many  forms  of  cirrhoses  of  the  liver  have 
one  feature  in  common — an  increase  in  the  connective  tissue  of  the  organ. 
In  fact,  we  use  the  term  cirrhosis  (by  which  Laennec  characterized  the  tawn}", 
yellow  color  of  the  common  atrophic  form)  to  indicate  similar  changes  in 
other  organs. 

The  cirrhoses  may  be  classified,  etiologically,  according  to  the  supposed 
causation;  anatomically,  according  to  the  structure  primarily  involved;  or 
clinically,  according  to  certain  special  symptoms. 

Etiological  Classification. — 1.  Toxic  Cirrhosis. — Alcohol  is  the  chief  cause 
of  cirrhosis  of  the  liver.  Other  poisons,  such  as  lead  and  the  toxic  products 
of  faulty  metabolism  in  gout,  diabetes,  rickets,  and  indigestion,  play  a  minor 
role. 

2.  Infectious  Cirrhoses. — With  many  of  the  specific  fevers  necrotic 
changes  occur  in  the  liver  which,  when  wide-spread,  may  be  followed  by  cirrho- 
sis. Possibly  the  h}^ertrophic  cirrhosis  of  Hanot  and  other  forms  met  with 
in  early  life  are  due  to  infection.  The  malarial  cirrhosis  is  a  well-recognized 
variety.    The  S3^hilitic  poison  produces  a  very  characteristic  form. 

3.  Cirrhosis  from  chronic  congestion  of  the  Mood-vessels  in  heart-disease 
—the  cardiac  liver. 

4.  Cirrhosis  from  chronic  obstruction  of  the  lile-ducts,  a  form  of  very 
slight  clinical  interest.  In  anthracosis  the  carbon  pigment  may  reach  the  liver 
•in  large  quantities  and  be  deposited  in  the  connective  tissue  about  the  portal 
canal,  leading  to  cirrhosis  (Welch). 

Anatomical  Classification. — 1.  Vascular  cirrhoses,  in  which  the  new 
growth  of  connective  tissue  has  its  starting  point  about  the  finer  branches  of 
the  portal  or  hepatic  veins. 

2.  Biliary  cirrhoses,  in  which,  the  process  is  supposed  to  begin  about  the 
finer  bile-ducts,  as  in  the  hypertrophic  cirrhosis  of  Hanot  and  in  the  form  from 
obstruction  of  the  larger  ducts. 

3.  Capsular  cirrhoses,  a  perihepatitis  leading  to  great  thickening  of  the  cap- 
sule and  reduction  in  the  volume  of  the  liver. 

Clinical  Classification. — For  practical  purposes  we  may  recognize  the  fol- 
lowing' varieties  of  cirrhosis  of  the  liver : 


DISEASES  OF  THE  LIVER.  557 

1.  The  alcoholic  cirrhosis  of  Laennec,  including  with  this  the  fatty  cir- 
rhotic liver. 

2.  The  hypertrophic  cirrhosis  of  Hanot. 

3.  Syphilitic  cirrhosis. 

4.  Capsular  cirrhosis — chronic  perihepatitis. 

Other  forms,  of  slight  clinical  interest,  are  considered  elsewhere  under  dia- 
betes, malaria,  tuberculosis,  and  heart-disease.  The  cirrhosis  from  malaria, 
upon  which  the  French  writers  lay  so  much  stress  (one  describes  thirteen  vari- 
eties ! ) ,  is  excessively  rare.  In  our  large  experience  with  malaria  during  the 
past  fifteen  years  not  a  single  case  of  advanced  cirrhosis  due  to  this  cause  has 
been  seen  in  the  wards  or  autopsy-room  of  the  Johns  Hopkins  Hospital. 

I.  Alcoholic  Cirrhosis. 

Etiology. — The  disease  occurs  most  frequently  in  middle-aged  males  who 
have  been  addicted  to  drink.  Whisky,  gin,  and  brandy  are  more  potent  to 
cause  cirrhosis  than  beer.  It  is  more  common  in  countries  in  which  strong 
spirits  are  used  than  in  those  in  which  malt  liquors  are  taken.  Among  1,000 
autopsies  in  my  colleague  Welch's  department  of  the  Johns  Hopkins  Hospital 
there  were  63  cases  of  small  atrophic  liver,  and  8  cases  of  the  fatty  cirrhotic 
organ.  Lancereaux  claims  that  the  vin  ordinaire  of  France  is  a  common  cause 
of  cirrhosis.  Of  210  cases,  excess  in  wine  alone  was  present  in  68  cases.  He 
thinks  it  is  the  sulphate  of  potash  in  the  plaster  of  Paris  used  to  give  the 
"  dry  "  flavor  which  damages  the  liver. 

Cirrhosis  of  the  liver  in  young  children  is  not  very  rare.  Palmer  Howard 
collected  63  cases,  to  which  Hatfield  added  93  and  Musser  529.  In  a  certain 
number  of  the  cases  there  is  an  alcoholic  history,  in  others  syphilis  has  been 
present,  while  a  third  group,  due  to  the  poisons  of  the  infectious  diseases, 
embraces  a  certain  number  of  the  cases  of  Hanot's  hypertrophic  cirrhosis. 

Morbid  Anatomy. — Practically  on  the  post-mortem  table  we  see  alcoholic 
cirrhosis  in  two  well-characterized  forms : 

The  Atrophic  Cirrhosis  of  Laennec. — The  organ  is  greatly  reduced  in 
size  and  may  be  deformed.  The  weight  is  sometimes  not  more  than  a  pound 
or  a  pound  and  a  half.  It  presents  numerous  granulations  on  the  surface; 
is  firm,  hard,  and  cuts  with  great  resistance.  The  substance  is  seen  to  be 
made  up  of  greenish-yellow  islands,  surrounded  by  grayish-white  connective 
tissue.  W.  G-.  MacCallum  has  shown  that  regenerative  changes  in  the  cells 
are  almost  constantly  present.  This  yellow  appearance  of  the  liver  induced 
Laennec  to  give  to  the  condition  the  name  of  cirrhosis.  Apart  from  the  fatty 
liver  there  may  be  enlargement  as  pointed  out  by  Foxwell  and  Eolleston. 

The  Fatty  Cirrhotic  Liver. — Even  in  the  atrophic  form  the  fat  is  in- 
creased, but  in  typical  examples  of  this  variety  the  organ  is  not  reduced  in 
size,  but  is  enlarged,  smooth  or  very  slightly  granular,  anaemic,  yellowish-white 
in  color,  and  resembles  an  ordinary  fatty  liver.  It  is,  however,  firm,  cuts  with 
resistance,  and  microscopically  shows  a  great  increase  in  the  connective  tissue. 
This  form  occurs  most  frequently  in  beer- drinkers. 

The  two  essential  elements  in  cirrhosis  are  destruction  of  liver-cells  and 
obstruction  to  the  portal  circulation. 

In  an  autopsy  on  a  case  of  atrophic  cirrhosis  the  peritongeum  is  usually 
found  to  contain  a  large  quantity  of  fluid,  the  membrane  is  opaque,  and  there 


558  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

is  chronic  catarrh  of  the  stomach  and  of  the  small  intestines.  The  spleen  is 
enlarged,  in  part,  at  least,  from  the  chronic  congestion,  possibly  due  in  part 
to  a  "  vital  reaction,"'  to  a  toxic  influence  (Parkes  Weber).  The  pancreas  fre- 
quently shoTTs  chronic  interstitial  changes.  The  kidneys  are  sometimes  cir- 
rhotic, the  bases  of  the  lungs  may  be  much  compressed  by  the  ascitic  fluid,  the 
heart  often  shows  marked  degeneration,  and  arterio-sclerosis  is  usually  present. 
A  remarkable  feature  is  the  association  of  acute  tuberculosis  with  cirrhosis. 
In  seven  cases  of  my  series  the  patients  died  with  either  acute  tuberculous  peri- 
tonitis or  acute  tuberculous  pleurisy.  EoUeston  has  found  that  tuberculosis 
was  present  in  28  per  cent  of  706  fatal  cases  of  cirrhosis.  Peritoneal  tuber- 
culosis was  found  in  9  per  cent  of  a  series  of  584  cases. 

The  compensatory  circulation  is  usually  readily  demonstrated.  It  is  car- 
ried out  by  the  following  set  of  vessels :  ( 1 )  The  accessory  portal  system  of 
Sappey,  of  which  important  branches  pass  in  the  round  and  suspensory  liga- 
ments and  unite  with  the  epigastric  and  mammary  systems.  These  vessels 
are  numerous  and  small.  Occasionally  a  large  single  vein,  which  may  attain 
the  size  of  the  little  finger,  passes  from  the  hilus  of  the  liver,  follows  the  round 
ligament,  and  joins  the  epigastric  veins  at  the  navel.  Although  this  has  the 
position  of  the  umbilical  vein,  it  is  usually,  as  Sappey  showed,  a  para-umbil- 
ical vein — that  is,  an  enlarged  vera  by  the  side  of  the  obliterated  umbilical 
vessel.  There  may  be  produced  about  the  navel  a  large  bunch  of  varices,  the 
so-called  caput  Medusa.  Other  branches  of  this  system  occur  in  the  gastro- 
epiploic omentum,  about  the  gall-bladder,  and,  most  important  of  all,  in  the 
suspensory  ligament.  These  latter  form  large  branches,  which  anastomose 
freely  with  the  diaphragmatic  veins,  and  so  unite  with  the  vena  azygos.  (2) 
By  the  anastomosis  between  the  oesophageal  and  gastric  veins.  The  veins  at 
the  lower  end  of  the  oesophagus  may  be  enormously  enlarged,  producing  varices 
which  project  on  the  mucous  membrane.  (3)  The  communications  between 
the  hsemorrhoidal  and  the  inferior  mesenteric  veins.  The  freedom  of  com- 
munication in  this  direction  is  very  variable,  and  in  some  instances  the  hsem- 
orrhoidal  veins  are  not  much  enlarged,  (-i)  The  veins  of  Retzius,  which  unite 
the  radicles  of  the  portal  branches  in  the  intestines  and  mesentery  with  the 
inferior  vena  cava  and  its  branches.  To  this  system  belong  the  whole  group 
of  retroperitoneal  veins,  which  are  in  most  instances  enormously  enlarged, 
particularly  about  the  kidneys,  and  which  serve  to  carry  off  a  considerable  pro- 
portion of  the  portal  blood. 

Symptoms. — The  most  extreme  grade  of  atrophic  cirrhosis  may  exist  with- 
out s}^nptoms.  So  long  as  the  compensatory  circulation  is  maintained  the 
patient  may  suffer  little  or  no  inconvenience.  The  remarkable  efficiency  of 
this  collateral  circulation  is  well  seen  in  those  rare  instances  of  permanent 
obliteration  of  the  portal  vein.  The  s}Tnptoms  may  be  divided  into  two  groups 
— obstructive  and  toxic. 

Obstructive. — The  overfilling  of  the  blood-vessels  of  the  stomach  and 
intestine  lead  to  chronic  catarrh,  and  the  patients  suffer  with  nausea  and  vom- 
iting, particularly  in  the  morning;  the  tongue  is  furred  and  the  bowels  are 
irregular.  Haemorrhage  from  the  stomach  may  be  an  early  symptom;  it  is 
often  profuse  and  liable  to  recur.  It  seldom  proves  fatal.  The  amount  vom- 
ited may  be  remarkable,  as  in  a  case  already  referred  to,  in  which  ten  pounds 
were  ejected  in  seven  days.     Following  the  haematemesis  melsena  is  common; 


DISEASES  OF  THE  LIVER.  559 

but  hsemorrhages  from  the  bowels  may  occur  for  several  years  without  hgema- 
temesis.  The  bleeding  very  often  comes  from  the  oesophageal  varices  already 
described  (p.  459).  Very  frequently  epistaxis  occurs.  Enlargement  of  the 
spleen  may,  as  Parkes  Weber  suggests,  be  due  to  a  toxemia.  The  organ  can 
usually  be  felt.  Evidences  of  the  establishment  of  the  collateral  circulation 
are  seen  in  the  enlarged  epigastric  and  mammary  veins,  more  rarely  in  the 
presence  of  the  caput  Medusae  and  in  the  development  of  haemorrhoids.  ■  The 
distended  venules  in  the  lower  thoracic  zone  along  the  line  of  attachment 
of  the  diaphragm  are  not  specially  marked  in  cirrhosis.  The  most  striking 
feature  of  failure  in  the  compensatory  circulation  is  ascites,  the  effusion  of 
serous  fluid  into  the  peritoneal  cavity,  which  may  appear  suddenly.  The 
conditions  under  which  this  occurs  are  still  obscure.  In  some  cases  it  is 
due  more  to  chronic  peritonitis  than  to  the  cirrhosis.  The  abdomen  gradu- 
ally distends,  may  reach  a  large  size,  and  contain  as  much  as  15  or  20  litres. 
QEdema  of  the  feet  may  precede  or  develop  with  the  ascites.  The  dropsy  is 
rarely  general. 

Jaundice  is  usually  slight,  and  was  present  in  107  of  ^^  cases^of_£irrhosis 
collected  by  JRolleston.  The  skin  has  frequently  a  sallow,  slightly  icteroid 
tint.  The  urine  is  often  reduced  in  amount,  contains  urates  in  abundance, 
often  a  slight  amount  of  albumin,  and,  if  jaundice  is  intense,  tube-casts.  The 
disease  may  be  afebrile  throughout,  but  in  many  cases,  as  shown  by  Carring- 
ton,  there  is  slight  fever,  from  100°  to  102.5°. 

Examination  at  any  early  stage  of  the  disease  may  show  an  enlarged  and 
painful  liver.  Dreschfeld,  Foxwell,  and  Eolleston  have  of  late  years  called 
particular  attention  to  the  fact  that  in  very  many  of  the.  cases  of  alcoholic  cir- 
rhosis the  organ  is  "  enlarged  at  all  stages  of  the  disease,  and  that  whether 
enlarged  or  contracted  the  clinical  symptoms  and  course  are  much  the  same  " 
(Foxwell).  The  patient  may  first  come  under  observation  for  dyspepsia, 
hsematemesis,  slight  jaundice,  or  nervous  symptoms.  Later  in  the  disease, 
the  patient  has  an  unmistakable  hepatic  f acies ;  he  is  thin,  the  eyes  are  sunken, 
the  conjunctivae  watery,  the  nose  and  cheeks  show  distended  venules,  and  the 
complexion  is  muddy  or  icteroid.  On  the  enlarged  abdomen  the  vessels  are 
distended,  and  a  bunch  of  dilated  veins  may  surround  the  navel.  Naevi  of  a 
remarkable  character  may  appear  on  the  skin,  either  localized  stellate  varices — 
spider  angiomata — usually  on  the  face,  neck,  and  back,  and  also  "  mat "  naevi, 
as  I  have  called  them — areas  of  skin  of  a  reddish  or  purplish  color  due  to  the 
uniform  distention  of  small  venules.  "When  much  fluid  is  in  the  peritonaeum 
it  is  impossible  to  make  a  satisfactory  examination,  but  after  withdrawal  the 
area  of  liver  dulness  is  found  to  be  diminished,  particularly  in  the  middle 
line,  and  on  deep  pressure  the  edge  of  the  liver  can  be  detected,  and  occa- 
sionally the  hard,  firm,  and  even  granular  surface.  The  spleen  can  be  felt 
in  the  left  hypochondriac  region.  Examination  of  the  anus  may  reveal  the 
presence  of  hremorrhoids. 

Toxic  Symptoms. — At  any  stage  of  atrophic  cirrhosis  the  patient  may 
have  cerebral  symptoms,  either  a  noisy,  joyous  delirium,  or  stupor,  coma,  or 
even  convulsions.  The  condition  is  not  infrequently  mistaken  for  uraemia. 
The  nature  of  the  toxic  agent  is  not  yet  settled.  Without  jaundice,  and  not 
attributable  to  cholaemia,  the  symptoms  may  come  on  in  hospital  when  the 
patient  has  not  had  alcohol  for  weeks. 


560  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

The  fatty  cirrhotic  liver  may  produce  symptoms  similar  to  those  of  the 
atrophic  form^  but  more  frequently  it  is  latent  and  is  found  accidentally  in 
topers  who  have  died  from  various  diseases.  The  greater  number  of  the  cases 
clinically  diagnosed  as  cirrhosis  with  enlargement  come  in  this  division. 

Diagnosis. — With  ascites,  a  well-marked  history  of  alcoholism,  the  hepatic 
facies,  and  hsemorrhage  from  the  stomach  or  bowels,  the  diagnosis  is  rarely 
doubtful.  If,  after  withdrawal  of  the  fluid,  the  spleen  is  found  to  be  en- 
larged and  the  liver  either  not  palpable  or,  if  it  is  enlarged,  hard  and  regu- 
lar, the  probabilities  in  favor  of  cirrhosis  are  very  great.  In  the  early  stages 
of  the  disease,  when  the  liver  is  increased  in  size,  it  may  be  impossible  to  say 
whether  it  is  a  cirrhotic  or  a  fatty  liver.  The  differential  diagnosis  between 
common  and  syphilitic  cirrhosis  can  sometimes  be  made.  A  marked  history 
of  syphilis  or  the  existence  of  other  syphilitic  lesions,  with  great  irregularity 
in  the  surface  or  at  the  edge  of  the  liver,  are  the  points  in  favor  of  the  latter. 
Thrombosis  or  obliteration  of  the  portal  vein  can  rarely  be  differentiated.  In 
a  case  of  fibroid  transformation  of  the  portal  vein  which  came  under  my 
observation,  the  collateral  circulation  had  been  established  for  years,  and  the 
symptoms  were  simply  those  of  extreme  portal  obstruction,  such  as  occur  in 
cirrhosis.  Thrombosis  of  the  portal  vein  may  occur  in  cirrhosis  and  be  char- 
acterized by  a  rapidly  developing  ascites. 

Prognosis. — The  prognosis  is  bad.  When  the  collateral  circulation  is  fully 
established  the  patient  may  have  no  symptoms  whatever.  Three  cases  of 
advanced  atrophic  cirrhosis  have  died  under  my  observation  of  other  affec- 
tions without  presenting  during  life  any  symptoms  pointing  to  disease  of  the 
liver.  There  are  instances,  too,  of  enlargement  of  the  liver,  slight  jaundice, 
cerebral  symptoms,  and  even  hgematemesis,  in  which  the  liver  becomes  reduced 
in  size,  the  symptoms  disappear,  and  the  patient  may  live  in  comparative  com- 
fort for  many  years.  There  are  cases,  too,  possibly  syphilitic,  in  which,  after 
one  or  two  tappings,  the  symptoms  have  disappeared  and  the  patients  have 
apparently  recovered.  Ascites  is  a  very  serious  event,  especially  if  due  to  the 
cirrhosis  and  not  to  an  associated  peritonitis.  Of  34  cases  with  ascites  10  died 
before  tapping  was  necessary;  14  were  tapped,  and  the  average  duration  of 
life  after  the  swelling  was  first  noticed  was  only  eight  weeks;  of  10  cases  the 
diagnosis  was  wrong  in  4,  and  in  the  remaining  6,  who  were  tapped  oftener 
than  once,  chronic  peritonitis  and  perihepatitis  were  present  (Hale  White). 

II.  Hypertrophic  Cirrhosis  {Hanoi). 

This  well-characterized  form  was  first  described  by  Eequin  in  1846,  but 
our  accurate  knowledge  of  the  condition  dates  from  the  work  of  the  lamented 
Hanot  (1875),  whose  name  in  France  it  bears — maladie  de  Hanoi. 

Cirrhosis  with  enlargement  occurs  in  the  early  stage  of  atrophic  cirrhosis; 
there  is  an  enlarged  fatty  and  cirrhotic  liver  of  alcoholics,  a  pigmentary  form 
in  diabetes  has  been  described,  and  in  association  with  syphilis  the  organ  is 
often  very  large.  The  h3rpertrophic  cirrhosis  of  Hanot  is  easily  distinguished 
from  these  forms. 

Etiology. — Males  are  more  often  affected  than  females — in  22  of  Schach- 
mann's  26  cases.  The  subjects  are  young;  some  of  the  cases  in  children  prob- 
ably belong  to  this  form.     Of  four  recent  cases  under  my  care  the  ages  were 


DISEASES  OF  THE  LIVER.  561 

from  twenty  to  thirty-five.  Two  were  brotliers.  Alcohol  plays  a  minor  part. 
Not  one  of  the  four  cases  referred  to  had  been  a  heavy  drinker.  The  absence 
of  all  known  etiological  factors  is  a  remarkable  feature  in  a  majority  of  the 
cases. 

Morbid  Anatomy. — The  organ  is  enlarged,  weighing  from  2,000  to  4,000 
grammes.  The  form  is  maintained,  the  surface  is  smooth,  or  presents  small 
granulations ;  the  color  in  advanced  cases  is  of  a  dark  olive  green ;  the  con- 
sistence is  greatly  increased.  The  section  is  uniform,  greenish-yellow  in  color, 
and  the  liver  nodules  may  be  seen  separated  by  connective  tissue.  The  bile- 
passages  present  nothing  abnormal.  In  a  case  without  much  jaundice  ex- 
ploratory operation  showed  a  very  large  red  organ,  with  a  slightly  roughened 
surface.  Microscopically  the  following  characteristics  are  described  by  French 
writers :  The  cirrhosis  is  mono-  or  multilobular,  with  a  connective  tissue  rich 
in  round  cells.  The  bile-vessels  are  the  seat  of  an  angiocholitis,  catarrhal  and 
productive,  and  there  is  an  extraordinary  development  of  new  biliary  canaliculi. 
The  liver-cells  are  neither  fatty  nor  pigmented,  and  may  be  increased  in  size 
and  show  karyokinetic  figures.  From  the  supposed  origin  about  the  bile- 
vessels  it  has  been  called  biliary  cirrhosis,  but  the  histological  details  have  not 
yet  been  worked  out  fully,  and  the  separation  of  this  as  a  distinct  form  should, 
for  the  present  at  least,  rest  upon  clinical  rather  than  anatomical  grounds. 
The  spleen  is  greatly  enlarged  and  may  weigh  600  or  more  grammes. 

Symptoms. — Hanot's  hypertrophic  cirrhosis  presents  the  following  very 
characteristic  group  of  symptoms.  As  previously  stated,  the  cases  occur  in 
young  persons;  there  is  not,  as  a  rule,  an  alcoholic  history,  and  males  are 
usually  affected:  (a)  A  remarkably  chronic  course  of  from  four  to  six,  or 
even  ten  years,  (h)  Jaundice,  usually  slight,  often  not  more  than,  a  lemon 
tint^or  a  tingingjpf  the  cpnjunctiyge.  At  any  time  during  the  course  an  icterus^ 
gravis,  with  high  fever  and  delirium,  may  develop.  There  is  bile  in  the  urine ; 
the  stools  are  not  clay-colored  as  in  obstructive  jaundice,  but  may  be  very 
dark  and  "bilious."  (c)  Attacks  of  pain  in  the  region  of  the  liver,  which 
may  be  severe  and  associated  with  nausea  and  vomiting.  The  pain  may  be 
slight  and  dragging,  and  in  some  cases  is  not  at  all  a  prominent  symptom. 
The  jaundice  may  deepen  after  attacks  of  pain,  (d)  Enlarged  liver.  A  ful- 
ness in  the  upper  abdominal  zone  may  be  the  first  complaint.  On  inspection 
the  enlargement  may  be  very  marked.  In  one  of  my  cases  the  left  lobe  was 
unusually  prominent  and  stood  out  almost  like  a  tumor.  An  exploratory  oper- 
ation showed  only  an  enlarged,  smooth  organ  without  adhesions.  On  palpa- 
tion the  hypertrophy  is  uniform,  the  consistence  is  increased,  and  the  edge 
distinct  and  hard.  The  gall-bladder  is  not  enlarged.  The  vertical  flatness  is 
much  increased  and  may  extend  from  the  sixth  rib  to  the  level  of  the  navel, 
(e)  The  spleen  is  enlarged,  easily  palpable,  and  very  hard.  (/)  Certain  nega- 
tive features  are  of  moment — the  usual  absence  of  ascites  and  of  dilatation 
of  the  subcutaneous  veins  of  the  abdomen.  Among  other  symptoms  may  be 
mentioned  haemorrhages.  One  of  my  cases  had  bleeding  at  the  gums  for  a 
year;  another  had  had  for  years  most  remarkable  attacks  of  purpura  with 
urticaria.  Pruritus,  xanthoma,  lichen,  and  telangiectasis  may  be  present  in 
the  skin.  In  one  of  my  cases  the  skin  became  very  bronzed,  almost  as  deeply 
as  in  Addison's  disease.  Slight  fever  may  be  present,  which  increases  during 
the  crises  of  pain.  There  may  be  a  marked  leucocytosis.  A  curious  attitude 
37 


562  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

of  the  body  lias  l)een  seen,  in  which  the  right  shoulder  and  right  side  look 
dragged  down.  The  patients  die  with  the  symptoms  of  icterus  gravis,  from 
haemorrhage,  from  an  intercurrent  infection,  or  in  a  profound  cachexia.  Cer- 
tain of  the  cases  of  cirrhosis  of  the  liver  in  children  are  of  this  type;  the 
enlargement  of  the  spleen  may  be  very  pronounced. 

III.  Syphilitic  Cirrhosis. 

This  has  already  been  considered  in  the  section  on  syphilis  (p.  275).  I 
refer  to  it  again  to  emphasize  (1)  its  frequency;  (2)  the  great  importance  of 
its  differentiation  from  the  alcoholic  form;  (3)  its  curability  in  many  cases; 
and  (4)  the  tumor  formations  in  connection  with  it. 

IV.  Capsular  Cirrhosis — Perihepatitis. 

Local  capsulitis  is  common  in  many  conditions  of  the  liver.  The  form 
of  disease  here  described  is  characterized  by  an  enormous  thickening  of  the 
entire  capsule,  with  great  contraction  of  the  liver,  but  not  necessarily  with  spe- 
cial increase  in  the  connective  tissue  of  the  organ  itself.  Our  chief  knowledge 
of  the  disease  we  owe  to  the  Guy's  Hospital  physicians,  particularly  to  Hilton 
Fagge  and  to  Hale  White,  who  has  collected  from  the  records  22  cases.  The 
liver  substance  itself  was  "  never  markedly  cirrhotic ;  its  tissue  was  nearly 
always  soft."  Chronic  capsulitis  of  the  spleen  and  a  chronic  proliferative  peri- 
tonitis are  almost  invariably  present.  In  19  of  the  22  cases  the  kidneys  were 
granular.  Hale  White  regards  it  as  a  sequel  of  interstitial  nephritis.  The 
youngest  case  in  his  series  was  twenty-nine.  The  symptoms  are  those  of 
atrophic  cirrhosis — ascites,  often  recurring  and  requiring  many  tappings. 
Jaundice  is  not  often  present.  I  have  met  with  two  groups  of  cases — the  one 
in  adults  usually  with  ascites  and  regarded  as  ordinary  cirrhosis.  I  have 
never  made  a  diagnosis  in  such  a  case.  Signs  of  interstitial  nephritis,  recur- 
ring ascites,  and  absence  of  jaundice  are  regarded  by  Hale  White  as  im- 
portant diagnostic  points.  In  the  second  group  of  cases  the  perihepatitis, 
perisplenitis,  and  proliferative  peritonitis  are  associated  with  adherent  pericar- 
dium and  chronic  mediastinitis.  In  one  such  case  the  diagnosis  of  capsular 
hepatitis  was  very  clear,  as  the  liver  could  be  grasped  in  the  hand  and  formed 
a  rounded,  smooth  organ  resembling  the  spleen.  The  child  was  tapped  121 
times  (Archives  of  Paediatrics,  1896). 

Treatment  of  the  Cirrhoses. — The  portal  function  of  the  liver  may  be  put 
out  of  action  without  much  damage  to  the  body.  There  may  be  an  extreme 
grade  of  cirrhotic  atrophy  without  symptoms;  the  portal  vein  may  be  obliter- 
ated, or,  experimentally  the  portal  vein  may  be  anastomosed  with  the  cava. 
So  long  as  there  is  an  active  compensatory  circulation  a  patient  with  atrophic 
cirrhosis  may  remain  well.  In  the  hypertrophic  form  toxaemia  is  the  special 
danger.  In  the  hypertrophic  cirrhosis  we  have  no  means  of  arresting  the  prog- 
ress of  the  disease.  In  the  alcoholic  form  it  is  too  late,  as  a  rule,  to  do  much 
after  symptoms  have  occurred.  In  a  few  cases  an  attack  of  jaundice  or 
hffimatemesis  may  prove  the  salvation  of  the  patient,  who  may  afterward  take 
to  a  temperate  life  and  a  bland  diet.  An  occasional  course  of  potassium  iodide 
may  be  given.  With  the  advent  of  ascites  the  critical  stage  is  reached.  A  dry 
diet,  without  salt,  and  free  purgation  may  relieve  a  small  exudate,  rarely  a 


DISEASES  OF  THE  LIVER.  563 

large  one,  and  it  is  best  to  tap  early,  or  to  advise  Talma's  operation.  In  the 
syphilitic  cirrhosis  much  more  can  be  done,  and  a  majority  of  the  cases  of  cure 
after  ascites  are  of  this  variety.  Iodide  of  potassium  in  moderate  doses,  15 
to  30  drops  of  the  saturated  solution,  and  the  Addison  pill  save  a  number  of 
cases  even  after  repeated  tapping.  The  diagnosis  may  be  reached  only  after 
removal  of  the  fluid,  but  in  every  case  with  a  history  of  syphilis  or  with  irreg- 
ularity of  the  liver  this  treatment  should  be  tried. 

Surgical  Treatment. — (a)  Tapping. — When  the  ascites  increases  it  is 
better  to  tap  early.  As  Hale  White  remarks,  a  case  of  cirrhosis  of  the  liver 
which  is  tapped  rarely  recovers,  but  there  are  instances  in  which  early  and 
repeated  paracentesis  is  followed  by  cure.  Accidents  are  rare;  hemorrhage 
occasionally  follows ;  acute  peritonitis ;  erysipelas  at  the  point  of  puncture ;  col- 
lapse during  the  operation,  to  guard  against  which  Mead  advised  the  use  of  the 
abdominal  binder.  Continuous  drainage  with  Southey's  tubes  is  not  often 
practicable  and  has  no  special  advantages,  (&)  Laparotomy,  with  complete 
removal  of  the  fluid,  and  freshening  or  rubbing  the  peritoneal  surfaces,  to 
stimulate  the  formation  of  adhesions,  (c)  Omentopexy,  the  stitching  of  the 
omentum  to  the  abdominal  wall,  and  the  establishment  of  collateral  circula- 
tion in  this  way  between  the  portal  and  the  systemic  vessels.  This  operation 
is  sometimes  very  successful,  and  may  be  recommended.  In  324  cases  there 
were  84  deaths  and  129  recoveries;  11  cases  doubtful.  Among  the  129  suc- 
cessful cases,  in  25  the  ascites  recurred ;  70  appeared  to  have  completely  recov- 
ered, (d)  Fistula  of  Ech.  The  porto-caval  anastomosis  has  been  performed 
once  in  man  in  cirrhosis  of  the  liver  by  Widal  {La  Semaine  Medicale,  1903). 
The  jDatient  lived  for  three  months. 

VIII.    ABSCESS    OF    THE   LIVER. 

Etiology. — Suppuration  within  the  liver,  either  in  the  parenchyma  or  in 
the  blood  or  bile  passages,  occurs  under  the  following  conditions : 

(1)  The  tropical  abscess,  also  called  the  solitary,  commonly  follows  amoebic 
dysentery.  It  frequently  occurs  among  Europeans  in  India,  particularly  those 
who  drink  alcohol  freely  and  are  exposed  to  great  heat.  The  relation  of  this 
form  of  abscess  to  dysentery  is  still  under  discussion,  and  Anglo-Indian  prac- 
titioners are  by  no  means  unanimous  on  the  subject.  Certainly  cases  may 
occur  without  a  history  of  previous  dysentery,  and  there  have  been  fatal  cases 
without  any  affection  of  the  large  bowel.  In  the  United  States  the  large  soli- 
tary abscess  is  not  very  infrequent.  The  relation  of  this  form  of  abscess  to 
the  Amceba  dysenterice  has  been  considered. 

(2)  Traumatism  is  an  occasional  cause.  The  injury  is  generally  in  the 
hepatic  region.  Two  instances  of  it  have  come  under  my  notice  in  brakemen 
who  were  injured  while  coupling  cars.  Injury  to  the  head  is  not  infrequently 
followed  by  liver  abscess. 

(3)  Embolic  or  pycemic  abscesses  are  the  most  numerous,  occurring  in  a 
general  pyaemia  or  following  foci  of  suppuration  in  the  territory  of  the  portal 
vessels.  The  infective  agents  may  reach  the  liver  through  the  hepatic  artery, 
as  in  those  cases  in  which  the  original  focus  of  infection  is  in  the  area  of  the 
systemic  circulation;  though  it  may  happen  occasionally  that  the  infective 
agent,  instead  of  passing  through  the  lungs,  reaches  the  liver  through  the  infe- 


564  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

rior  vena  cava  and  the  hepatic  veins.  A  remarkable  instance  of  multiple 
abscesses  of  arterial  origin  was  afforded  by  the  case  of  aneurism  of  the  hepatic 
artery  reported  by  Eoss  and  myself.  Infection  through  the  portal  vein  is 
much  more  common.  It  results  from  dysentery  and  other  ulcerative  affections 
of  the  bowels,  appendicitis,  occasionally  after  typhoid  fever,  in  rectal  affec- 
tions, and  in  abscesses  in  the  pelvis.  In  these  cases  the  abscesses  are  multiple 
and,  as  a  rule,  within  the  branches  of  the  portal  vein — suppurative  pylephle- 
bitis. 

(4)  A  not  uncommon  cause  of  suppuration  is  inflammation  of  tJie  tile- 
passages  caused  by  gall-stones,  more  rarely  by  parasites — suppurative  cho- 
langitis. 

In  some  instances  of  tuberculosis  of  the  liver  the  affection  is  chiefly  of 
the  bile-ducts,  with  the  formation  of  multiple  tuberculous  abscesses  containing 
a  bile-stained  pus. 

(5)  Foreign  todies  and  parasites.  In  rare  instances  foreign  bodies,  such 
as  a  needle,  may  pass  from  the  stomach  or  gullet,  lodge  in  the  liver,  and 
excite  an  abscess,  or,  as  in  several  instances  which  have  been  reported,  a  for- 
eign body,  such  as  a  needle  or  a  fish-bone,  has  perforated  a  branch  or  the  por- 
tal vein  itself  and  induced  pylephlebitis.  Echinococcus  cysts  frequently  cause 
suppuration,  the  penetration  of  round  worms  into  the  liver  less  commonly, 
and  most  rarely  of  all  the  liver-fluke. 

Morbid  Anatomy. —  (a)  Of  the  Solitary  or  Tropical  Abscess. — This 
has  been  described  under  amoebic  dysentery  (p.  4). 

(6)  Oe  Septic  and  Pyemic  Abscesses. — These  are  usually  multiple, 
though  occasionally,  following  injury,  there  may  be  a  large  solitary  collection 
of  pus. 

In  suppurative  pylephlebitis  the  liver  is  uniformly  enlarged.  The  cap- 
sule may  be  smooth  and  the  external  surface  of  the  organ  of  normal  appearance. 
In  other  instances,  numerous  yellowish-white  points  appear  beneath  the  cap- 
sule. On  section  there  are  isolated  pockets  of  pus,  either  having  a  round  out- 
line or  in  some  places  distinctly  dendritic,  and  from  these  the  pus  may  be 
squeezed.  They  look  like  small,  solitary  abscesses,  but,  on  probing,  are  found 
to  communicate  with  the  portal  vein  and  to  represent  its  branches,  distended 
and  suppurating.  The  entire  portal  system  vsdthin  the  liver  may  be  involved ; 
sometimes  territories  are  cut  off  by  thrombi.  The  suppuration  may  extend  into 
the  main  branch  or  even  into  the  mesenteric  and  gastric  veins.  The  pus  may 
be  fetid  and  is  often  bile-stained;  it  may,  however,  be  thick,  tenacious,  and 
laudable.  In  suppurative  cholangitis  there  is  usually  obstruction  by  gall- 
stones, the  ducts  are  greatly  distended,  the  gall-bladder  enlarged  and  full  of 
pus,  and  the  branches  within  the  liver  are  extremely  distended,  so  that  on 
section  there  is  an  appearance  not  unlike  that  described  in  pylephlebitis. 

Suppuration  about  the  echinococcus  cysts  may  be  very  extensive,  forming 
enormous  abscesses,  the  characters  of  which  are  at  once  recognized  by  the  rem- 
nants of  the  cysts. 

Symptoms. — {a)  Oe  the  Large  Solitary  Abscess. — The  abscess  may  be 
latent  and  run  a  course  without  definite  s5miptoms;  death  may  occur  sud- 
denly from  rupture. 

Fever,  pain,  enlargement  of  the  liver,  and  a  septic  condition  are  the  impor- 
tant symptoms  of  hepatic  abscess.     The  temperature  is  elevated  at  the  outset 


DISEASES  OF  THE  LIVER.  565 

and  is  of  an  intermittent  or  septic  type.  It  is  irregular,  and  may  remain 
normal  or  even  subnormal  for  a  few  days;  then  the  patient  has  a  rigor  and 
the  temperature  rises  to  103°  or  higher.  Owing  to  this  intermittent  character 
of  the  fever  the  disease  is  often  mistaken  for  malaria.  The  fever  may  rise 
every  afternoon  without  a  rigor.  Profuse  sweating  is  common,  particularly 
when  the  patient  falls  asleep.  In  chronic  cases  there  may  be  little  or  no 
fever.  One  of  my  patients,  with  a  liver  abscess  which  had  perforated  the  lung, 
coughed  up  pus  after  his  temperature  had  been  normal  for  weeks.  The  pain 
is  variable,  and  is  usually  referred  to  the  back  or  shoulder;  or  there  is  a  dull 
aching  sensation  in  the  right  hypochondrium.  When  turned  on  the  left  side, 
the  patient  often  complains  of  a  heavy,  dragging  sensation,  so  that  he  usually 
prefers  to  lie  on  the  right  side ;  at  least,  this  has  been  the  case  in  a  majority  of 
the  instances  which  have  come  under  my  observation.  Pain  on  pressure  over 
the  liver  is  usually  present,  particularly  on  deep  pressure  at  the  costal  margin 
in  the  nipple  line. 

The  enlargement  of  the  liver  is  most  marked  in  the  right  lobe,  and,  as 
the  abscess  cavity  is  usually  situated  more  toward  the  upper  than  the  under 
.surface,  the  increase  in  volume  is  upward  and  to  the  right,  not  downward,  as 
in  cancer  and  the  other  affections  producing  enlargement.  Percussion  in  the 
mid-sternal  and  parasternal  lines  may  show  a  normal  limit.  At  the  nipple- 
line  the  curve  of  liver  dulness  begins  to  rise,  and  in  the  mid-axillary  it  may 
reach  the  fifth  rib,  while  behind,  near  the  spine,  the  area  of  dulness  may  be 
almost  on  a  level  with  the  angle  of  the  scapula.  Of  course  there  are  instances 
in  which  this  characteristic  feature  is  not  present,  as  when  the  abscess  occu- 
pies the  left  lobe.  The  enlargement  of  the  liver  may  be  so  great  as  to  cause 
bulging  of  the  right  side,  and  the  edge  may  project  a  hand's-breadth  or  more 
below  the  costal  margin.  In  such  instances  the  surface  is  smooth.  Palpation 
is  painful,  and  there  may  be  fremitus  on  deep  inspiration.  In  some  instances 
fluctuation  may  be  detected.  Adhesions  may  form  to  the  abdominal  wall  and 
the  abscess  may  point  below  the  margin  of  the  ribs,  or  even  in  the  epigastric 
region.  In  many  cases  the  appearance  of  the  patient  is  suggestive.  The  skin 
has  a  sallow,  slightly  icteroid  tint,  the  face  is  pale,  the  complexion  muddy,  the 
conjunctivae  are  infiltrated,  and  often  slightly  bile-tinged.  There  is  in  the 
facies  and  in  the  general  appearance  of  the  patient  a  strong  suggestion  of  the 
existence  of  abscess.  There  is  no  internal  affection  associated  with  suppura- 
tion which  gives,  I  think,  just  the  same  hue  as  certain  instances  of  abscess  of 
the  liver.  Marked  jaundice  is  rare.  Diarrhoea  may  be  present  and  may  give 
an  important  clew  to  the  nature  of  the  case,  particularly  if  amoebae  are  found 
in  the  stools.     Constipation  may  occur. 

Perforation  of  the  lung  occurred  in  9  of  the  27  cases  in  my  series.  The 
symptoms  are  most  characteristic.  The  extension  may  occur  through  the  dia- 
phragm, without  actual  rupture,  and^  with  the  production  of  a  purulent  pleu- 
risy and  invasion  of  the  lung.  With  cough  of  an  aggravated  and  convulsive 
character,  there  are  signs  of  involvement  at  the  base  of  the  right  lung,  defective 
resonance,  feeble  tubular  breathing,  and  increase  in  the  tactile  fremitus;  but 
the  most  characteristic  feature  is  the  presence  of  a  reddish-brown  expectoration 
of  a  brick-dust  color,  resembling  anchovy  sauce.  This,  which  was  noted  origi- 
nally by  Budd,  was  present  in  our  cases,  and  in  addition  Eeese  and  Lafleur 
found  the  amcebce  coli  identical  with  those  which  exist  in  the  liver  abscess  and 


566  DISEASES  OF   THE  DIGESTIVE  SYSTEM. 

in  the  stools.  They  are  present  in  variable  numbers  and  display  active  amoe- 
boid movements.  The  brownish  tint  of  the  exj)ectoration  is  due  to  blood- 
pigment  and  blood-corpuscles^  and  there  may  be  orange-red  crystals  of  h^ma- 
toidin. 

The  abscess  may  perforate  externally,  as  mentioned  already,  or  into  the 
stomach  or  bowel;  occasionally  into  the  pericardium.  The  duration  of  this 
form  is  very  variable.  It  may  run  its  course  and  prove  fatal  in  six  or  eight 
weeks  or  may  persist  for  several  years. 

The  prognosis  is  serious,  as  the  mortality  is  more  than  50  per  cent.  The 
death-rate  has  been  lowered  of  late  years,  owing  to  the  great  fearlessness  with 
which  the  surgeons  now  attack  these  cases. 

(b)  Of  the  Pyemic  Abscess  and  Suppurative  Pylephlebitis. — Clin- 
ically these  conditions  can  not  be  separated.  Occurring  in  a  general  pygemia, 
no  special  features  may  be  added  to  the  case.  When  there  is  suppuration 
within  the  portal  vein  the  liver  is  uniformly  enlarged  and  tender,  though 
pain  may  not  be  a  marked  feature.  There  is  an  irregular,  septic  fever,  and 
the  complexion  is  muddy,  sometimes  distinctly  icteroid.  The  features  are 
indeed  those  of  pyaemia,  plus  a  slight  icteroid  tinge,  and  an  enlarged  and 
painful  liver.  The  latter  features  alone  are  peculiar.  The  sweats,  chills,  pros- 
tration, and  fever  have  nothing  distinctive. 

Diagnosis. — Abscess  of  the  liver  may  be  confounded  with  intermittent 
fever,  a  common  mistake  in  malarial  regions.  Practically  an  intermittent 
fever  which  resists  quinine  is  not  malarial.  Laveran's  organisms  are  also 
absent  from  the  blood.  When  the  abscess  bursts  into  the  pleura  a  right-sided 
empyema  is  produced  and  perforation  of  the  lung  usually  follows.  When 
the  liver  abscess  has  been  latent  and  dysenteric  symptoms  have  not  been 
marked,  the  condition  may  be  considered  empyema  or  abscess  of  the  lung. 
In  such  cases  the  anchovy-sauce-like  color  of  the  pus  and  the  presence  of 
the  amoeba  will  enable  one  to  make  a  definite  diagnosis.  Perforation  exter- 
nally is  readily  recognized,  and  yet  in  an  abscess  cavity  in  the  epigastric  region 
it  may  be  difficult  to  say  whether  it  has  proceeded  from  the  liver  or  is  in  the 
abdominal  wall.  When  the  abscess  is  large,  and  the  adhesions  are  so  firm 
that  the  liver  does  not  descend  during  inspiration,  the  exploratory  needle  does 
not  make  an  up-and-down  movement  during  aspiration.  The  diagnosis  of 
suppurating  echinococcus  cyst  is  rarely  possible,  except  in  Australia  and  Ice- 
land, where  hydatids  are  so  common. 

Perhaps  the  most  important  affection  from  which  suppuration  within  the 
liver  is  to  be  separated  is  the  intermittent  hepatic  fever  associated  with  gall- 
stones. Of  the  cases  reported  a  majority  have  been  considered  due  to  suppu- 
ration, and  in  two  of  my  cases  the  liver  had  been  repeatedly  aspirated.  Post- 
mortem examinations  have  shown  conclusively  that  the  high  fever  and  chills 
may  recur  at  intervals  for  years  without  suppuration  in  the  ducts.  The  dis- 
tinctive features  of  this  condition  are  paroxysms  of  fever  with  rigors  and 
sweats — which  may  occur  with  great  regularity,  but  which  more  often  are 
separated  by  long  intervals — the  deepening  of  the  jaundice  after  the  parox- 
ysms, the  entire  apyrexia  in  the  intervals,  and  the  maintenance  of  the  general 
nutrition.  The  time  element  also  is  important,  as  in  some  of  these  cases  the 
disease  has  lasted  for  several  years.  Finally,  it  is  to  be  remembered  that 
abscess  of  the  liver,  in  temperate  climates  at  least,  is  invariably  secondary,  and 


DISEASES  OF  THE  LIVER.  567 

the  primary  source  must  be  carefully  sought  for,  either  in  dysentery,  slight 
ulceration  of  the  rectum,  suppurating  haemorrhoids,  ulcer  of  the  stomach,  or 
in  suppurative  disease  of  other  parts  of  the  body,  particularly  within  the  skull 
or  in  the  bones. 

Leucocytosis  may  be  absent  in  the  amoebic  abscess  of  the  liver;  in  septic 
cases  it  may  be  very  high. 

In  suspected  cases,  whether  the  liver  is  enlarged  or  not,  exploratory  aspira- 
tion may  be  performed  without  risk.  The  needle  may  be  entered  in  the  ante- 
rior axillary  line  in  the  lowest  interspace,  or  in  the  seventh  interspace  in  the 
mid-axillary  line,  or  over  the  centre  of  the  area  of  dulness  behind.  The  patient 
should  be  placed  under  ether,  for  it  may  be  necessary  to  make  several  deep 
punctures.  It  is  not  well  to  use  too  small  an  aspirator.  No  ill  effects  follow 
this  procedure,  even  though  blood  may  leak  into  the  peritoneal  cavity.  Ex- 
tensive suppuration  may  exist,  and  yet  be  missed  in  the  aspiration,  particu- 
larly when  the  branches  of  the  portal  vein  are  distended  with  pus. 

Treatment. — Pysemic  abscess  and  suppurative  pylephlebitis  are  invariably 
fatal.  Treves,  however,  reports  a  case  of  pyaemic  abscess  following  appendi- 
citis in  which  the  patient  recovered  after  an  exploratory  operation.  Surgical 
measures  are  not  justified  in  these  cases,  unless  an  abscess  shows  signs  of 
pointing.  As  the  abscesses  associated  with  dysentery  are  often  single,  they 
afford  a  reasonable  hope  of  benefit  from  operation.  If,  however,  the  patient 
is  expectorating  the  pus,  if  the  general  condition  is  good  and  the  hectic  fever 
not  marked,  it  is  best  to  defer  operation,  as  many  of  these  instances  recover 
spontaneously.  The  large  single  abscesses  are  the  most  favorable  for  operation. 
The  general  medical  treatment  of  the  cases  is  that  of  ordinary  septicsemia. 

IX.    NEW    GROWTHS    IN    THE    LIVER. 

These  may  be  cancer,  either  primary  or  secondary,  sarcoma,  or  angioma. 

Etiology. — Cancer  of  the  liver  is  third  in  order  of  frequency  of  internal 
cancer.  It  is  rarely  primary,  usually  secondary  to  cancer  in  other  organs. 
It  is  a  disease  of  late  adult  life.  According  to  Leichtenstern,  over  50  per  cent 
of  the  cases  occur  between  the  fortieth  and  the  sixtieth  years.  It  occasionally 
occurs  in  children.  Women  are  attacked  less  frequently  than  men.  It  is 
stated  by  some  authors  that  secondary  cancer  is  more  common  in  women,  owing 
to  the  frequency  of  cancer  of  the  uterus.  Heredity  is  believed  to  have  an  influ- 
ence in  from  15  to  20  per  cent. 

In  many  cases  trauma  is  an  antecedent,  and  cancer  of  the  bile-passages  is 
associated  in  many  instances  with  gall-stones.  Cancer  is  stated  to  be  less 
common  in  the  tropics. 

Morbid  Anatomy. — The  following  forms  of  new  growths  occur  in  the  liver 
and  have  a  clinical  importance : 

Cancek. —  (1)   Primary  cancer,  of  which  three  forms  may  be  recognized. 

(a)  The  massive  cancer,  which  causes  great  enlargement  and  on  section 
shows  a  uniform  mass  of  new  growth,  which  occupies  a  large  portion  of  the 
organ.  It  is  grayish-white,  usually  not  softened,  and  is  abruptly  outlined 
from  the  contiguous  liver  substance. 

(&)  Nodular  cancer,  in  which  the  liver  is  occupied  by  nodular  masses, 
some  large,  some  small,  irregularly  scattered  throughout  the  organ.     Usu- 


568  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

ally  in  one  region  there  is  a  larger,  perhaps  firmer,  older-looking  mass,  which 
indicates  the  primary  seat,  and  the  numerous  nodules  are  secondary  to  it. 
This  form  is  much  like  the  secondary  cancerous  involvement,  except  that  it 
seldom  reaches  a  large  size. 

(c)  Adeno-carcinoma  with  cirrhosis.  The  liver  varies  in  size,  small  as 
a  rule,  but  in  a  few  cases  enlarged.  The  surface  is  usually  mottled  dark  green, 
with  elevated  yellowish  nodules  beneath  the  capsule,  or  even  large  globular 
masses  projecting.  On  section  the  tissue  is  bile-stained,  and  there  are  innu- 
merable tumor  masses,  varying  in  size,  separated  from  each  other  by  strands 
of  connective  tissue,  which  may  be  5  to  10  mm.  across.  The  growths  may  be 
unevenly  distributed.  The  connection  between  the  adenoma  and  the  cirrhosis 
is  not  known,  nor  is  it  known  which  is  primary.  There  is,  as  a  rule,  extensive 
vicarious  hypertrophy  of  the  liver  tissue.  Of  the  two  cases  which  have  been 
under  my  care,  in  one  I  diagnosed  cirrhosis,  and  the  clinical  picture  was  that 
of  the  ordinary  atrophic  form;  the  other  I  thought  to  be  carcinoma  (C.  H. 
Travis,  J.  H.  H.  Bull.,  1902).  The  latter  patient  died  of  haemorrhage  into 
the  peritoneal  cavity,  a  similar  ending  to  that  in  the  case  reported  by  Peabody. 

Histologically,  the  primary  cancers  are  epitheliomata — alveolar  and  trabec- 
ular. The  character  of  the  cells  varies  greatly.  In  some  varieties  they  are  poly- 
morphous ;  in  others  small  polyhedral ;  in  others,  again,  giant  cells  are  found. 
In  rare  instances,  as  in  one  described  by  Greenfield,  the  cells  are  cylindrical. 
The  trabecular  form  of  epithelioma  is  also  known  as  adenoma  or  adeno- 
carcinoma. 

(2)  Secondary  Cancer. — The  organ  may  reach  an  enormous  size,  30^ 
pounds  (Osier),  33  pounds  (Christian).  The  cancerous  nodules  project 
beneath  the  capsule,  and  can  be  felt  during  life  or  even  seen  through  the 
thin  abdominal  walls.  They  are  usually  disseminated  equally,  though  in  rare 
instances  they  may  be  confined  to  one  lobe.  The  consistence  of  the  nodules 
varies;  in  some  cases  they  are  firm  and  hard  and  those  on  the  surface  show 
a  distinct  umbilication,  due  to  the  shrinking  of  the  fibrous  tissue  in  the  centre. 
These  superficial  cancerous  masses  are  still  sometimes  spoken  of  as  "  Farre's 
tubercles."  More  frequently  the  masses  are  on  section  grayish-white  in  color, 
or  hsemorrhagic.  Eupture  of  blood-vessels  is  not  uncommon  in  these  cases. 
In  one  specimen  there  was  an  enormous  clot  beneath  the  capsule  of  the  liver, 
together  with  haemorrhage  into  the  gall-bladder  and  into  the  peritonaeum. 
The  secondary  cancer  shows  the  same  structure  as  the  initial  lesion,  and  is 
usually  either  an  alveolar  or  cylindrical  carcinoma.  Degeneration  is  common 
in  these  secondary  growths ;  thus  the  hyaline  transformation  may  convert  large 
areas  into  a  dense,  dry,  grayish-yellow  mass.  Extensive  areas  of  fatty  degen- 
eration may  occur,  sclerosis  is  not  uncommon,  and  haemorrhages  are  frequent. 
Suppuration  sometimes  follows. 

(3)  Cancer  of  the  hile-passages  which  has  been  already  considered. 

Sarcoma. — Of  primary  sarcoma  of  the  liver  very  few  cases  have  been  re- 
ported. Secondary  sarcoma  is  more  frequent,  and  many  examples  of  lympho- 
sarcoma and  myxo-sarcoma  are  on  record,  less  frequently  glio-sarcoma  or  the 
smooth  or  striped  myoma. 

The  most  important  form  is  the  melano-sarcoma,  secondary  to  sarcoma 
of  the  eye  or  of  the  skin.  Very  rarely  melano-sarcoma  occurs  primarily  in  the 
liver.     Of  the  reported  cases  Hanot  excludes  all  but  one.     In  this  form  the 


DISEASES  OF  THE  LIVER.  569 

liver  is  greatly  enlarged,  is  either  uniformly  infiltrated  with  the  growth  which 
gives  the  cut  surface  the  appearance  of  dark  granite,  or  there  are  large  nodu- 
lar masses  of  a  deep  black  or  marbled  color.  There  are  usually  extensive  metas- 
tases, and  in  some  instances  every  organ  of  the  body  is  involved.  Nodules  of 
melano-sarcoma  of  the  skin  may  give  a  clew  to  the  diagnosis. 

Other  Forms  of  Liver  Tumor. — One  of  the  commonest  tumors  in  the 
liver  is  the  angioma,  which  occurs  as  a  small,  reddish  body  the  size  of  a 
walnut,  and  consists  simply  of  a  series  of  dilated  vessels.  Occasionally  in  chil- 
dren angiomata  grow  and  produce  large  tumors. 

Cysts  are  occasionally  found  in  the  liver,  either  single,  which  is  not  very 
uncommon,  or  multiple,  when  they  usually  coexist  with  congenital  cystic 
kidneys. 

Symptoms. — It  is  often  impossible  to  differentiate  primary  and  secondary 
cancer  of  the  liver  unless  the  primary  seat  of  the  disease  is  evident,  as  in  the 
case  of  scirrhus  of  the  breast,  or  cancer  of  the  rectum,  or  of  a  tumor  in  the 
stomach,  which  can  be  felt.  As  a  rule,  cancer  of  the  liver  is  associated  with 
progressive  enlargement;  but  in  some  cases  of  primary  nodular  cancer,  and 
in  the  cancer  with  cirrhosis  the  organ  may  not  be  enlarged.  Gastric  disturb- 
ance, loss  of  appetite,  nausea,  and  vomiting  are  frequent.  Progressive  loss  of 
flesh  and  strength  may  be  the  first  symptoms.  Pain  or  a  sensation  of  uneasi- 
ness in  the  right  hypochondriac  region  may  be  present,  but  enormous  enlarge- 
ment of  the  liver  may  occur  without  the  slightest  pain.  Jaundice,  which  is 
present  in  at  least  one-half  of  the  cases,  is  usually  of  moderate  extent,  unless 
the  common  duct  is  occluded.  Ascites  is  rare,  except  in  the  form  of  cancer 
with  cirrhosis,  in  which  the  clinical  picture  is  that  of  the  atrophic  form.  Pres- 
sure by  nodules  on  the  portal  vein  or  extension  of  the  cancer  to  the  peritonaeum 
may  also  induce  ascites. 

Inspection  shows  the  abdomen  to  be  distended,  particularly  in  the  upper 
zone.  In  late  stages  of  the  disease,  when  emaciation  is  marked,  the  cancerous 
nodules  can  be  plainly  seen  beneath  the  skin,  and  in  rare  instances  even  the 
umbilications.  The  superficial  veins  are  enlarged.  On  palpation  the  liver  is 
felt,  a  hand's-breadth  or  more  below  the  costal  margin,  descending  with  each 
inspiration.  The  surface  is  usually  irregular,  and  may  present  large  masses 
or  smaller  nodular  bodies,  either  rounded  or  with  central  depressions.  In 
instances  of  diffuse  infiltration  the  liver  may  be  greatly  enlarged  and  present 
a  perfectly  smooth  surface.  The  growth  is  progressive,  and  the  edge  of  the 
liver  may  ultimately  extend  below  the  level  of  the  navel.  Although  generally 
uniform  and  producing  enlargement  of  the  whole  organ,  occasionally  the 
tumor  in  the  left  lobe  forms  a  solid  mass  occupying  the  epigastric  region.  By 
percussion  the  outline  can  be  accurately  limited  and  the  progressive  growth  of 
the  tumor  estimated.  The  spleen  is  rarely  enlarged.  Pyrexia  is  present  in 
many  cases,  usually  a  continuous  fever,  ranging  from  100°  to  102° ;  it  may  be 
intermittent,  with  rigors.  This  may  be  associated  with  the  cancer  alone,  or, 
as  in  one  of  my  cases,  with  suppuration.  (Edema  of  the  feet,  from  anaemia, 
usually  Supervenes.  Cancer  of  the  liver  kills  in  from  three  to  fifteen  months. 
One  of  my  patients  lived  for  more  than  two  years. 

Diagnosis. — The  diagnosis  is  easy  when  the  liver  is  greatly  enlarged  and 
the  surface  nodular.  The  smoother  forms  of  diffuse  carcinoma  may  at  first 
be  mistaken  for  fatty  or  amyloid  liver,  but  the  presence  of  jaundice,  the  rapid 
38 


570  DISEASES  OP  THE  DIGESTIVE  SYSTEM. 

enlargement,  and  the  more  marked  cachexia  will  usually  suffice  to  differen- 
tiate it.  Perhaps  the  most  puzzling  conditions  occur  in  the  rare  cases  of 
enlarged  amyloid  liver  with  irregular  gummata.  The  large  echinococcus  liver 
may  present  a  striking  similarity  to  carcinoma,  but  the  projecting  nodules 
are  usually  softer,  the  disease  lasts  much  longer,  and  the  cachexia  is  not 
marked. 

Hypertrophic  cirrhosis  may  at  first  be  mistaken  for  carcinoma,  as  the  jaun- 
dice is  usually  deep  and  the  liver  very  large;  but  the  absence  of  a  marked 
cachexia  and  wasting,  and  the  painless,  smooth  character  of  the  enlargement 
are  points  against  cancer.  When  in  doubt  in  these  cases,  aspiration  may  be 
safely  performed,  and  positive  indication  may  be  gained  from  the  materials 
so  obtained.  In  large,  rapidly  growing  secondary  cancers  the  superficial 
rounded  masses  may  almost  fluctuate  and  these  soft  tumor-like  projections  may 
contain  blood.  The  form  of  cancer  with  cirrhosis  can  scarcely  be  separated 
from  atrophic  cirrhosis  itself.  Perhaps  the  wasting  is  more  extreme  and  more 
rapid,  but  the  jaundice  and  the  ascites  are  identical.  Melano-sarcoma  causes, 
great  enlargement  of  the  organ.  There  are  frequently  symptoms  of  involve- 
ment of  other  viscera,  as  the  lungs,  kidneys,  or  spleen.  Secondary  tumors 
may  occur  in  the  skin.  A  very  important  symptom,  not  present  in  all  cases, 
is  melanuria,  the  passage  of  a  very  dark-colored  urine,  which  may,  however, 
when  first  voided,  be  quite  normal  in  color.  The  existence  of  a  melano-sar- 
coma of  the  eye,  or  the  history  of  blindness  in  one  eye,  with  subsequent  extir- 
pation, may  indicate  at  once  the  true  nature  of  the  hepatic  enlargement.  The 
secondary  tumors  may  arise  some  time  after  the  extirpation  of  the  eye,  as  in 
a  case  under  the  care  of  J.  C.  Wilson,  at  the  Philadelphia  Hospital,  or,  as  in 
a  case  under  Tyson  at  the  same  institution,  the  patient  may  have  a  sarcoma 
of  the  choroid  which  had  never  caused  any  symptoms. 

The  treatment  must  be  entirely  symptomatic.  The  question  of  surgical 
interference  may  be  discussed.  Keen  has  collected  reports  of  76  cases  of  resec- 
tion of  tumors  of  the  liver,  63  of  which  recovered. 

X.    FATTY   LIVER. 

Two  different  forms  of  this  condition  are  recognized — ^the  fatty  infiltra- 
tion and  fatty  degeneration. 

Fatty  infiltration  occurs,  to  a  certain  extent,  in  normal  livers,  since  the  cells 
always  contain  minute  globules  of  oil. 

In  fatty  degeneration,  which  is  a  much  less  common  condition,  the  proto- 
plasm of  the  liver-cells  is  destroyed  and  the  fat  takes  its  place,  as  seen  in  cases 
of  malignant  jaundice  and  in  phosphorus  poisoning. 

Fatty  liver  occurs  under  the  following  conditions:  (a)  In  association  with 
general  obesity,  in  which  case  the  liver  appears  to  be  one  of  the  storehouses  of 
the  excessive  fat.  (h)  In  conditions  in  which  the  oxidation  processes  are  inter- 
fered with,  as  in  cachexia,  profound  angemia,  and  in  phthisis.  The  fatty  infil- 
tration of  the  liver  in  heavy  drinkers  is  to  be  attributed  to  the  excessive  demand 
made  by  the  alcohol  upon  the  oxygen,  (c)  Certain  poisons,  of  which  phos- 
phorus is  the  most  characteristic,  produce  an  intense  fatty  degeneration  with 
necrosis  of  the  liver-cells.  The  poison  of  acute  yellow  atrophy,  whatever  its 
nature,  acts  in  the  same  way. 


DISEASES  OF  THE  LIVER.  571 

The  fatty  liver  is  uniformly  increased  in  size.  The  edge  may  reach  below 
the  level  of  the  navel.  It  is  smooth,  looks  pale  and  bloodless ;  on  section  it  is 
dry,  and  renders  the  surface  of  the  knife  greasy.  The  liver  may  weigh  many 
pounds,  and  yet  the  specific  gravity  is  so  low  that  the  entire  organ  floats  in 
water. 

The  symptoms  of  fatty  liver  are  not  definite.  Jaundice  is  never  present; 
the  stools  may  be  light-colored,  but  even  in  the  most  advanced  grades  the  bile 
is  still  formed.  Signs  of  portal  obstruction  are  rare.  Hsemorrhoids  are  not 
very  infrequent.  Altogether,  the  symptoms  are  ill-defined,  and  are  chiefly  those 
of  the  disease  with  which  the  degeneration  is  associated.  In  cases  of  great 
obesity,  the  physical  examination  is  uncertain;  but  in  phthisis  and  cachectic 
conditions,  the  organ  can  be  felt  to  be  greatly  enlarged,  though  smooth  and 
painless.    Fatty  livers  are  among  the  largest  met  with  at  the  bedside, 

XI.    AMYLOID   LIVER. 

The  waxy,  lardaceous,  or  amyloid  liver  occurs  as  part  of  a  general  degen- 
eration, associated  with  cachexias,  particularly  when  the  result  of  long-stand- 
ing suppuration. 

In  practice,  it  is  found  oftenest  in  the  prolonged  suppuration  of  tubercu- 
lous disease,  either  of  the  lungs  or  of  the  bones.  Next  in  order  of  frequency 
are  the  cases  associated  with  syphilis.  Here  there  may  be  ulceration  of  the 
rectum,  with  which  it  is  often  connected,  or  chronic  disease  of  the  bone,  or  it 
may  be  present  when  there  are  no  suppurative  changes.  It  is  found  occasion- 
ally in  rickets,  in  prolonged  convalescence  from  the  infectious  fevers,  and  in 
the  cachexia  of  cancer. 

The  amyloid  liver  is  large,  and  may  attain  dimensions  equalled  only  by 
those  of  the  cancerous  organ.  Wilks  speaks  of  a  liver  weighing  fourteen 
pounds.  It  is  solid,  flrm,  resistant,  on  section  anaemic,  and  has  a  semitranslu- 
cent,  infiltrated  appearance.  Stained  with  a  dilute  solution  of  iodine,  the 
areas  infiltrated  with  the  amyloid  matter  assume  a  rich  mahogany-brown  color. 
The  precise  nature  of  this  change  is  still  in  question.  It  first  attacks  the 
capillaries,  usually  of  the  median  zone  of  the  lobules,  and  subsequently  the 
interlobular  vessels  and  the  connective  tissue.  The  cells  are  but  little  if  at 
all  affected. 

There  are  no  characteristic  symptoms  of  this  condition.  Jaundice  does  not 
occur ;  the  stools  may  be  light-colored,  but  the  secretion  of  bile  persists.  The 
physical  examination  shows  the  organ  to  be  uniformly  enlarged  and  painless, 
the  surface  smooth,  the  edge  rounded,  and  the  consistence  greatly  increased. 
Sometimes  the  edge,  even  in  very  great  enlargement,  is  sharp  and  hard.  The 
spleen  also  may  be  involved,  but  there  are  no  evidences  of  portal  obstruction. 

The  diagnosis  of  the  condition  is,  as  a  rule,  easy.  Progressive  and  great 
enlargement  in  connection  with  suppuration  of  long  standing  or  with  syphilis, 
is  almost  always  of  this  nature.  In  rare  instances,  however,  the  amyloid  liver 
is  reduced  in  size. 

In  leukcemia  the  liver  may  attain  considerable  size  and  be  smooth  and  uni- 
form, resembling,  on  physical  examination,  the  fatty  organ.  The  blood  condi- 
tion at  once  indicates  the  true  nature  of  the  case. 


572  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


XII.    ANOMALIES    IN    FORM    AND    POSITION    OF    THE 

LIVER. 

In  transposition  of  the  viscera  the  right  lobe  of  the  organ  may  occupy  the 
left  side.  A  common  and  important  anomaly  is  the  tilting  forward  of  the 
organ,  so  that  the  antero-posterior  axis  becomes  vertical,  not  horizontal.  In- 
stead of  the  edge  of  the  right  lobe  presenting  just  below  the  costal  margin,  a 
considerable  portion  of  the  surface  of  the  lobe  is  in  contact  with  the  abdominal 
parietes,  and  the  edge  may  be  felt  as  low,  perhaps,  as  the  navel.  This  ante- 
version  is  apt  to  be  mistaken  for  enlargement  of  the  organ. 

The  "  lacing  "  liver  is  met  with  in  two  chief  types.  In  one  the  anterior 
portion,  chiefly  of  the  right  lobe,  is  greatly  prolonged,  and  may  reach  the 
transverse  navel  line,  or  even  lower.  A  shallow  transverse  groove  separates 
the  thin  extension  from  the  main  portion  of  the  organ.  The  peritoneal  coat- 
ing of  this  groove  may  be  fibroid,  and  in  rare  instances  the  deformed  portion 
is  connected  with  the  organ  by  an  almost  tendinous  membrane.  The  liver  may 
be  compressed  laterally  and  have  a  p^Tamidal  shape,  and  the  extreme  left  bor- 
der and  the  hinder  margin  of  the  left  lobe  may  be  much  folded  and  incurved. 
The  projecting  portion  of  the  liver,  extending  low  in  the  right  flank,  may  be 
mistaken  for  a  tumor,  or  more  frequently  for  a  movable  right  kidney.  Its 
continuity  with  the  liver  itself  may  not  be  evident  on  palpation  or  on  percus- 
sion, as  coils  of  intestine  may  lie  in  front.  It  descends,  however,  with  inspira- 
tion, and  usually  the  margin  can  be  traced  continuously  with  that  of  the  left 
lobe  of  the  liver.  The  greatest  difficulty  arises  when  this  anomalous  lappet  of 
the  liver  is  either  naturally  very  thick  and  united  to  the  liver  by  a  very  thin 
membrane,  or  when  it  is  swollen  in  conditions  of  great  congestion  of  the 
organ. 

The  other  principal  type  of  lacing  liver  is  quite  different  in  shape.  It 
is  thick,  broader  above  than  below,  and  lies  almost  entirely  above  the  trans- 
verse line  of  the  cartilages.  There  is  a  narrow  groove  just  above  the  anterior 
border,  which  is  placed  more  transversely  than  normal. 

Movable  Liver. — This  rare  condition  has  received  much  attention,  and 
J.  E.  Graham  collected  70  reported  cases  from  the  literature.  In  a  very  con- 
siderable number  of  these  there  has  been  a  mistaken  diagnosis.  A  slight  grade 
of  mobility  of  the  organ  is  found  in  the  pendulous  abdomen  of  enteroptosis, 
and  after  repeated  asciteg. 

The  organ  is  so  connected  at  its  posterior  margin  with  the  inferior  vena 
cava  and  diaphragm  that  any  great  mobility  from  this  point  is  impossible,  ex- 
cept on  the  theory  of  a  meso-hepar  or  congenital  ligamentous  union  between 
these  structures.  The  ligaments,  however,  may  show  an  extreme  grade  of 
relaxation  (the  suspensory  7.5  cm.,  and  the  triangular  ligament  4  cm.,  in  one 
of  Leube's  cases) ;  and  when  the  patient  is  in  the  erect  posture  the  organ  may 
drop  down  so  far  that  its  upper  surface  is  entirely  below  the  costal  margin. 
The  condition  is  rarely  met  with  in  men;  56  of  the  cases  were  in  women. 


DISEASES  OF  THE  PANCREAS.  573 

I.    DISEASES  OF  THE  PANCREAS. 

I,    PANCREATIC    INSUFFICIENCY. 

Much  attention  has  been  given  to  the  study  of  conditions  in  which  the 
secretions  of  the  gland  are  defective.  No  one  sign  is  distinctive,  but  a  com- 
bination gives  a  fairly  accurate  picture.  The  lesions  are  sclerosis,  atrophy, 
acute  and  chronic  inflammatory  changes,  new  growths  and  possibly  functional 
disturbances  without  obvious  alterations  of  structure.     The  indications  are, 

1,  Changes  in  the  character  of  the  stools;  (a)  an  excess  of  total  fat  in  the 
fjeces,  which  in  some  cases  has  been  as  high  as  90  per  cent.  The  neutral  fats 
predominate  in  cases  not  associated  with  jaundice,  (h)  Diminution  of  the 
tryptic  energy,  as  shown  by  the  failure  to  digest  the  nuclei  of  the  muscle 
fibres  (Schmidt  test)  ;  (c)  imperfect  digestion  of  the  carbohydrates.  The 
stools  are  bulky,  soft,  acid,  grayish  white  in  color  and  have  a  peculiar  odor. 

2,  Changes  in  the  urine;  (a)  sugar  is  present  in  certain  cases,  as  considered 
under  diabetes;  (&)  Cammidge's  reaction. — In  many  lesions  of  the  pancreas 
this  author  claims  that  there  is  excreted  by  the  kidneys  a  substance  which  in 
hydrolysis  gives  the  reaction  of  a  pentose.  The  value'  of  this  is  still  under 
discussion;  the  results  with  the  improved  method  have  been  favorable,  (c) 
The  value  of  the  presence  in  the  urine  of  the  fat-splitting  ferment  of  Opie, 
the  Sahli  reaction,  of  lipuria,  and  of  maltosuria,  has  yet  to  be  determined. 

II.    H^MOmiHAGE. 

Both  Spiess  (1866)  and  Zenker  (1874)  were  acquainted  with  haemor- 
rhage into  the  pancreas  as  a  cause  of  sudden  death,  but  the  great  medico-legal 
importance  of  the  subject  was  first  fully  recognized  by  F.  W.  Draper,  of  Bos- 
ton, whose  townsmen,  Harris,  Fitz,  Whitney,  and  others  have  contributed 
additional  studies.  In  4,000  autopsies  Draper  met  with  19  cases  of  pancreatic 
hgemorrhage,  in  9  or  10  of  which  no  other  cause  of  death  was  found.  When 
the  bleeding  is  extensive  the  entire  tissue  of  the  gland  is  destroyed  and  the 
blood  invades  the  retro-peritoneal  tissue.  In  other  instances  the  peritoneal 
covering  is  broken  and  the  blood  fills  the  lesser  peritonaeum  (see  hsemoperito- 
nseum).  The  hsemorrhage  may  be  in  connection  with  an  acute  pancreatitis  or 
with  necrotic  inflammation  of  the  gland. 

The  symptoms  are  thus  briefly  summarized  by  Prince :  "  The  patient  who 
has  previously  been  perfectly  well,  is  suddenly  taken  with  the  illness  which 
terminates  his  life.  .  .  .  When  the  haemorrhage  occurs  the  patient  may  be 
quietly  resting  or  pursuing  his  usual  occupation.  The  pain  which  ushers  in 
the  attack  is  usually  very  severe  and  located  in  the  upper  part  of  the  abdomen. 
It  steadily  increases  in  severity,  is  sharp  or  perhaps  colicky  in  character.  It 
is  almost  from  the  first  accompanied  by  nausea  and  vomiting;  the  latter  be- 
comes frequent  and  obstinate,  but  gives  no  relief.  The  patient  soon  becomes 
anxious,  restless,  and  depressed;  he  tosses  about,  and  only  with  difficulty  can 
.  he  be  restrained  in  bed.  The  surface  is  cold  and  the  forehead  is  covered  with 
a  cold  sweat.  The  pulse  is  weak,  rapid,  and  sooner  or  later  imperceptible.  The 
abdomen  becomes  tender,  the  tenderness  being  located  in  the  upper  part  of  the 


574  DISEASES  OF   THE  DIGESTIVE  SYSTEM. 

abdomen  or  epigastrmm.     Tympanites  is  sometimes  marked.     The  tempera- 
ture is  usually  normal  or  subnormal.     The  bowels  are  apt  to  be  constipated. 

III.    ACUTE    PANCREATITIS. 

(a)  Acute  Hsemorrhagic  Pancreatitis. — In  this  form  the  inflammation  is 
combined  with  haemorrhage,  and  it  is  difficult  to  separate  clearly  the  two  proc- 
esses. 

Etiology. — A  large  majority  of  the  cases  occur  in  adult  males.  McPhed- 
ran  has  reported  one  in  a  nine  months'  old  child.  Many  of  the  patients  had 
been  addicted  to  alcohol;  others  had  suffered  occasionally  with  severe  pains 
and  vomiting  or  with  gall-stone  colic.  Peiser  found  that  8  out  of  131  col- 
lected cases  of  acute  pancreatitis  were  associated  with  parturition.  He  sug- 
gests that  the  changes  bringing  about  the  pancreatitis  in  these  cases  may  be 
analogous  to  those  occurring  in  the  liver,  kidneys,  and  other  organs  in  eclamp- 
sia. Miinzer,  on  the  other  hand,  advances  the  hypothesis  that  the  initial 
necrosis  may  result  from  embolism  with  giant  cells  from  the  placenta.- 

The  pancreas  is  found  enlarged,  and  the  interlobular  tissue  infiltrated 
with  blood,  and  perhaps  with  clots.  The  relation  of  gall-stones  to  the  con- 
dition has  been  demonstrated  in  a  recent  case  (Opie).  A  small  calculus  had 
lodged  in  the  diverticulum  of  Yater,  closing  its  duodenal  orifice  and  converting 
the  common  bile  duct  and  the  duct  of  Wirsung  into  a  closed  channel.  Bile 
finding  its  way  into  the  pancreas  had  caused  hasmorrhagic  inflammation.  In- 
jection of  bile  into  the  pancreatic  ducts  of  dogs  reproduces  the  lesion.  The 
gland  cells  have  undergone  more  or  less  wide-spread  necrosis,  and  at  the  mar- 
gin of  the  necrotic  areas  are  accumulations  of  inflammatory  products,  red 
blood-corpuscles,  polynuclear  leucocytes,  and  fibrin.  There  can  be  seen  about 
the  lobules  and  upon  the  omentum  and  mesentery  opaque  white  specks,  the 
fat  necroses  of  Balser. 

Symptoms. — One  of  the  most  characteristic  features  is  the  suddenness  of 
the  onset,  usually  with  violent  colicky  pain  in  the  upper  part  of  the  abdomen. 
Nausea  and  vomiting  follow,  with  collapse  symptoms,  more  or  less  severe 
according  to  the  intensity  of  the  attack.  The  abdomen  becomes  swollen  and 
tense  and  there  is  constipation.  The  temperature  at  first  may  be  low;  sub- 
sequently fever  sets  in,  sometimes  initiated  by  a  chill.  There  may  be  early 
delirium.  Collapse  symptoms  supervene,  and  death  occurs  usually  from  the 
second  to  the  fourth  day,  or  even  earlier.  The  swelling  and  infiltration  in  the 
region  of  the  pancreas  necessarily  involve  the  cceliac  plexus,  and  the  stretch- 
ing of  the  nerves  may  account  for  the  agonizing  pain  and  the  sudden  col- 
lapse. In  a  case  which  I  have  reported  the  semilunar  ganglia  were  swollen, 
the  nerve-cells  indistinct,  and  there  was  an  interstitial  infiltration  of  round 
cells.  The  Pacinian  corpuscles  in  the  neighborhood  of  the  pancreas  were  enor- 
mously swollen  and  oedematous. 

Deep  pressure  on  the  upper  part  of  the  abdomen  may  give  evidence  of 
circumscribed  resistance. 

Diagnosis. — Intestinal  obstruction  or  acute  perforating  peritonitis  is  usu- 
ally suspected.  Now  that  the  condition  has  become  better  known  the  diagno- 
sis intra  vitam  has  been  made.  "  Acute  pancreatitis  is  to  be  suspected  when 
a  previously  healthy  person  or  a  sufferer  from  occasional  attacks  of  indiges- 


DISEASES  OF  THE  PANCREAS.  575 

tion  is  suddenly  seized  with  a  violent  pain  in  the  epigastrium  followed  by  vom- 
iting and  collapse,  and  in  the  course  of  twenty-four  hours  by  a  circumscribed 
epigastric  swelling,  tympanitic  or  resistant,  with  slight  elevation  of  tempera- 
ture. Circumscribed  tenderness  in  the  course  of  the  pancreas  and  tender  spots 
throughout  the  abdomen  are  valuable  diagnostic  signs"  (Fitz).  An  interest- 
ing case  admitted  to  the  Johns  Hopkins  Hospital  illustrates  a  common  mis- 
take. The  young  man  had  had  symptoms  of  obstruction  of  the  bowels  .for 
three  or  four  days.  The  abdomen  was  distended,  tender,  and  very  painful. 
I  saw  him  on  admission,  agreed  in  the  diagnosis  of  probable  obstruction,  and 
ordered  him  to  be  transferred  at  once  to  the  operating-room.  Halsted  found 
no  evidence  of  obstruction,  but  in  the  region  of  the  pancreas  and  at  the  root 
of  the  mesentery  there  was  a  dense,  thick,  indurated  mass,  and  there  were  areas 
of  fat-necrosis  in  both  mesentery  and  omentum.  Oddly  enough  this  patient 
returned  four  years  afterward  with  another  attack,  but  he  refused  to  be  oper- 
ated upon  and  was  taken  away  by  his  friends. 

(&)  Acute  Suppurative  Pancreatitis — Pancreatic  Abscess. — Fitz,  in  his 
monograph  in  1889,  reported  33  cases.  To  this  list  Korte  has  added  34.  Of 
the  cases,  33  were  in  males. 

Etiology. — The  etiology  in  a  majority  of  cases  is  doubtful.  Dyspeptic  dis- 
turbances and  trauma  have  preceded  the  onset  in  some  instances.  In  34  cases 
there  was  a  single  abscess ;  in  14  there  were  numerous  small  abscesses.  In  other 
instances  there  was  a  diffuse  purulent  infiltration.  Some  of  the  sequels  are 
peri-pancreatic  abscess,  perforation  into  the  stomach,  the  duodenum,  or  the 
peritonaeum,  and  thrombosis  of  the  portal  vein. 

Symptoms. — The  symptoms  of  suppurative  pancreatitis  are  not  always  well 
defined.  In  one  case  in  my  wards  Thayer  made  a  correct  diagnosis.  The 
patient,  aged  thirty-four,  had  had  occasional  attacks  of  severe  pain  and  vomit- 
ing. This  was  followed  by  fever  and  delirium.  A  deep-seated  mass  was  felt 
in  the  median  line  just  above  the  umbilicus.  Finney  operated  and  found  dis- 
seminated fat-necrosis  and  a  deep-seated  abscess  with  necrotic  pancreatic  tis- 
sue. The  patient  recovered.  The  course  of  the  suppurative  form  is  much 
more  chronic.  Icterus,  fatty  diarrhoea,  and  sugar  in  the  urine  have  been  met 
with  in  some  cases.  The  presence  of  a  tumor  mass  in  the  epigastrium  is  of 
the  greatest  moment. 

(c)  Gangrenous  Pancreatitis. — Complete  necrosis  of  the  gland,  or  part  of 
it,  may  follow  either  haemorrhage  or  hgemorrhagic  inflammation,  and  in  excep- 
tional cases  may  occur  after  suppurative  infiltration  or  after  injury  or  the 
perforation  of  an  ulcer  of  the  stomach.  In  Fitz's  monograph  15  cases  are 
reported.  Korte  has  increased  this  number  to  40.  Symptoms  of  hgemorrhagic 
pancreatitis  may  precede  or  be  associated  with  it.  Death  usually  follows  in 
from  ten  to  twenty  days,  with  symptoms  of  collapse. 

Anatomically  the  pancreas  may  present  a  dry  necrotic  appearance,  but  as 
a  rule  the  organ  is  converted  into  a  dark  slaty-colored  mass  lying  nearly  free 
in  the  omental  cavity  or  attached  by  a  few  shreds.  In  other  instances  the 
totally  or  partially  sequestrated  organ  may  lie  in  a  large  abscess  cavity,  form- 
ing a  palpable  tumor  in  the  epigastric  region.  In  two  cases,  reported  by  Chiari, 
the  necrotic  pancreas  was  discharged  per  rectum,  with  recovery. 

Relation  of  Fat-necrosis  to  Pancreatic  Disease. — In  connection  with  all 
forms  of  pancreatic  disease  small  yellowish  areas,  to  which  Balser  first  directed 


576  DISEASES  OF   THE  DIGESTIVE  SYSTEM. 

attention,  may  be  found  in  the  interlobular  pancreatic  tissue,  in  the  mesen- 
tery, in  the  omentum,  in  the  abdominal  fatty  tissue  generally,  and  occasion- 
ally in  the  pericardial  and  subcutaneous  fat.  It  is  stated  that  they  may  be 
present  without  disease  of  the  gland,  but  this  is  doubtful.  They  are  most  fre- 
quent in  the  hemorrhagic  and  necrotic  forms  of  pancreatitis,  less  common 
in  the  suppurative.  In.  the  pancreas  the  lobules  are  seen  to  be  separated  by  a 
dead-white  necrotic  tissue,  which  gives  a  remarkable  appearance  to  the  section. 
In  the  abdominal  fat  the  areas  are  usually  not  larger  than  a  pin's  head;  they 
at  once  attract  attention,  and  may  be  mistaken,  on  superficial  examination,  for 
miliary  tubercles  or  neoplasms.  They  may  be  larger;  instances  have  been  re- 
ported in  which  they  were  the  size  of  a  hen's  egg.  On  section  they  have  a  soft, 
tallow}^  consistence.  E.  Langerhans  has  shown  that  this  substance  is  a  com- 
bination of  lime  with  certain  fatty  acids.  They  may  be  crusted  with  lime, 
and  in  a  man,  aged  eighty,  who  died  of  Bright's  disease,  I  found  the  lobules 
of  the  pancreas  entirely  isolated  by  areas  of  fat-necrosis  with  extensive  depo- 
sition of  lime  salts.  There  is  no  necessary  etiological  relation  between  disease 
of  the  pancreas  and  disseminated  fat-necroses  of  the  abdomen  at  the  time 
the  latter  are  discovered.  They  have  been  found  accidentally  in  laparotomy 
for  ovarian  tumor  and  in  instances  in  which  the  pancreas  has  been  normal. 
They  may  be  present  in  thin  persons  or  in  association  with  gall-stones.  Bacil- 
lus coli  was  present  in  two  instances,  with  diphtheritic  colitis,  examined  by 
Welch,  though  in  most  cases  the  areas  of  necrosis  are  sterile.  Langerhans 
produced  fat-necrosis  by  injecting  extract  of  pancreas  into  the  peri-renal 
fatty  tissue  of  a  dog ;  and  Hildebrand  and  Dettmer  have  shown  experimentally 
that  the  fat-necroses  are  caused  by  certain  constituents  of  the  pancreatic 
juice,  but  not  by  trypsin.  Flexner  has  demonstrated  by  chemical  tests 
the  existence  of  the  fat-splitting  ferment  in  peritoneal  fat-necroses  in 
recent  human  and  experimental  cases.  The  ferment  (steapsin)  disappears 
after  five  or  six  days  in  experimental  necroses,  and  can  not  be  demonstrated 
in  the  lime-incrusted  human  ones.  H.  U.  Williams  has  produced  similar 
lesions  in  the  subcutaneous  fat  by  inserting  bits  of  sterile  pancreas  beneath 
the  skin.  By  ligating  the  pancreatic  ducts  of  cats  Opie  produced  at  the  end  of 
several  weeks  necrosis  of  almost  the  entire  abdominal  fat,  together  with  foci 
in  the  subcutaneous  tissue  and  in  the  pericardium.  Flexner  has  produced  acute 
hemorrhagic  pancreatitis  by  injecting  artificial  gastric  juice  into  the  duct  of 
Wirsung.  Opie  has  recently  made  the  interesting  observation  that  hsemor- 
rhagic  pancreatitis  and  fat-necrosis  may  be  produced  by  injecting  bile  into  the 
pancreatic  duct  of  dogs,  and  has  also  shown  that  the  penetration  of  bile  into 
the  pancreas  may  be  the  cause  of  these  conditions  in  human  cases. 

It  is  well  for  surgeons  to  remember  that  in  two  cases  at  least  the  most 
serious  symptoms  of  acute  pancreatic  disease  have  been  found  in  association 
only  with  wide-spread  fat-necrosis  of  the  gland.  In  a  case  reported  by  Stock- 
ton and  Williams  a  man,  on  his  return  journey  from  Europe,  was  seized  with 
vomiting  and  pain,  without  fever,  but  with  a  very  small  pulse.  The  patient 
died  soon  after  his  arrival  in  America.  The  post  mortem  showed  a  pancreas 
18  cm.  long,  at  first  sight  normal,  but  on  section  most  extensive  fatty  infiltra- 
tion with  fat-necrosis  was  demonstrable. 


DISEASES  OF  THE  PANCREAS.  577 


IV.    CHRONIC    PANCREATITIS. 

Anatomically  there  are  two  forms  (a)  interlobular,  including  that  caused 
by  occlusion  of  the  duct,  and  (&)  interacinar,  a  more  diffuse  process  invading 
the  islands  of  Langerhans,  which  are  spared  in  the  other  forms.  It  is  found 
as  a  common  condition,  if  microscopical  examination  is  made.  The  organ  is 
enlarged  and  hard  and  the  lobules  stand  out  clearly.  So  hard  may  the  gland 
be  that  surgeons  have  frequently  mistaken  the  enlarged  and  firm  head  for  a 
new  growth.  In  the  later  stages  the  gland  may  be  shrunken  and  cirrhotic. 
Pancreatic  calculi,  gall-stones,  infections  of  the  duct  (catarrhal  by  exten- 
sion from  the  duodenum)  are  the  common  causes;  a  very  typical  form  occurs 
in  hgemochromatosis.  The  symptoms  are  not  very  well  defined.  Many  of 
the  most  characteristic  specimens  have  been  met  with  accidentally.  When  due 
to  calculi  and  infection  of  the  ducts  there  are  pain,  dyspepsia,  fatty  stools, 
jaundice,  at  times  fever,  and  loss  of  weight.  The  jaundice  may  be  due  to 
compression  of  the  head  of  the  common  bile-duct  wher€  it  passes  through  the 
gland.  Progressive  wasting,  the  urinary  reactions  (Cammidge's  in  practised 
hands)  and  jaundice  are  the  most  important  diagnostic  features,  but  at  best 
there  is  a  good  deal  of  uncertainty.  It  is  quite  possible,  as  Mayo  Eobson  sug- 
gests, that  many  instances  of  so-called  catarrhal  jaundice  are  due  to  pressure 
on  the  common  duct  by  the  swollen  pancreatic  tissue.  From  a  surgical  stand- 
point jaundice  is  a  most  important  symptom  and  was  present  in  every  one  of 
the  18  cases  selected  to  illustrate  the  clinical  course,  etc.,  in  Mayo  Eobson  and 
Cammidge's  work  on  the  Pancreas.  Drainage  of  the  ducts  and  removal  of 
the  stones  are  advised. 


V.    PANCREATIC    CYSTS. 

Of  121  cases  operated  upon  by  surgeons  60  were  in  males  and  56  in 
females;  in  5  the  sex  was  not  given  (Korte).  Sixty-six  of  the  cases  occurred 
in  the  fourth  decade.  T.  C.  Eailton's  case  (which  is  not  in  Korte's  series), 
an  infant  aged  six  months,  and  Shattuck's  case  in  a  child  of  thirteen  and  a 
half  months,  are  the  youngest  in  the  literature.  According  to  the  origin 
Korte  recognizes  three  varieties. 

(1)  Traumatic  Cases. — In  this  list  of  33  cases  30  were  in  men  and  only 
3  in  women.  Blows  on  the  abdomen  or  constantly  repeated  pressure  are  the 
most  common  forms  of  trauma.  One  case  followed  severe  massage.  Usually 
with  the  onset  there  are  inflammatory  symptoms,  pain,  and  vomiting,  some- 
times suggestive  of  peritonitis.  The  contents  of  the  cyst  are  usually  bloody, 
though  in  13  of  the  traumatic  cases  it  was  clear  or  yellowish. 

(3)  Cysts  following  Inflammatory  Conditions. — In  51  cases  the  trouble 
began  gradually  after  attacks  of  dyspepsia  with  colic,  simulating  somewhat 
that  of  gall-stones.  Occasionally  the  attack  set  in  with  very  severe  symptoms, 
suggestive  of  obstruction  of  the  bowel.  In  this  group  the  tumor  appeared  in 
19  cases  soon  after  the  onset  of  the  pain ;  in  others  it  was  delayed  for  a  period 
of  from  a  few  weeks  to  two  or  three  years.  McPhedran  has  reported  a  re- 
markable instance  in  which  the  tumor  appeared  in  the  epigastrium  with  signs 
of  severe  inflammation.     It  was  opened  and  drained  and  believed  to  be  a 


578  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

hydrops  of  the  lesser  peritoneal  cavity.  Three  months  later  a  second  cyst 
developed,  which  appeared  to  spring  directly  from  the  pancreas. 

(3)  Cysts  without  any  Inflammatory  or  Traumatic  Etiology. — Of  33  cases 
in  this  group  36  were  in  women.  A  remarkable  feature  is  the  prolonged  period 
of  their  existence — in  one  case  for  forty-seven  years,  in  one  for  between  six- 
teen and  twenty  years,  in  others  for  sixteen,  nine,  and  eight  years,  in  the  major- 
ity for  from  two  to  four  years. 

Morbid  Anatomy. — Anatomically  Korte  recognizes  ( 1 )  retention  cysts  due 
to  plugging  of  the  main  duct;  (2)  proliferation  cysts  of  the  pancreatic  tissue — 
the  cysto-adenoma ;  (3)  retention  cysts  arising  from  the  alveoli  of  the  gland 
and  of  the  smaller  ducts,  which  become  cut  off  and  dilate  in  consequence  of 
chronic  interstitial  pancreatitis;  (4)  pseudo-cysts  follovv^ing  inflammatory  or 
traumatic  affections  of  the  pancreas,  usually  the  result  of  injury,  causing  h£em- 
orrhage  and  hydrops  of  the  lesser  peritonaeum. 

Situation. — In  its  growth  the  cyst  may  (1)  be  in  the  lesser  peritonaeum, 
push  the  stomach  upward,  and  reach  the  abdominal  wall  between  the  stomach 
and  the  transverse  colon;  (2)  more  rarely  the  cyst  appears  above  the  lesser 
curvature  and  pushes  the  stomach  downward;  in  both  of  these  cases  the  situ- 
ation of  the  tumor  is  high  in  the  abdomen,  but  (3)  it  may  develop  between 
the  leaves  of  the  transverse  meso-colon  and  lie  below  both  the  colon  and  the 
stomach.  The  relation  of  these  two  organs  to  the  tumor  is  variable,  but  in 
the  majority  of  cases  the  stomach  lies  above  and  the  transverse  colon  below  the 
cyst.  Occasionally,  too,  as  in  T.  C.  Eailton's  case,  the  cyst  may  arise  in  the 
tail  of  the  pancreas  and  project  far  over  in  the  left  hypochondrium  in  the 
position  of  the  spleen  or  of  a  renal  tumor. 

General  Symptoms. — Apart  from  the  features  of  onset  already  referred 
to,  the  patient  may  complain  of  no  trouble  whatever,  particularly  in  the  very 
chronic  cases,  unless  the  cyst  reaches  a  very  large  size.  Painful  colicky  attacks, 
with  nausea  and  vomiting  and  progressive  enlargement  of  the  abdomen,  have 
frequently  been  noted.  Fatty  diarrhoea  from  disturbance  of  the  function  of 
the  pancreas  is  rare.  Sugar  in  the  urine  has  been  present  in  a  number  of 
cases.  Increased  secretion  of  the  saliva,  the  so-called  pancreatic  salivation, 
is  also  rare.  Pressure  of  the  cyst  may  sometimes  cause  jaundice,  and  in  rare 
instances  dyspnoea.  Very  marked  loss  of  flesh  has  been  present  in  a  number 
of  cases.  A  remarkable  feature  often  noticed  has  been  the  transitory  disap- 
pearance of  the  cyst.  In  one  of  Halsted's  cases  the  girth  of  the  abdomen  de- 
creased from  43  to  31  inches  in  ten  days  with  profuse  diarrhoea.  Sometimes 
the  disappearance  has  followed  blows. 

Diagnosis. — The  cyst  occupies  the  upper  abdomen,  usually  forming  a 
semicircular  bulging  in  the  median  line,  rarely  to  either  side.  In  16  cases 
Korte  states  that  the  chief  projection  was  below  the  navel.  In  one  case  oper- 
ated upon  by  Halsted  the  tumor  occupied  the  greater  part  of  the  abdomen. 
The  cyst  is  immobile,  respiration  having  little  or  no  influence  on  it.  As  already 
mentioned,  the  stomach,  as  a  rule,  lies  above  it  and  the  colon  below. 

In  a  majority  of  the  cases  the  fluid  is  of  a  reddish  or  dark-brown  color, 
and  contains  blood  or  blood  coloring  matter,  cell  detritus,  fat  granules,  and 
sometimes  cholesterin.  The  consistence  of  the  fluid  is  usually  mucoid,  rarely 
thin.  The  reaction  is  alkaline,  the  specific  gravity  from  1.010  to  1.020.  In 
22  cases  Korte  states  that  the  fluid  was  not  haemorrhagic. 


DISEASES  OF  THE  PANCREAS.  579 

The  existence  of  ferments  is  important.  In  54  cases  they  were  present 
in  the  fluid  or  in  the  material  from  the  fistula.  In  20  cases  only  one  ferment 
was  present,  in  30  cases  two,  and  in  14  cases  all  three  of  the  pancreatic  fer- 
ments were  found.  In  view  of  the  wide  occurrence  of  diastatic  and  fat- 
emulsifying  ferments  in  various  exudates,  the  most  important  and  only  posi- 
tive sign  in  the  diagnosis  of  the  pancreatic  secretion  is  the  digestion  of  fibrin 
and  albumin. 

Operation. — ^Of  160  cases  of  operation  there  were  150  recoveries.  Incision 
and  drainage  was  the  operation  performed  in  138  cases,  in  15  excision  was 
performed. 

VI.    TUMORS    OF    THE   PANCREAS. 

Of  new  growths  in  the  organ  carcinoma  is  the  most  frequent.  Sarcoma, 
adenoma,  and  lymphoma  are  rare. 

Frequency. — At  the  General  Hospital  in  Vienna  in  18,069  autopsies  there 
were  23  cases  of  cancer  of  the  pancreas  (Biach).  In  11,472  post  mortems  at 
Milan,  Segre  found  132  tumors  of  the  pancreas,  127  of  which  were  carci- 
nomata,  2  sarcomata,  2  cysts,  and  1  syphiloma.  In  6,000  autopsies  at  Guy's 
Hospital  there  were  only  20  cases  of  primary  malignant  disease  of  the  organ 
(Hale  White).  In  the  first  1,500  autopsies  at  the  Johns  Hopkins  Hospital 
there  were  6  cases  of  adeno-carcinoma,  and  1  doubtful  case  in  which  the  exact 
origin  could  not  be  stated.  There  were  8  cases  of  secondary  malignant  disease 
of  the  pancreas.  The  head  of  the  gland  is  most  commonly  involved,  but  the 
disease  may  be  limited  to  the  body  or  to  the  tail.  The  majority  of  the  patients 
are  in  the  middle  period  of  life. 

Symptoms. — The  diagnosis  is  not  often  possible.  The  following  are  the 
most  important  and  suggestive  features:  (a)  Epigastric  pains,  often  occur- 
ring in  paroxysms.  (&)  Jaundice,  due  to  pressure  of  the  tumor  in  the  head 
of  the  pancreas  on  the  bile-duct.  The  jaundice  is  intense  and  permanent,  and 
associated  with  dilatation  of  the  gall-bladder,  which  may  reach  a  very  large 
size,  (c)  The  presence  of  a  tumor  in  the  epigastrium.  This  is  very  variable. 
In  137  cases  Da  Costa  found  the  tumor  present  in  only  13.  Palpation  under 
anaesthesia  with  the  stomach  empty  would  probably,  give  a  very  much  larger 
percentage.  As  the  tumor  rests  directly  upon  the  aorta  there  is  usually  a 
marked  degree  of  pulsation,  sometimes  with  a  bruit.  There  may  be  pressure 
on  the  portal  vein,  causing  thrombosis  and  its  usual  sequels,  (d)  Symptoms 
due  to  loss  of  function  of  the  pancreas  are  less  important.  Fatty  diarrhoea  is 
not  very  often  present.  In  consequence  of  the  absence  of  bile  the  stools  are 
usually  very  clay-colored  and  greasy.  Diabetes  also  is  not  common,  (e)  A 
very  rapid  wasting  and  cachexia.  Of  other  symptoms  nausea  and  vomiting 
are  common.  In  some  instances  the  pylorus  is  compressed  and  there  is  great 
dilatation  of  the  stomach.     In  a  few  cases  there  has  been  profuse  salivation. 

The  points  of  greatest  importance  in  the  diagnosis  are  the  intense  and 
permanent  jaundice,  with  dilatation  of  the  gall-bladder,  rapid  emaciation, 
and  the  presence  of  a  tumor  in  the  epigastric  region.  Of  less  importance  are 
features  pointing  to  disturbance  of  the  function  of  the  gland. 

Of  other  new  growths  sarcoma  and  lymphoma  have  been  occasionally 
found.     Miliary  tubercle  is  not  very  uncommon  in  the  gland.     Syphilis  may 


580  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

occur  as  rather  a  chronic  interstitial  inflammation,  or  in  the  form  of  gummata. 
The  outlook  in  tumors  of  the  pancreas  is,  as  a  rule,  hopeless.     However, 
of  10  cases  operated  upon  of  late  years,  6  recovered  (Korte). 

VII.    PANCREATIC    CALCULI. 

Pancreatic  lithiasis  is  comparatively  rare.  In  1883  George  W.  Johnston 
collected  35  cases  in  the  literature.  In  1,500  autopsies  at  the  Johns  Hopkins 
Hospital  there  were  2  cases. 

The  stones  are  usually  numerous,  either  round  in  shape  or  rough,  spinous 
and  coral-like.  The  color  is  opaque  white.  They  are  composed  chiefly  of  car- 
bonate of  lime.  The  effects  of  the  stones  are:  (1)  A  chronic  interstitial  in- 
flammation of  the  gland  substance  with  dilatation  of  the  duct ;  sometimes  there 
is  cystic  dilatation  of  the  gland;  (2)  acute  inflammation  with  suppuration; 
(3)  the  irritation  of  the  stones,  as  in  the  gall-bladder,  may  lead  to  carcinoma. 

Symptoms. — The  cases  are  not  often  diagnosed.  Pains  in  the  epigastrium, 
often  very  severe,  but  not  characteristic;  the  signs  of  pancreatic  insufficiency 
already  described,  and  the  X-rays,  which  show  the  pancreatic  but  not  the 
biliary  concretions,  are  suggestive  features.  An  analysis  of  the  calculi  passed 
with  the  stools  may  alone  serve  to  distinguish  a  case  from  one  of  gall-stones. 
Operation  has  been  performed  in  five  or  six  cases.  In  Mayo  Eobson's  case 
the  stones  were  removed  from  the  duct  of  Wirsung. 


J.    DISEASES  OE  THE  PERITONEUM. 

I.     ACUTE    GENERAL    PERITONITIS. 

Definition. — Acute  inflammation  of  the  peritonaeum. 

Etiology. — The  condition  may  be  primary  or  secondary. 

(a)  Primary,  Idiopathic  Peritonitis. — Considering  how  frequently  the 
pleura  and  pericardium  are  primarily  inflamed  the  rarity  of  idiopathic  in- 
flammation of  the  peritonseum  is  somewhat  remarkable.  It  may  follow  cold  or 
exposure  and  is  then  known  as  rheumatic  peritonitis.  No  instance  of  the  kind 
has  come  under  my  notice.  In  Bright's  disease,  gout,  and  arterio-sclerosis 
acute  peritonitis  may  occur  as  a  terminal  event.  Of  102  cases  of  peritonitis 
which  came  to  autopsy  at  the  Johns  Hopkins  Hospital,  12  were  of  this  form. 
In  these  there  was  some  pre-existing  chronic  disease  (Flexner). 

(h)  Secondary  peritonitis  is  due  to  extension  of  inflammation  from,  or 
perforation  of  one  of  the  organs  covered  by  the  peritonseum.  Peritonitis  from 
extension  may  follow  inflammation  of  the.  stomach  or  intestines,  extensive 
ulceration  in  these  parts,  cancer,  acute  suppurative  inflammations  of  the  spleen, 
liver,  pancreas,  retroperitoneal  tissues,  and  the  pelvic  viscera. 

Perforative  peritonitis  is  the  most  common,  following  external  wounds, 
perforation  of  ulcer  of  the  stomach  or  bowels,  perforation  of  the  gall-bladder, 
abscess  of  the  liver,  spleen,  or  kidneys.  Two  important  causes  are  appendi- 
citis and  suppurating  inflammation  about  the  Fallopian  tubes  and  ovaries. 
There  are  instances  in  which  peritonitis  has  followed  rupture  of  an  appar- 
ently normal  Graafian  follicle. 


DISEASES  OF   THE  PERITONEUM.  581 

Of  the  above  103  cases,  56  originated  in  an  extension  from  some  diseased 
abdominal  viscus.  The  remaining  34  followed  surgical  operations  upon  the 
peritonaeum  or  the  contained  organs. 

The  peritonitis  of  septicaemia  and  pyaemia  is  almost  invariably  the  result 
of  a  local  process.  An  exceedingly  acute  form  of  peritonitis  may  be  caused  by 
the  development  of  tubercles  on  the  membrane. 

Morbid  Anatomy. — In  recent  cases,  on  opening  the  abdomen  the  intes- 
tinal coils  are  distended  and  glued  together  by  lymph,  and  the  peritonaeum 
presents  a  patchy,  sometimes  a  uniform  injection.  The  exudation  may  be: 
(a)  Fibrinous,  with  little  or  no  fluid,  except  a  few  pockets  of  clear  serum 
between  the  coils.  (&)  Sero-fibrinous.  The  coils  are  covered  with  lymph, 
and  there  is  in  addition  a  large  amount  of  a  yellowish,  sero-fibrinous  fluid. 
In  instances  in  which  the  stomach  or  intestine  is  perforated  this  may  be  mixed 
with  food  or  faeces,  (c)  Purulent,  in  which  the  exudate  is  either  thin  and 
greenish-yellow  in  color,  or  opaque  white  and  creamy,  (d)  Putrid.  Occa- 
sionally in  puerperal  and  perforative  peritonitis,  particularly  when  the  latter 
has  been  caused  by  cancer,  the  exudate  is  thin,  grayish-green  in  color,  and 
has  a  gangrenous  odor,  (e)  Haemorrhagic.  This  is  sometimes  found  as  an 
admixture  in  cases  of  acute  peritonitis  following  wounds,  and  occurs  in  the 
cancerous  and  tuberculous  forms.  (/)  A  rare  form  occurs  in  which  the  injec- 
tion is  present,  but  almost  all  signs  of  exudation  are  wanting.  Close  inspection 
may  be  necessary  to  detect  a  slight  dulling  of  the  serous  surfaces. 

The  amount  of  the  effusion  varies  from  half  a  litre  to  20  or  30  litres. 
There  are  probably  essential  differences  between  the  various  kinds  of  peri- 
tonitis. 

Bacteriology  of  Acute  Peritonitis. — Much  work  has  been  done  lately  upon 
the  subject.  Flexner  has  analyzed  103  cases  of  peritonitis,  in  which  bacterio- 
logical studies  were  made,  which  came  to  autopsy  in  the  Johns  Hopkins  Hos- 
pital. He  makes  three  classes.  The  first  class  embraces  the  primary  or  idio- 
pathic form,  of  which  13  cases  were  found.  These  were  with  one  exception 
mono-infections.  The  prevailing  micro-organism  was  the  streptococcus  pyog- 
enes (five  times),  the  remaining  ones  being  the  staphylococcus  aureus,  micro- 
coccus lanceolatus,  bacillus  proteus,  pyocyaneus,  coli  communis,  and  the  in- 
fluenza bacillus.  The  second  class  followed  operations  upon  the  peritonaeum, 
excepting  operations  upon  the  intestine.  The  majority  of  these  cases  were 
examples  of  wound  infection.  They  were  33  in  number.  In  35  of  these  mono- 
infections, in  8  mixed  infections  existed.  The  prevailing  micro-organism  was 
the  staphylococcus  aureus,  which  was  present  alone  in  13  and  combined  in  3 
cases.  The  streptococcus  occurred  5  times  uncombined  and  4  times  com- 
bined. The  bacillus  coli  was  found  5  times  in  all,  being  unassociated  in  3 
cases.  Other  organisms  found  were  the  micrococcus  lanceolatus,  staphylococcus 
albus,  bacillus  pyocyaneus,  and  aerogenes  capsulatus.  The  remaining  56  cases, 
forming  the  third  class,  were  instances  of  intestinal  infection.  These  com- 
prised 33  mono-  and  33  polyinfections.  The  predominating  micro-organism 
was  the  bacillus  coli  communis  which  occurred  in  43  cases,  8  times  alone  and 
35  in  association.  The  streptococcus  was  present  in  37  cases,  being  alone  in  7. 
The  staphylococci,  pneumococcus,  bacillus  proteus,  pyocyaneus,  typhosus,  and 
aerogenes  capsulatus  occurred  in  a  smaller  number  of  instances. 

Among  the  micro-organisms  thus  far  found  rarely  in  peritonitis,  may  be 


582  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

mentioned  the  gonocoecus,  the  anthrax  bacillus,  the  proteus  bacillus,  and  the 
typhoid  bacillus.  The  gonorrhoeal  form  arises  from  salpingitis  and  may  occur 
in  children.  Welch  has  found  the  bacillus  coli  communis  in  peritonitis  due 
to  ulceration  of  the  intestines  without  perforation. 

Symptoms. — In  the  perforative  and  septic  cases  the  onset  is  marked  by 
chilly  feelings  or  an  actual  rigor  with  intense  pain  in  the  abdomen.  In  typhoid 
fever,  when  the  sensorium  is  benumbed,  the  onset  may  not  be  noticed.  The 
pain  is  general,  and  is  usually  intense  and  aggravated  by  movements  and  pres- 
sure. A  position  is  taken  which  relieves  the  tension  of  the  abdominal  mus- 
cles, so  that  the  patient  lies  on  the  back  with  the  thighs  drawn  up  and  the 
shoulders  elevated.  The  greatest  pain  is  usually  below  the  umbilicus,  but  in 
peritonitis  from  perforation  of  the  stomach  pain  may  be  referred  to  the  back, 
the  chest,  or  the  shoulder.  The  respiration  is  superficial — costal  in  type — 
as  it  is  painful  to  use  the  diaphragm.  For  the  same  reason  the  action  of 
coughing  is  restrained,  and  even  the  movements  necessary  for  talking  are  lim- 
ited. In  this  early  stage  the  sensitiveness  may  be  great  and  the  abdominal 
muscles  are  often  rigidly  contracted.  If  the  patient  is  at  perfect  rest  the  pain 
may  be  very  slight,  and  there  are  instances  in  which  it  is  not  at  all  marked, 
and  may,  indeed,  be  absent. 

The  abdomen  gradually  becomes  distended  and  tense  and  is  tympanitic  on 
percussion.  The  pulse  is  rapid,  small,  and  hard,  and  often  has  a  peculiar  wiry 
quality.  It  ranges  from  110  to  150,  The  temperature  may  rise  rapidly  after 
the  chill  and  reach  104°  or  105°,  but  the  subsequent  elevation  is  moderate. 
In  some  very  severe  cases  there  may  be  no  fever  throughout.  The  tongue  at 
first  is  white  and  moist,  but  subsequently  becomes  dry  and  often  red  and  fis- 
sured. Vomiting  is  an  early  and  prominent  feature  and  causes  great  pain.  The 
contents  of  the  stomach  are  first  ejected,  then  a  yellowish  and  bile-stained 
fluid,  and  finally  a  greenish  and,  in  rare  instances,  a  brownish-black  liquid  with 
slight  fffical  odor.  The  bowels  may  be  loose  at  the  onset  and  then  constipa- 
tion may  follow.  Frequent  micturition  may  be  present,  less  often  retention. 
The  urine  is  usually  scanty  and  high-colored,  and  contains  a  large  quantity 
of  indican. 

The  appearance  of  the  patient  when  these  symptoms  have  fully  developed 
is  very  characteristic.  The  face  is  pinched,  the  eyes  are  sunken,  and  the  expres- 
sion is  very  anxious.  The  constant  vomiting  of  fiuids  causes  a  wasted  appear- 
ance, and  the  hands  sometimes  present  the  washer-woman's  skin.  Except  in 
cholera,  we  see  the  Hippocratic  facies  more  frequently  in  this  than  in  any 
other  disease — "  a  sharp  nose,  hollow  eyes,  collapsed  temples;  the  ears  cold, 
contracted,  and  their  lobes  turned  out;  the  shin  about  the  forehead  being  rough, 
distended,  and  parched;  the  color  of  the  whole  face  being  brown,  black,  livid, 
or  lead-colored."  There  are  one  or  two  additional  points  about  the  abdomen. 
The  tympany  is  usually  excessive,  owing  to  the  great  relaxation  of  the  walls  of 
the  intestines  by  inflammation  and  exudation.  The  splenic  dulness  may  be 
obliterated,  the  diaphragm  pushed  up,  and  the  apex  beat  of  the  heart  dislo- 
cated to  the  fourth  interspace.  The  liver  dulness  may  be  greatly  reduced,  or 
may,  in  the  mammary  line,  be  obliterated.  It  has  been  claimed  that  this  is  a 
distinctive  feature  of  perforative  peritonitis,  but  on  several  occasions  I  have 
been  able  to  demonstrate  that  the  liver  dulness  in  the  middle  and  mammary 
line  was  obliterated  by  tympanites  alone.     In  the  axillary  line,  on  the  other 


DISEASES  OF  THE  PERITONEUM.  583 

hand,  the  liver  dulness,  though  diminished,  may  persist.  Pneumo-peritongeum 
following  perforation  more  certainly  obliterates  the  hepatic  dulness.  In  such 
cases  the  fluid  efi^used  produces  a  dulness  in  the  lateral  regions;  but  with  gas 
in  the  peritonaeum,  if  the  patient  is  turned  on  the  left  side,  a  clear  note  is 
heard  beneath  the  seventh  and  eighth  ribs.  Acute  peritonitis  may  present  a 
flat,  rigid  abdomen  throughout  its  course. 

Effusion  of  fluid — ascites — is  usually  present  except  in  some  acute  rapidly 
fatal  cases.  The  flanks  are  dull  on  percussion.  The  dulness  may  be  movable, 
though  this  depends  altogether  upon  the  degree  of  adhesions.  There  may  be 
considerable  effusion  without  either  movable  dulness  or  fluctuation.  A  fric- 
tion-rub may  be  present,  as  first  pointed  out  by  Bright,  but  it  is  not  nearly  so 
common  in  acute  as  in  chronic  peritonitis. 

Course. — The  acute  diffuse  peritonitis  usually  terminates  in  death.  The 
most  intense  forms  may  kill  within  thirty-six  to  forty-eight  hours ;  more  com- 
monly death  results  in  four  or  five  days,  or  the  attack  may  be  prolonged  to 
eight  or  ten  days.  The  pulse  becomes  irregular,  the  heart-sounds  weak,  the 
breathing  shallow;  there  are  lividity  with  pallor,  a  cold  skin  with  high  rectal 
temperature — a  group  of  symptoms  indicating  profound  failure  of  the  vital 
functions  for  which  Gee  has  revived  the  old  term  lipothyvtia.  Occasion- 
ally death  occurs  with  great  suddenness,  owing,  possibly,  to  paralysis  of  the 
heart. 

Diagnosis. — In  typical  cases  the  severe  pain  at  onset,  the  distention  of  the 
abdomen,  the  tenderness,  the  fever,  the  gradual  onset  of  effusion,  collapse, 
and  the  vomiting  give  a  characteristic  picture.  Careful  inquiries  should  at 
once  be  made  concerning  the  previous  condition,  from  which  a  clew  can  often 
be  had  as  to  the  starting-point  of  the  trouble.  In  young  adults  a  considerable 
proportion  of  all  cases  depends  upon  perforating  appendicitis,  and  there  may 
be  an  account  of  previous  attacks  of  pain  in  the  iliac  region,  or  of  constipa- 
tion alternating  with  diarrhoea.  In  women  the  most  frequent  causes  are  sup- 
purative processes  in  the  pelvic  viscera,  associated  with  salpingitis,  abscesses 
in  the  broad  ligaments,  or  acute  puerperal  infection.  Perforation  of  gastric 
ulcer  is  a  more  common  factor  in  women  than  in  men.  It  is  not  always  easy 
to  determine  the  cause.  Many  cases  come  under  observation  for  the  first  time 
with  the  abdomen  distended  and  tender,  and  it  is  impossible  to  make  a  satis- 
factory examination.  In  such  instances  the  pelvic  organs  should  be  examined 
with  the  greatest  care.  In  typhoid  fever,  if  the  patient  is  conscious,  the  sud- 
den onset  of  pain,  the  tenderness,  rigidity,  muscle  spasm,  and  the  aggravation 
of  the  general  symptoms  indicate  what  has  happened.  When  the  patient  is 
in  deep  coma,  on  the  other  hand,  the  perforation  may  be  overlooked.  The  fol- 
lowing conditions  are  most  apt  to  be  mistaken  for  acute  peritonitis : 

(a)  Acute  Entero-colitis. — Here  the  pain  and  distention  and  the  sensitive- 
ness on  pressure  may  be  marked.  The  pain  is  more  colicky  in  character,  the 
diarrhoea  is  more  frequent,  and  the  collapse  is  more  extreme. 

(&)  The  So-called  Hysterical  Peritonitis. — This  has  deceived  the  very 
elect,  as  almost  every  feature  of  genuine  peritonitis,  even  the  collapse,  may 
be  simulated.  The  onset  may  be  sudden,  with  severe  pain  in  the  abdomen, 
tenderness,  vomiting,  diarrhoea,  difficulty  in  micturition,  and  the  character- 
istic decubitus.  Even  the  temperature  may  be  elevated.  There  may  be  recur- 
rence of  the  attack.     A  case  has  been  reported  by  Bristowe  in  which  four 


584  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

attacks  occurred  within  a  year,  and  it  was  not  until  special  hysterical  symp- 
toms developed  that  the  true  nature  of  the  trouble  was  suspected. 

(c)  Obstruction  of  the  Ijowel,  as  already  mentioned,  may  simulate  perito- 
nitis, both  having  pain,  vomiting,  tympanites,  and  constipation  in  common. 
It  may  for  a  couple  of  days  really  be  impossible  to  make  a  diagnosis  in  the 
absence  of  a  satisfactory  history. 

{d)  Rupture  of  an  abdominal  aneurism  or  embolism  of  the  superior  mes- 
enteric artery  may  cause  symptoms  which  simulate  peritonitis.  In  the  latter, 
sudden  onset  with  severe  pain,  the  collapse  s3rmptoms,  frequent  vomiting,  and 
great  distention  of  the  abdomen  may  be  present. 

(e)  I  have  already  referred  to  the  fact  that  acute  hsemorrhagic  pancre- 
atitis may  be  mistaken  for  peritonitis.  Lastly,  a  ruptured  tubal  pregnancy 
may  resemble  acute  peritonitis. 

II.  PERITONITIS    IN    INFANTS. 

Peritonitis  may  occur  in  the  foetus  as  a  consequence  of  syphilis,  and  may 
lead  to  constriction  of  the  bowel  by  fibrous  adhesions. 

In  the  new-born  a  septic  peritonitis  may  extend  from  an  inflamed  cord. 
Distention  of  the  abdomen,  slight  swelling  and  redness  about  the  cord,  and 
not  infrequently  jaundice  are  present.  It  is  an  uncommon  event,  and  existed 
in  only  4  of  51  infants  dying  with  inflammation  of  the  cord  and  septicaemia 
(Eunge).  •    .       .  .        . 

During  childhood  peritonitis  arises  from  causes  similar  to  those  affect- 
ing the  adult.  Perforative  appendicitis  is  common.  Peritonitis  following 
blows  or  kicks  on  the  abdomen  occurs  more  frequently  at  this  period.  In 
boys  injury  while  playing  foot-ball  may  be  followed  by  diffuse  peritonitis.  A 
rare  cause  in  children  is  extension  through  the  diaphragm  from  an  empyema. 
There  are  on  record  instances  of  peritonitis  occurring  in  several  children  at 
the  same  school,  and  it  has  been  attributed  to  sewer-gas  poisoning.  It  was  in 
investigating  an  epidemic  of  this  kind  at  the  Wandsworth  school,  in  London, 
that  Anstie  received  the  post-mortem  wound  of  which  he  died.  It  is  to  be 
remembered  that  peritonitis  in  children  may  follow  the  gonorrhoeal  vulvitis 
so  common  in  infant  homes  and  hospitals. 

III.  LOCALIZED    PERITONITIS. 

1.  Subphrenic  Peritonitis. — The  general  peritona3um  covering  the  right 
and  left  lobes  of  the  liver  may  be  involved  in  an  extension  from  the  pleura 
of  suppurative,  tuberculous,  or  cancerous  processes.  In  various  affections 
of  the  liver — cancer,  abscess,  hydatid  disease,  and  in  affections  of  the  gall- 
bladder— the  inflammation  may  be  localized  to  the  peritonaeum  covering  the 
upper  surface  of  the  organ.  These  forms  of  localized  subphrenic  peritonitis 
in  the  greater  sac  are  not  so  important  in  reality  as  those  which  occur  in  the 
lesser  peritonaeum.  The  anatomical  relations  of  this  structure  are  as  follows : 
It  lies  behind  and  below  the  stomach,  the  gastro-hepatic  omentum,  and  the 
anterior  layer  of  the  great  omentum.  Its  lower  limit  forms  the  upper  layer 
of  the  transverse  meso-colon.  On  either  side  it  reaches  from  the  hepatic  to 
the  splenic  flexure  of  the  colon,  and  from  the  foramen  of  Winslow  to  the 


DISEASES  OF  THE  PERITONAEUM.  585 

hilus  of  the  spleen.  Behind  it  covers  and  is  tightly  adherent  to  the  front  of 
the  pancreas.  Its  upper  limit  is  formed  by  the  transverse  fissure  of  the  liver, 
and  by  that  portion  of  the  diaphragm  which  is  covered  by  the  lower  layer  of  the 
right  lateral  ligament  of  the  liver;  the  lobus  Spigelii  lies  bare  in  the  cavity. 
The  foramen  of  Winslow,  through  which  the  lesser  communicates  with  the 
greater  peritonasum,  is  readily  closed  by  inflammation. 

Inflammatory  processes,  exudates,  and  haemorrhages  may  be  confined  en- 
tirely to  the  lesser  peritonaeum.  The  exudate  of  tuberculous  peritonitis  may 
be  confined  to  it.  Perforations  of  certain  parts  of  the  stomach,  of  the  duode- 
num, and  of  the  colon  may  excite  inflammation  in  it  alone;  and  in  various 
affections  of  the  pancreas,  particularly  trauma  and  haemorrhage,  the  effusion 
into  the  sac  has  often  been  confounded  with  cyst  of  this  organ.  "  Pathological 
distention  of  the  lesser  peritonaeum  gives  rise  to  a  tumor  in  the  left  hypo- 
chondriac, epigastric,  and  umbilical  regions  of  a  somewhat  characteristic  shape, 
but  which  appears  to  vary  from  time  to  time  in  form  and  size,  according  to 
the  conditions  of  the  overlying  stomach;  for  when  the  viscus  is  full  of  liquid 
contents  it  increases  the  area  of  the  tumor's  dulness,  while  it  makes  its  out- 
lines less  definable  by  palpation,  and  if  the  stomach  is  distended  with  gas  the 
dull  area  becomes  resonant  and  apparently  the  tumor  may  disappear  alto- 
gether. The  colon  always  lies  below  the  tumor  and  never  in  front  of  or  above 
it,  as  is  the  case  in  kidney  enlargement "  (Jordan  Lloyd), 

Special  mention  must  be  made  of  the  remarkable  form  of  subphrenic 
abscess  containing  air,  which  may  simulate  closely  pneumothorax,  and  hence 
was  called  by  Leyden  Pyo-pneumotliorax  subplirenicus.  The  affection  has 
been  thoroughly  studied  of  late  years  by  Scheurlen,  Mason,  Meltzer,  and  Lee 
Dickinson.  In  143  out  of  170  recorded  cases  the  cause  was  known.  In  a  few 
instances,  as  in  one  reported  by  Meltzer,  the  subphrenic  abscess  seemed  to  have 
followed  pneumonia.  Pyothorax  is  an  occasional  cause.  By  far  the  most  fre- 
quent condition  is  gastric  ulcer,  which  occurred  in  80  of  the  cases.  Duodenal 
ulcer  was  the  cause  in  6  per  cent.  In  about  10  per  cent  of  the  cases  the  appen- 
dix was  the  starting-point  of  the  abscess.  Cancer  of  the  stomach  is  an  occa- 
sional cause.  Other  rare  causes  are  trauma,  which  was  present  in  one  of  my 
cases,  perforation  of  an  hepatic  or  a  renal  abscess,  lesions  of  the  spleen, 
abscess,  and  cysts  of  the  pancreas. 

In  a  majority  of  all  the  cases  in  which  the  stomach  or  duodenum  is  per- 
forated— sometimes,  indeed,  in  the  cases  following  trauma,  as  in  Case  3  of  my 
series — the  abscess  contains  air. 

The  symptoms  of  subphrenic  abscess  vary  very  considerably,  depending 
a  good  deal  upon  the  primary  cause.  The  onset,  as  a  rule,  is  abrupt,  particu- 
larly when  due  to  perforation  of  a  gastric  ulcer.  There  are  severe  pain,  vom- 
iting, often  of  bilious  or  of  bloody  material ;  respiration  is  embarrassed,  owing 
to  the  involvement  of  the  diaphragm ;  then  the  constitutional  symptoms  occur 
associated  with  suppuration,  chills,  irregular  fever,  and  emaciation.  Subse- 
quently perforation  may  take  place  into  the  pleura  or  into  the  lung,  with  severe 
cough  and  abundant  purulent  expectoration. 

The  conditions  are  so  obscure  that  the  diagnosis  of  subphrenic  abscess  is 
not  often  made.  The  perihepatic  abscess  beneath  the  arch  of  the  diaphragm, 
whether  to  the  right  or  left  of  the  suspensory  ligament,  when  it  does  not  contain 
air,  is  almost  invariably  mistaken  for  empyema.    When  a  pus  collection  of 


586  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

any  size  is  in  the  lesser  peritonEeum,  the  tumor  is  formed  which  has  the  char- 
acters alread}'  mentioned  in  a  quotation  from  Mr.  Jordan  Lloyd. 

The  most  remarkable  features  are  those  which  are  superadded  when  the 
abscess  cavity  contains  air.  Here^  on  the  right  side,  when  the  abscess  is  in 
the  greater  peritonasum,  above  the  right  lobe  of  the  liver,  the  diaphragm  may 
be  pushed  up  to  the  level  of  the  second  or  third  rib,  and  the  physical  signs  on 
percussion  and  auscultation  are  those  of  pneumothorax,  particularly  the  tym- 
panitic resonance  and  the  movable  dulness.  The  liver  is  usually  greatly  de- 
pressed and  there  is  bulging  on  the  right  side.  Still  more  obscure  are  the 
cases  of  air-containing  abscesses  due  to  perforation  of  the  stomach  or  duode- 
num, in  which  the  gas  is  contained  in  the  lesser  peritongeum.  Here  the  dia- 
phragm is  pushed  up  and  there  are  signs  of  pneumothorax  on  the  left  side. 
In  a  large  majority  of  all  the  cases  which  follow  perforation  of  a  gastric  ulcer 
the  effusion  lies  between  the  diaphragm  above,  and  the  spleen,  stomach,  and 
the  left  lobe  of  the  liver  below. 

The  prognosis  in  subphrenic  abscess  is  not  very  hopeful.  Of  the  cases  on 
record  about  20  per  cent  only  have  recovered. 

2.  Appendicular. — The  most  frequent  cause  in  the  male  of  localized  peri- 
tonitis is  inflammation  of  the  appendix  vermiformis.  The  situation  varies 
with  the  position  of  this  extremely  variable  organ.  The  adhesion,  perforation, 
and  intraperitoneal  abscess  cavity  may  be  within  the  pelvis,  or  to  the  left  of 
the  median  line  in  the  iliac  region,  in  the  lower  right  quadrant  of  the  umbil- 
ical region — a  not  uncommon  situation — or,  of  course,  most  frequentlj^  in  the 
right  iliac  fossa.  In  the  most  common  situation  the  localized  abscess  lies  upon 
the  psoas  muscle,  bounded  by  the  caecum  on  the  right  and  the  terminal  por- 
tion of  the  ileum  and  its  mesentery  in  front  and  to  the  left.  In  many  of  these 
cases  the  limitation  is  perfect,  and  post-mortem  records  show  that  complete 
healing  may  take  place  with  the  obliteration  of  the  appendix  in  a  mass  of 
firm  scar  tissue. 

3.  Pelvic  Peritonitis. — The  most  frequent  cause  is  inflammation  about  the 
uterus  and  Fallopian  tubes.  Puerperal  septicsemia,  gonorrhoea,  and  tubercu- 
losis are  the  usual  causes.  The  tubes  are  the  starting-point  in  a  majority 
of  the  cases.  The  fimbria  become  adherent  and  closely  matted  to  the  ovary, 
and  there  is  gradually  produced  a  condition  of  thickening  of  the  parts,  in 
which  the  individual  organs  are  scarcely  recognizable.  The  tubes  are  dilated 
and  filled  with  cheesy  matter  or  pus,  and  there  may  be  small  abscess  cavities 
in  the  broad  ligaments.  Eupture  of  one  of  these  may  cause  general  perito- 
nitis, or  the  membrane  may  be  involved  by  extension,  as  in  tuberculosis  of 
these  parts. 

IV.     CHRONIC    PERITONITIS. 

The  following  varieties  may  be  recognized : 

(a)  Local  adhesive  peritonitis,  a  very  common  condition,  which  occurs 
particularly  about  the  spleen,  forming  adhesions  between  the  capsule  and  the 
diaphragm,  about  the  liver,  less  frequently  about  the  intestines  and  mesen- 
tery. Points  of  thickening  or  puckering  on  the  peritoneum  occur  sometimes 
with  union  of  the  coils  or  with  fibrous  bands.  In  a  majority  of  such  cases  the 
condition  is  met  accidentally  post  mortem.  Two  sets  of  s3Tnptoms  may,  how- 
ever, be  caused  by  these  adhesions.    When  a  fibrous  band  is  attached  in  such 


DISEASES  OF  THE  PERITONMVM.  587 

a  way  as  to  form  a  loop  or  snare,  a  coil  of  intestine  may  pass  through  it.  Thus, 
of  the  295  cases  of  intestinal  obstruction  analyzed  by  Fitz,  63  were  due  to 
this  cause.  The  second  group  is  less  serious  and  comprises  cases  with  persist- 
ent abdominal  pain  of  a  colicky  character,  sometimes  rendering  life  miserable. 

(&)  Diffuse  Adhesive  Peritonitis. — This  is  a  consequence  of  an  acute  in- 
flammation, either  simple  or  tuberculous.  The  peritoneum  is  obliterated.  On 
cutting  through  the  abdominal  wall,  the  coils  of  intestines  are  uniformly 
matted  together  and  can  neither  be  separated  from  each  other  nor  can  the 
visceral  and  parietal  layers  be  distinguished.  There  may  be  thickening  of  the 
layers,  and  the  liver  and  spleen  are  usually  involved  in  the  adhesions. 

(c)  Proliferative  Peritonitis. — Apart  from  cancer  and  tubercle,  which  pro- 
duce typical  lesions  of  chronic  peritonitis,  the  most  characteristic  form  is  that 
which  may  be  described  under  this  heading.  The  essential  anatomical  feature 
is  great  thickening  of  the  peritoneal  layers,  usually  without  much  adhesion. 
The  cases  are  sometimes  seen  with  sclerosis  of  the  stomach.  In  one  instance 
I  found  it  in  connection  with  a  sclerotic  condition  of  the  caecum  and  the  first 
part  of  the  colon.  It  is  not  uncommon  with  cirrhosis  of  the  liver.  In  the 
inspection  of  a  case  of  this  kind  there  is  usually  moderate  effusion,  more  rarely 
extensive  ascites.  The  peritoneum  is  opaque- white  in  color,  and  everywhere 
thickened,  often  in  patches.  The  omentum  is  usually  rolled  and  forms  a 
thickened  mass  transversely  placed  between  the  stomach  and  the  colon.  The 
peritoneum  over  the  stomach,  intestines,  and  mesentery  is  sometimes  greatly 
thickened.  The  liver  and  spleen  may  simply  be  adherent,  or  there  is  a  con- 
dition of  chronic  perihepatitis  or  perisplenitis,  so  that  a  layer  of  firm,  almost 
gristly  connective  tissue  of  from  one-fourth  to  half  an  inch  in  thickness  encir- 
cles these  organs.  Usually  the  volume  of  the  liver  is  in  consequence  greatly 
reduced.  The  gastro-hepatic  omentum  may  be  constricted  by  this  new  growth 
and  the  calibre  of  the  portal  vein  much  narrowed.  A  serous  effusion  may  be 
present.  On  account  of  the  adhesions  which  form,  the  peritoneum  may  be 
divided  into  three  or  four  different  sacs,  as  is  more  fully  described  under  the 
tuberculous  peritonitis.  In  these  cases  the  intestines  are  usually  free,  though 
the  mesentery  is  greatly  shortened.  There  are  instances  of  chronic  peritonitis 
in  which  the  mesentery  is  so  shortened  by  this  proliferative  change  that  the 
intestines  form  a  ball  not  larger  than  a  cocoa-nut  situated  in  the  middle  line, 
and  after  the  removal  of  the  exudation  can  be  felt  as  a  solid  tumor.  The 
intestinal  wall  is  greatly  thickened  and  the  mucous  membrane  of  the  ileum 
is  thrown  into  folds  like  the  valvule  conniventes.  This  proliferative  perito- 
nitis is  found  frequently  in  the  subjects  of  chronic  alcoholism.  In  cases  of 
long-continued  ascites  the  serous  surfaces  generally  become  thickened  and  pre- 
sent an  opaque,  dead-white  color.  This  condition  is  observed  especially  in 
hepatic  cirrhosis,  but  attends  tumors,  chronic  passive  congestion,  etc. 

In  all  forms  of  chronic  peritonitis  a  friction  may  be  felt  usually  in  the 
upper  zone  of  the  abdomen.  Polyorrhomenitis,  polyserositis,  general  chronic 
inflammation  of  the  serous  membranes,  Concato's  disease  (as  the  Italians  call 
it),  may  occur  with  this  form  as  well  as  in  the  tuberculous  variety.  The  peri- 
cardium and  both  pleure  may  be  involved. 

In  some  instances  of  chronic  peritonitis  the  membrane  presents  numer- 
ous nodular  thickenings,  which  may  be  mistaken  for  tubercles.  J.  F.  Payne 
has  described  a  case  of  this  sort  associated  with  disseminated  growths  through- 


588  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

out  the  liver  vhich  were  not  cancerous.  It  has  been  suggested  that  some  of 
the  cases  of  tuberculous  peritonitis  cured  by  operation  have  been  of  this 
nature,  but  histological  exaniination  would,  as  a  rule,  readily  determine  be- 
tvreen  the  conditions.  Miura,  in  Japan,  has  reported  a  case  in  which  these 
nodules  contained  the  ova  of  a  parasite.  One  case  has  been  reported  in  which 
the  exciting  cause  was  regarded  as  cholesterin  plates,  which  were  contained 
within  the  granulomatous  nodules. 

(d)  Chronic  Haemorrhagic  Peritonitis. — Blood-stained  effusions  in  the 
peritonseum  occur  particularly  in  cancerous  and  tuberculous  disease.  There 
is  a  form  of  chronic  inflammation  analogous  to  the  haemorrhagic  pachymen- 
ingitis of  the  brain.  It  was  described  first  by  Yirchow,  and  is  localized  most 
commonly  in  the  pelvis.  Layers  of  new  connective  tissue  form  on  the  surface 
of  the  peritonseum  with  large  wide  vessels  from  which  haemorrhage  occurs. 
This  is  repeated  from  time  to  time  with  the  formation  of  regular  layers  of 
hsemorrhagic  effusion.     It  is  rarely  diffuse,  more  commonly  circumscribed. 

V.    NEW    GROWTHS    IN    THE    PERITON-ffiXJM. 

(a)   Tuberculous  Peritonitis. — This  has  already  been  considered. 

(&)  Cancer  of  the  Peritonaeum. — Although,  as  a  rule,  secondary  to  disease 
of  the  stomach,  liver,  or  pelvic  organs,  cases  of  primary  cancer  have  been 
described.  It  is  probable  that  the  so-called  primary  cancers  of  the  serous 
membranes  are  endotheliomata  and  not  carcinomata.  Secondary  malignant 
peritonitis  occurs  in  connection  with  all  forms  of  cancer.  It  is  usually  char- 
acterized by  a  number  of  round  tumors  scattered  over  the  entire  peritoneum, 
sometimes  small  and  miliary,  at  other  times  large  and  nodular,  with  puckered 
centres.  The  disease  most  commonly  starts  from  the  stomach  or  the  ovaries. 
The  omentum  is  indurated,  and,  as  in  tuberculous  peritonitis,  forms  a  mass 
which  lies  transversely,  across  the  upper  portion  of  the  abdomen.  Primary 
malignant  disease  of  the  peritonasum  is  extremely  rare.  Colloid  is  said  to 
have  occurred,  forming  enormous  masses,  which  in  one  case  weighed  over  100 
pounds.  Cancer  of  this  membrane  spreads,  either  by  the  detachment  of  small 
particles  which  are  carried  in  the  lymph  currents  and  by  the  movements  to 
distant  parts,  or  by  contact  of  opposing  surfaces.  It  occurs  more  frequently 
in  women  than  in  men,  and  more  commonly  at  the  later  period  of  life. 

The  diagnosis  of  cancer  of  the  peritongeum  is  easy  with  a  history  of  a 
local  malignant  disease ;  as  when  it  occurs  with  ovarian  tumor  or  with  cancer 
of  the  pylorus.  In  cases  in  which  there  is  no  evidence  of  a  primary  lesion  the 
diagnosis  may  be  doubtful.  The  clinical  picture  is  usually  that  of  chronic 
ascites  with  progressive  emaciation.  There  may  be  no  fever.  If  there  is  much 
effusion  nothing  definite  can  be  felt  on  examination.  After  tapping,  irregular 
nodules  or  the  curled  omentum  may  be  felt  lying  transversely  across  the  upper 
portion  of  the  abdomen.  Unfortunately,  this  tumor  upon  which  so  much  stress 
is  laid  occurs  as  frequently  in  tuberculous  peritonitis  and  may  be  present  in 
a  typical  manner  in  the  chronic  proliferative  form,  so  that  in  itself  it  has  no 
special  diagnostic  value.  Multiple  nodules,  if  large,  indicate  cancer,  particu- 
larly in  persons  above  middle  life.  Modular  tuberculous  peritonitis  is  most 
frequent  in  children.  The  presence  about  the  navel  of  secondary  nodules  and 
indurated  masses  is  more  common  in  cancer.    Inflammation,  suppuration,  and 


DISEASES  OF   THE  PERITONEUM.  589 

the  discharge  of  pus  from  the  navel  rarely  occurs  except  in  tuberculous  disease. 
Considerable  enlargement  of  the  inguinal  glands  may  be  present  in  cancer. 
The  nature  of  the  fluid  in  cancer  and  in  tubercle  may  be  much  alike.  It  may 
be  hsemorrhagic  in  both ;  more  often  in  the  latter.  The  histological  examina- 
tion in  cancer  may  show  large  multinuclear  cells  or  groups  of  cells — the 
sprouting  cell-groups  of  Foulis — which  are  extremely  suggestive.  The  colloid 
cancer  may  produce  a  totally  different  picture;  instead  of  ascitic  fluid,  the 
abdomen  is  occupied  by  the  semi-solid  gelatinous  substance,  and  is  firm,  not 
fluctuating. 

And,  lastly,  there  are  instances  of  echinococci  in  the  peritonaeum  which 
may  simulate  cancer  very  closely. 

VI.    ASCITES    (Hydro-peritonaeiini). 

Definition. — The  accumulation  of  serous  fluid  in  the  peritoneal  cavity. 

Etiology. —  (1)  Local  Causes. —  (a)  Chronic  inflammation  of  the  peri- 
toneum, either  simple,  cancerous,  or  tuberculous.  (&)  Portal  obstruction  in 
the  terminal  branches  within  the  liver,  as  in  cirrhosis  and  chronic  passive 
congestion,  or  by  compression  of  the  vein  in  the  gastro-hepatic  omentum, 
either  by  proliferative  peritonitis,  by  new  growths,  or  by  aneurism,  (c)  Throm- 
bosis of  the  portal  vein,  (d)  Tumors  of  the  abdomen.  The  solid  growths 
of  the  ovaries  may  cause  considerable  ascites,  which  may  completely  mask  the 
true  condition.  The  enlarged  spleen  in  leukaemia,  less  commonly  in  malaria, 
may  be  associated  with  recurring  ascites. 

(2)  Geneeal  Causes. — The  ascites  is  part  of  a  general  dropsy,  the  result 
of  mechanical  effects,  as  in  heart-disease,  chronic  emphysema,  and  sclerosis 
of  the  lung.  In  cardiac  lesions  the  effusion  is  sometimes  confined  to  the  peri- 
tonaeum, in  which  case  it  is  due  to  secondary  changes  in  the  liver,  or  it  has 
been  suggested  to  be  connected  with  a  failure  of  the  suction  action  of  this 
organ,  by  which  the  peritonaeum  is  kept  dry.  Ascites  occurs  also  in  the  dropsy 
of  Bright's  disease,  and  in  hydrsemic  states  of  the  blood. 

Symptoms. — A  gradual  uniform  enlargement  of  the  abdomen  is  the  char- 
acteristic symptom  of  ascites.  The  physical  signs  are  usually  distinctive, 
(a)  Inspection. — According  to  the  amount  of  fluid  the  abdomen  is  protu- 
berant and  flattened  at  the  sides.  With  large  effusions,  the  skin  is  tense  and 
may  present  the  lineae  albicantes.  Frequently  the  navel  itself  and  the  parts 
about  it  are  very  prominent.  In  many  cases  the  superficial  veins  are  enlarged 
and  a  plexus  joining  the  mammary  vessels  can  be  seen.  Sometimes  it  can 
be  determined  by  pressure  on  these  veins  that  the  current  is  from  below  upward. 
In  some  instances,  as  in  thrombosis  or  obliteration  of  the  portal  vein,  these 
superficial  abdominal  vessels  may  be  extensively  varicose.  About  the  navel 
in  cases  of  cirrhosis  there  is  occasionally  a  large  bunch  of  distended  veins,  the 
so-called  caput  Medusae.    The  heart  may  be  displaced  upward. 

(&)  Palpation. — Fluctuation  is  obtained  by  placing  the  fingers  of  one 
hand  upon  one  side  of  the  abdomen  and  by  giving  a  sharp  tap  on  the  opposite 
side  with  the  other  hand,  when  a  wave  is  felt  to  strike  as  a  definite  shock 
against  the  applied  fingers.  Even  comparatively  small  quantities  of  fluid 
may  give  this  fluctuation  shock.  When  the  abdominal  walls  are  thick  or  very 
fat,  an  assistant  may  place  the  edge  of  the  hand  or  a  piece  of  cardboard  in 


590  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

• 

front  of  the  abdomen.  A  different  procedure  is  adopted  in  palpating  for 
the  solid  organs  in  case  of  ascites.  Instead  of  placing  the  hand  flat  upon  the 
abdomen,  as  in  the  ordinary  method,  the  pads  of  the  fingers  only  are  placed 
lightly  upon  the  skin,  and  then  by  a  sudden  depression  of  the  fingers  the  fluid 
is  displaced  and  the  solid  organ  or  tumor  may  be  felt.  By  this  method  of 
"  dipping  "  or  displacement,  as  it  is  called,  the  liver  may  be  felt  below  the 
costal  margin,  or  the  spleen,  or  sometimes  solid  tumors  of  the  omentum  or 
intestine. 

(c)  Percussion. — In  the  dorsal  position  with  a  moderate  quantity  of  fluid 
in  the  peritongeum  the  flanks  are  dull,  while  the  umbilical  and  epigastric 
regions,  into  which  the  intestines  float,  are  tympanitic.  This  area  of  clear 
resonance  may  have  an  oval  outline.  Having  obtained  the  lateral  limit  of  the 
dulness  on  one  side,  if  the  patient  turns  on  the  opposite  side,  the  fluid  gravi- 
tates to  the  dependent  part  and  the  uppermost  flank  is  now  tympanitic.  In 
moderate  effusions  this  movable  dulness  changes  greatly  in  the  different  pos- 
tures. Small  amounts  of  fluid,  probably  under  a  litre,  would  scarcely  give 
movable  dulness,  as  the  pelvis  and  the  renal  regions  hold  a  considerable  quan- 
tity. In  such  cases  it  is  best  to  place  the  patient  in  the  knee-elbow  position, 
when  a  dull  note  will  be  determined  at  the  most  dependent  portion.  By  care- 
ful attention  to  these  details  mistakes  are  usually  avoided. 

The  following  are  among  the  conditions  which  may  be  mistaken  for  dropsy : 
Ovarian  tumor,  in  which  the  sac  develops,  as  a  rule,  unilaterally,  though  when 
large  it  is  centrally  placed.  The  dulness  is  anterior  and  the  resonance  is  in 
the  flanks,  into  which  the  intestines  are  pushed  by  the  cyst.  Examination  per 
vaginam  may  give  important  indications.  In  those  rare  instances  in  which 
gas  develops  in  the  cyst  the  diagnosis  may  be  very  difficult.  Succussion  has 
been  obtained  in  such  cases.  A  distended  bladder  may  reach  above  the  umbil- 
icus. In  such  instances  some  urine  dribbles  away,  and  suspicion  of  ascites 
or  a  cyst  is  occasionally  entertained.  I  once  saw  a  trocar  thrust  into  a  dis- 
tended bladder,  which  was  supposed  to  be  an  ovarian  cyst,  and  it  is  stated  that 
John  Hunter  tapped  a  bladder,  supposing  it  to  be  ascites.  Such  a  mistake 
should  be  avoided  by  careful  catheterization  prior  to  any  operative  procedures. 
And  lastly,  there  are  large  pancreatic  or  hydatid  cysts  in  the  abdomen  which 
may  simulate  ascites. 

Nature  of  the  Ascitic  Fluid. — ^Usually  this  is  a  clear  serum,  light  yellow 
in  the  ascites  of  ansemia  and  Bright's  disease,  often  darker  in  color  in  cirrho- 
sis of  the  liver.  The  specific  gravity  is  low,  seldom  more  than  1.010  or  1.015, 
whereas  in  the  fluid  of  ovarian  cysts  or  chronic  peritonitis  the  specific  gravity 
is  over  1.015.  It  is  albuminous  and  sometimes  coagulates  spontaneously. 
Dock  has  called  attention  to  the  importance  of  the  study  of  the  cells  in  the 
exudate.  In  cancer  very  characteristic  forms,  with  nuclear  figures,  may  be 
found.  Hsemorrhagic  effusion  usually  occurs  in  cancer  and  tuberculosis,  and 
occasionally  in  cirrhosis.  I  have  already  referred  to  the  instances  of  haem- 
orrhagic  effusion  in  connection  with  ruptured  tubal  pregnancy. 

A  chylous,  milky  exudate  is  occasionally  found.  There  are,  as  Quincke 
has  pointed  out,  two  distinct  varieties,  a  fatty  and  a  chylous,  which  may  be 
distinguished  by  the  microscope,  as  in  the  former  there  are  distinct  fat-glob- 
ules. These  cases  have  been  sometimes  connected  with  peritoneal  or  mesen- 
teric cancer.     In  the  true  chylous  ascites  the  fluid  is  turbid  and  milky.     In 


DISEASES  OF  THE  PERITONEUM.  591 

some  of  the  cases,  as  in  Whitla's,  a  perforation  of  the  thoracic  duct  has  been 
found,  but  the  condition  does  not  necessarily  follow  obliteration  of  the  thoracic 
duct.  Mild  grades  of  chylous  ascites,  which  are  occasionally  found  clinically, 
may  be  due  to  the  fact  that  the  patient  upon  a  milk  diet  has  a  permanent 
lipaemia,  such  as  is  present  in  young  animals  and  in  diabetics,  in  whom 
the  liquor  sanguinis  is  always  fatty.  Under  such  circumstances  an  exu- 
date may  contain  enough  of  the  molecular  base  of  the  chyle  to  produce  turbid- 
ity of  the  fluid.    Some  of  the  cases  have  been  associated  with  filariasis. 

Treatment  of  the  Previous  Conditions. — (a)  Acute  Peritonitis. — Rest 
is  enjoined  upon  the  patient  by  the  severe  pain  which  follows  the  slightest 
movement,  and  he  should  be  propped  in  the  position  which  gives  him  greatest 
relief.  Whether  morphia  should  be  given  will  depend  upon  the  cause.  In 
the  pain  of  appendicitis  and  of  perforation  in  typhoid  fever  it  is  best  to  use 
an  ice-bag  and  withhold  the  drug.  Late  in  the  disease  and  in  hopeless  condi- 
tions it  may  be  given  freely.  The  opium  treatment  so  strongly  advocated  by 
the  late  Alonzo  Clark  has  gone  out  of  vogue. 

Local  applications — the  ice-bag,  hot  turpentine  stupes,  or  cloths  wrung 
out  of  ice-water — may  be  laid  upon  the  abdomen. 

The  question  of  the  use  of  purgatives  in  peritonitis  has  of  late  been  warmly 
discussed.  Theoretically  it  appears  correct  to  give  salines  in  concentrated 
form,  which  cause  a  rapid  and  profuse  exosmosis  of  serum  from  the  intestinal 
vessels,  relieving  the  congestion  and  reducing  the  oedema,  which  is  one  impor- 
tant factor  in  causing  the  meteorism.  It  is  also  urged  that  the  increased  peri- 
stalsis prevents  the  formation  of  adhesions.  In  reading  the  reports  of  these 
successful  cases,  one  is  not  always  convinced,  however,  that  peritonitis  actually 
existed.  Still,  in  cases  of  acute  peritonitis  due  to  extension  or  following  oper- 
ation or  in  septic  conditions  the  judgment  of  many  careful  men  is  decidedly 
in  favor  of  the  use  of  salines.  The  majority  of  cases  of  peritonitis  which  come 
under  the  care  of  the  physician  follow  lesions  of  the  abdominal  viscera  or  are 
due  to  perforation  of  ulcer  of  the  stomach,  the  ileum,  or  the  appendix.  In 
such  cases,  particularly  in  the  large  group  of  appendix  cases,  to  give  saline 
purgatives  is,  to  say  the  least,  most  injudicious  treatment.  In  these  instances 
rectal  injections  should  be  employed  to  relieve  the  large  bowel.  No  symptom 
in  acute  peritonitis  is  more  serious  than  the  tympanites,  and  none  is  more 
difficult  to  meet.  The  use  of  the  long  tube  and  injections  containing  turpen- 
tine may  be  tried.    Drugs  by  the  mouth  can  not  be  retained. 

For  the  vomiting,  ice  and  small  quantities  of  soda  water  may  be  employed. 
The  patient  should  be  fed  on  milk,  but  if  the  vomiting  is  distressing  it  is  best 
not  to  attempt  to  give  food  by  the  mouth,  but  to  use  small  nutrient  enemata. 
In  all  cases  it  is  best  to  have  a  surgeon  in  consultation  early  in  the  disease, 
as  the  question  of  operation  may  come  up  at  any  moment.  In  the  acute  forms 
of  tuberculous  peritonitis  operative  measures  appear  to  be  more  hopeful,  but 
they  are  not  always  successful. 

(&)  Cheonic  Peritonitis. — For  the  cases  of  chronic  proliferative  perito- 
nitis very  little  can  be  done.  The  treatment  is  practically  that  of  ascites.  In 
all  these  forms,  when  the  distention  becomes  extreme,  tapping  is  indicated. 
The  treatment  of  tubercnlous  peritonitis  has  fallen  largely  into  the  hands  of 
the  surgeons,  but  the  results  depend  on  the  stage  at  which  the  operation  is 
performed  and  the  variety  of  the  disease.     With  ascites  the  outlook  is  good; 


592  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

but  when  there  are  tuberculous  tumors  and  man}-  adhesions  the  results  are 
not  very  satisfactory.  Maurice  Eichardson,  in  a  child  aged  tive,  with  a  sus- 
pected appendicitis  (tumor,  etc.),  found  the  s}Tnptoms  to  be  due  to  enlarged, 
tuberculous  mesenteric  glands,  which  were  removed,  and  the  boy  remained  well 
five  years  after  the  operation. 

(c)  Ascites. — The  treatment  depends  somewhat  on  the  nature  of  the  case. 
In  cirrhosis  early  and  repeated  tapping  may  give  time  for  the  establishment 
of  the  collateral  circulation,  and  temporary  cures  have  followed  this  procedure. 
Permanent  drainage  with  Southe}''s  tube,  incision,  and  washing  out  the  peri- 
tonaeum have  also  been  practised.  In  the  ascites  of  cardiac  and  renal  disease 
the  cathartics  are  most  satisfactory,  particularly  the  bitartrate  of  potash,  given 
alone  or  with  jalap,  and  the  large  doses  of  salts  given  an  hour  before  breakfast 
with  as  little  water  as  possible.  These  sometimes  cause  rapid  disappearance 
of  the  effusion,  but  they  are  not  so  successful  in  ascites  as  in  pleurisy  with 
effusion.  The  stronger  cathartics  may  sometimes  be  necessary.  The  ascites 
forming  part  of  the  general  anasarca  of  Bright's  disease  will  receive  consider- 
ation under  another  section. 


SECTION    VI. 
DISEASES   OF  THE   EESPIRATORT  ,  SYSTEM. 


A.    DISEASES   OF   THE   NOSE. 

I.     ACUTE    CORYZA. 

Acute  catarrhal  inflammation  of  the  upper  air-passages,  popularly  known 
as  a  "  catarrh  "  or  a  "  cold/'  is  usually  an  independent  affection,  but  may  pre- 
cede the  development  of  another  disease. 

Etiology. — Prevailing  most  extensively  in  the  changeable  vs^eather  of  the 
spring  and  early  winter,  it  may  occur  in  epidemic  form,  many  cases  arising 
in  a  community  within  a  few  weeks,  outbreaks  which  are  very  like,  though 
less  intense  than  the  epidemic  influenza.  A  special  organism.  Micrococcus 
catarrlialis,  has  been  described.  Irritating  fumes,  such  as  those  of  iodine  or 
ammonia,  also  may  cause  an  acute  catarrh  of  the  nose. 

Symptoms. — The  patient  feels  indisposed,  perhaps  chilly,  has  slight  head- 
ache, and  sneezes  frequently.  In  severe  cases  there  are  pains  in  the  back  and 
limbs.  There  is  usually  slight  fever,  the  temperature  rising  to  101°.  The 
pulse  is  quick,  the  skin  is  dry,  and  there  are  all  the  features  of  a  feverish  attack. 
At  first  the  mucous  membrane  of  the  nose  is  swollen,  "  stuffed  up,"  and  the 
patient  has  to  breathe  through  the  mouth.  A  thin,  clear,  irritating  secretion 
flows,  and  makes  the  edges  of  the  nostrils  sore.  The  mucous  membrane  of 
the  tear-ducts  is  swollen,  so  that  the  eyes  weep  and  the  conjunctivae  are  in- 
jected. The  sense  of  smell  and,  in  part,  the  sense  of  taste  is  lost.  With  the 
nasal  catarrh  there  is  slight  soreness  of  the  throat  and  stiffness  of  the  neck; 
the  pharynx  looks  red  and  swollen,  and  sometimes  the  act  of  swallowing  is 
painful.  The  larynx  also  may  be  involved,  and  the  voice  becomes  husky  or  is 
even  lost.  If  the  inflammation  extends  to  the  Eustachian  tubes  the  hearing 
may  be  impaired.  In  more  severe  cases  there  are  bronchial  irritation  and 
cough.  Occasionally  there  is  an  outbreak  of  labial  or  nasal  herpes.  Usually 
within  thirty-six  hours  the  nasal  secretion  becomes  turbid  and  more  profuse, 
the  swelling  of  the  mucosa  subsides,  the  patient  gradually  becomes  able  to 
breathe  through  the  nostrils,  and  within  four  or  five  days  the  symptoms  dis- 
appear, with  the  exception  of  the  increased  discharge  from  the  nose  and  upper 
pharynx.  There  are  rarely  any  bad  effects  from  a  simple  coryza.  When  the 
attacks  are  frequently  repeated  the  disease  may  become  chronic. 

The  diagnosis  is  always  easy,  but  caution  must  be  exercised  lest  the  initial 
catarrh  of  measles  or  severe  influenza  should  be  mistaken  for  the  simple  coryza. 
39  593 


594  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

Treatment. — Many  cases  are  so  mild  that  the  patients  are  able  to  be  about 
and  to  attend  to  their  work.  If  there  are  fever  and  constitutional  disturbance, 
the  patient  should  be  kept  in  bed  and  should  take  a  simple  fever  mixture, 
and  at  night  a  drink  of  hot  lemonade  and  a  full  dose  of  Dover's  powder. 
Many  persons  find  great  benefit  from  the  Turkish  bath.  For  the  distressing 
sense  of  tightness  and  pain  over  the  frontal  sinuses,  cocaine  is  very  useful 
and  sometimes  gives  immediate  relief.  The  4-per-cent  solution  may  be  in- 
jected into  the  nostrils,  or  cotton-wool  soaked  in  it  may  be  inserted  into  them. 
Later,  the  snuif  recommended  by  Ferrier  is  advantageous,  composed,  as  it  is, 
of  morphia  (gr.  ij),  bismuth  (3  iv),  acacia  powder  (3  ij).  This  may  occasion- 
ally be  blown  or  snuif ed  into  the  nostrils.  The  fluid  extract  of  hamamelis, 
"  snuffed  "  from  the  hand  every  two  or  three  hours,  is  much  better. 

II.    AUTUMNAL    CATARRH    (Hay  Fever). 

Definition. — An  affection  of  the  upper  air-passages,  often  associated  with 
asthmatic  attacks,  due  to  the  action  of  the  pollen  of  certain  grasses  and  plants 
upon  a  hypersensitive  mucous  membrane. 

Etiology. — This  affection  was  first  described  in  1819  by  Bostock,  who  called 
it  catarrhus  cestivus.  Morrill  Wyman,  of  Cambridge,  Mass.,  wrote  a  mono- 
graph on  the  subject,  and  described  two  forms,  the  "  June  cold,"  or  "  rose 
cold,"  which  comes  on  in  the  spring,  and  the  autumnal  form  which,  in  the 
United  States,  comes  on  in  August  and  September,  and  never  persists  after  a 
severe  frost.  In  the  Southern  States  cases  occur  all  through  the  year.  It  is 
more  common  in  America  and  in  Great  Britain  than  on  the  Continent.  The 
disposition  to  the  disease  is  hereditary.  Women  are  more  subject  to  it  than  men. 
Young  and  middle-aged  persons  are  most  often  attacked.  The  tendency  les- 
sens as  age  advances,  though  there  are  statements  to  the  contrary.  Dwellers 
in  cities  are  chiefly  attacked.  The  educated  and  highly  nervous  are  more  sus- 
ceptible. The  disease  affects  certain  families,  and  Beard  found  an  hereditary 
factor  in  33  per  cent  of  his  cases.  A  morbid  sensitiveness  of  the  nasal  mucosa 
is  present  in  many  cases. 

The  disease  must  be  differentiated  from  nervous  coryza  (which  has  been 
induced  by  suggestion)  and  from  the  attacks  of  irritation  of  the  nasal,  con- 
junctival, and  bronchial  mucous  membranes  excited  by  the  odor  of  a  horse, 
or  of  the  "  harmless  necessary  cat." 

Dunbar's  researches  have  placed  the  etiology  of  the  disease  on  a  scientific 
basis.  He  has  shown  that  there  is  but  one  cause,  the  pollen  of  grasses  and 
certain  plants.  The  pollen  of  about  130  different  plants  has  now  been  exam- 
ined, of  which  that  of  25  grasses  and  of  only  7  other  kinds  of  plants  exert  a 
definite  action.  The  pollen  of  rye  is  the  most  active.  Dunbar  and  his  stu- 
dents have  found  that  the  severity  of  hay-fever  attacks  is  in  direct  proportion 
to  the  quantity  of  pollen  present  in  the  atmosphere.  In  persons  predisposed 
to  the  disease  the  pollen  applied  to  the  conjunctivae  or  nasal  mucosa  excites 
characteristic  attacks.  He  has  isolated  a  peculiar  poison  of  an  albuminous 
nature  from  the  pollen.  It  is  so  powerful  that  .000025  milligrammes  excites 
irritation  in  the  conjunctiva  of  a  susceptible  subject.  This  is  the  amount  of 
toxin  which  corresponds  to  two  or  three  pollen  grains.  It  is  entirely  without 
influence  on  normal  persons.     In  larger  doses  severer  attacks  are  caused,  and, 


DISEASES  OF  THE  NOSE.  595 

injected  subcutaneously,  it  has  been  followed  by  very  unpleasant  symptoms. 
He  has  succeeded  in  obtaining  an  antitoxin  by  injecting  the  poison  into  ani- 
mals.   It  is  capable  of  cutting  short  attacks  of  ordinary  hay  fever. 

Symptoms. — These  are,  in  a  majority  of  the  cases,  very  like  those  of  ordi- 
nary coryza.  There  may,  however,  be  much  more  headache  and  distress,  and 
some  patients  become  very  low-spirited.  At  the  outset,  or  even  daily  through- 
out the  attack,  sneezing  may  be  frequent.  Cough  is  a  common  symptom  and 
may  be  very  distressing.  Paroxysms  of  asthma  may  occur  indistinguishable 
from  the  ordinary  bronchial  form.  The  two  conditions  may  indeed  alternate, 
the  patient  having  at  one  time  an  attack  of  common  hay  fever  and  at  another, 
under  similar  circumstances,  an  attack  of  bronchial  asthma. 

Treatment. — This  may  be  comprised  under  four  heads :  First,  remedies 
may  be  given  to  improve  the  stability  of  the  nervous  system — such  as 
arsenic,  phosphorus,  and  strychnia.  Secondly,  climatic.  Dwellers  in  the 
cities  of  the  Atlantic  seaboard  and  of  the  Central  States  enjoy  complete 
immunity  in  the  Adirondacks  and  White  Mountains.  As  a  rule  the  disease  is 
aggravated  by  residence  in  agricultural  districts.  The  dry  mountain  air  is 
unquestionably  the  best;  there  is  no  general  rule,  and  there  are  cases  which 
do  well  at  the  seaside.  Thirdly,  the  thorough  local  treatment  of  the  nose,  par- 
ticularly the  destruction  of  the  vessels  and  sinuses  over  the  sensitive  areas. 
Fourthly,  the  antitoxin  treatment  of  Dunbar  in  suitable  cases  gives  excellent 
results.  Owing  to  the  peculiar  nature  of  the  disease  and  the  constant  reinfec- 
tion of  the  mucous  membranes  by  pollen  on  exposure  to  the  outside  air,  it  is 
advised  to  sleep  with  the  windows  closed  and  to  apply  the  serum  in  the  morn- 
ing before  rising  both  to  eyes  and  nose,  and  again  during  the  day  if  the 
slightest  irritation  is  felt  in  the  conjunctiva  or  nasal  mucous  membranes 
(E.  A.  Glegg).    The  Pollantin  of  Dunbar  is  now  "on  the  market." 

III.    EPISTAXIS. 

Etiology. — Bleeding  from  the  nose  may  result  from  local  or  constitutional 
conditions.  Among  local  causes  may  be  mentioned  traumatism,  small  ulcers, 
picking  or  scratching  the  nose,  new  growths,  and  the  presence  of  foreign  bodies. 
In  chronic  nasal  catarrh  bleeding  is  not  infrequent.  The  blood  may  come 
from  one  or  both  nostrils.    The  flow  may  be  profuse  after  an  injury. 

Among  general  conditions  with  which  nose-bleeding  is  associated,  the  fol- 
lowing are  the  most  important:  It  occurs  in  growing  children,  particularly 
about  the  age  of  puberty ;  more  frequently  in  the  delicate  and  in  the  rheumatic 
than  in  the  strong  and  vigorous.  There  is  a  family  form  in  which  many  mem- 
bers in  several  generations  are  affected.  There  is  a  chronic  recurring  epistaxis 
associated  with  multiple  telangiectasis  of  the  skin  and  mucous  membranes 
{Quarterly  Journal  of  Medicine,  Vol.  I). 

Epistaxis  is  a  very  common  event  in  persons  of  so-called  plethoric  habit. 
It  is  stated  sometimes  to  precede,  or  to  indicate  a  liability  to,  apoplexy.  In 
venous  engorgement  epistaxis  is  not  common  and  there  may  be  a  most  extreme 
grade  of  cyanosis  without  its  occurrence.  It  is  frequent  in  cirrhosis  hepatis. 
In  balloon  and  mountain  ascensions,  in  the  very  rarefied  atmosphere,  haemor- 
rhage from  the  nose  is  a  common  event.  In  hsemophilia  the  nose  ranks  first 
of  the  mucous  membranes  from  which  bleeding  arises.    It  occurs  in  all  forms  of 


596  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

chronic  anaemias,  in  chronic  interstitial  nephritis,  and  in  cirrhosis  of  the  liver. 
It  precedes  the  onset  of  certain  fevers,  more  particularly  typhoid,  with  which 
it  seems  associated  in  a  special  manner.  Vicarious  epistaxis  has  been  described 
in  cases  of  suppression  of  the  menses.  Lastly,  it  is  said  to  be  brought  on  by 
certain  psychical  impressions,  but  the  observations  on  this  point  are  not  trust- 
worthy. The  blood  in  epistaxis  results  from  capillary  oozing  or  diapedesis. 
The  mucous  membrane  is  deeply  congested  and  there  are  often  capillary  angi- 
omata  situated  usually  in  the  respiratory  portion  of  the  nostril  and  upon  the 
cartilaginous  septum. 

Symptoms. — Slight  haemorrhage  is  not  associated  with  any  special  fea- 
tures. When  the  bleeding  is  protracted  the  patients  have  the  more  serious 
manifestations  of  loss  of  blood.  In  the  slow  dripping  which  takes  place  in 
some  instances  of  haemophilia,  there  may  be  formed  a  remarkable  blood  tumor 
projecting  from  one  nostril  and  extending  even  below  the  mouth. 

Death  from  ordinary  epistaxis  is  very  rare.  The  more  blood  is  lost,  the 
greater  is  the  tendency  to  clotting  with  spontaneous  cessation  of  the  bleeding. 

Diagnosis. — The  diagnosis  is  usually  easy.  One  point  only  need  be  men- 
tioned ;  namely,  that  bleeding  from  the  posterior  nares  occasionally  occurs  dur- 
ing sleep  and  the  blood  trickles  into  the  pharynx  and  may  be  swallowed.  If 
vomited,  it  may  be  confounded  with  haematemesis ;  or,  if  coughed  up,  with 
haemoptysis. 

Treatment. — In  a  majority  of  the  cases  the  bleeding  ceases  of  itself.  Vari- 
ous simple  measures  may  be  employed,  such  as  holding  the  arms  above  the 
head,  the  application  of  ice  to  the  nose,  or  the  injection  of  cold  or  hot  water 
into  the  nostrils.  Astringents,  such  as  zinc,  alum,  or  tannin,  may  be  used; 
and  the  tincture  of  the  perchloride  of  iron,  diluted  with  ice-water,  may  be 
introduced  into  the  nostrils.  If  the  bleeding  comes  from  an  ulcerated  surface, 
an  attempt  should  be  made  to  apply  chromic  acid  or  the  cautery.  If  the  bleed- 
ing is  at  all  severe  and  obstinate,  the  posterior  nares  should  be  plugged.  One 
of  the  patients  with  epistaxis  and  spider  angiomata  of  the  skin  and  mucous 
membranes  used  a  finger  of  a  rubber  glove  with  a  small  rubber  tube  and  stop- 
cock by  which  he  could  dilate  the  glove  finger,  inserted  into  the  nostril,  and 
so  effectually  control  the  bleeding.  The  inhalation  of  carbonic-acid  gas  may  be 
tried  or  a  solution  of  gelatine  or  of  adrenalin  injected  into  the  nostril. 


B.    DISEASES  OF  THE  LARYNX. 

I.    ACUTE    CATARRHAL    LARYNGITIS. 

This  may  come  on  as  an  independent  affection  or  in  association  with  gen- 
eral catarrh  of  the  upper  respiratory  passages. 

Etiology. — Many  cases  are  due  to  catching  cold  or  to  overuse  of  the  voice ; 
others  come  on  in  consequence  of  the  inhalation  of  irritating  gases.  It  may 
occur  in  the  general  catarrh  associated  with  influenza  and  measles.  Very  severe 
laryngitis  is  excited  by  traumatism,  either  injuries  from  without  or  the  lodg- 
ment of  foreign  bodies.  It  may  be  caused  by  the  action  of  very  hot  liquids 
or  corrosive  poisons. 

Symptoms. — There  is  a  sense  of  tickling  referred  to  the  lar}aix;  the  cold 
air  irritates  and,  owing  to  the  increased  sensibility  of  the  mucous  membrane. 


DISEASES  OF   THE  LARYNX.  597 

the  act  of  inspiration  may  be  painful.  There  is  a  dry  cough,  and  the  voice  is 
altered.  At  first  it  is  simply  husky,  but  soon  phonation  becomes  painful,  and 
finally  the  voice  may  be  completely  lost.  In  adults  the  respirations  are  not 
increased  in  frequency,  but  in  children  dyspnoea  is  not  uncommon  and  may 
occur  in  spasmodic  attacks  and  become  urgent  if  there  is  much  oedema  with 
the  inflammatory  swelling. 

The  laryngoscope  shows  a  swollen  mucous  membrane  of  the  larynx,  par- 
ticularly the  ary-epiglottidean  folds.  The  vocal  cords  have  lost  their  smooth 
and  shining  appearance  and  are  reddened  and  swollen.  Their  mobility  also 
is  greatly  impaired,  owing  to  the  infiltration  of  the  adjoining  mucous  mem- 
brane and  of  the  muscles.  A  slight  mucoid  exudation  covers  the  parts.  The 
constitutional  symptoms  are  not  severe.  There  is  rarely  much  fever,  and  in 
many  cases  the  patient  is  not  seriously  ill.  Occasionally  cases  come  on  with 
greater  intensity,  the  cough  is  very  distressing,  deglutition  is  painful,  and  there 
may  be  urgent  dyspnoea. 

Diagnosis. — There  is  rarely  any  difficulty  in  determining  the  nature  of  a 
case  if  a  satisfactory  laryngoscopic  examination  can  be  made.  The  severer 
forms  may  simulate  oedema  of  the  glottis.  When  the  loss  of  voice  is  marked, 
the  case  may  be  mistaken  for  one  of  nervous  aphonia,  but  the  laryngoscope 
would  decide  the  question  at  once.  Much  more  difficult  is  the  diagnosis  of 
acute  laryngitis  in  children,  particularly  in  the  very  young,  in  whom  it  is  so 
hard  to  make  a  proper  examination.  From  ordinary  laryngismus  it  is  to  be 
distinguished  by  the  presence  of  fever,  the  mode  of  onset,  and  particularly  the 
coryza  and  the  previous  symptoms  of  hoarseness  or  loss  of  voice.  Membranous 
laryngitis  may  at  first  be  quite  impossible  to  differentiate,  but  in  a  majority 
of  cases  of  this  affection  there  are  patches  on  the  pharynx  and  early  swelling  of 
the  cervical  glands.     The  symptoms,  too,  are  much  more  severe. 

Treatment. — Rest  of  the  larynx  should  be  enjoined,  so  far  as  phonation  is 
concerned.  In  cases  of  any  severity  the  patient  should  be  kept  in  bed.  The 
room  should  be  at  an  even  temperature  and  the  air  saturated  with  moisture. 
Early  in  the  disease,  if  there  is  much  fever,  aconite  and  citrate  of  potash  may 
be  given,  and  for  the  irritating  painful  cough  a  full  dose  of  Dover's  powder 
at  night.     An  ice-bag  externally  often  gives  great  relief. 

II.     CHRONIC    LARYNGITIS. 

Etiology. — The  cases  usually  follow  repeated  acute  attacks.  The  most  com- 
mon causes  are  overuse  of  the  voice,  particularly  in  persons  whose  occupation 
necessitates  shouting  in  the  open  air.  The  constant  inhalation  of  irritating 
substances,  as  tobacco-smoke,  may  also  cause  it. 

Symptoms. — The  voice  is  usually  hoarse  and  rough  and  in  severe  cases  may 
be  almost  lost.  There  is  usually  very  little  pain ;  only  the  unpleasant  sense  of 
tickling  in  the  larynx,  which  causes  a  frequent  desire  to  cough.  With  the 
laryngoscope  the  mucous  membrane  looks  swollen,  but  much  less  red  than  in 
the  acute  condition.  In  association  with  the  granular  pharyngitis,  the  mucous 
glands  of  the  epiglottis  and  of  the  ventricles  may  be  involved. 

Treatment. — The  nostrils  should  be  carefully  examined,  since  in  some 
instances  chronic  laryngitis  is  associated  with  and  even  dependent  upon  ob- 
struction to  the  free  passage  of  air  through  the  nose.    Local  application  must 


598  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

be  made  directly  to  the  larjoix,  either  with  a  brush  or  by  means  of  a  spray. 
Among  the  remedies  most  recommended  are  the  solutions  of  nitrate  of  silver, 
elilorate  of  potash,  perchloride  of  zinc,  and  tannic  acid.  Insufflations  of  bis- 
muth are  sometimes  useful. 

Among  directions  to  be  given  are  the  avoidance  of  heated  rooms  and  loud 
speaking,  and  abstinence  from  tobacco  and  alcohol.  The  throat  should  not  be 
too  much  muffled,  and  morning  and  evening  the  neck  should  be  sponged  with 
cold  water„ 

III.     CE3DEMAT0TJS    LARYNGITIS. 

Etiology. — CEdema  of  the  glottis,  or,  more  correctly,  of  the  structures 
which  form  the  glottis,  a  very  serious  affection,  is  met  with  (a)  as  a  rare 
sequence  of  ordinary  acute  laryngitis;  (&)  in  chronic  diseases  of  the  larynx, 
as  syphilis  or  tubercle;  (c)  in  severe  inflammatory  diseases  like  diphtheria,  in 
.erysipelas  of  the  neck,  and  in  various  forms  of  cellulitis;  (d)  occasionally 
in  the  acute  infectious  diseases — scarlet  fever,  typhus,  or  typhoid ;  in  Bright's 
disease,  either  acute  or  chronic,  there  may  be  a  rapidly  developing  oedema; 
(e)  in  angio-neurotic  oedema. 

Symptoms. — There  is  dyspnoea,  increasing  in  intensity,  so  that  within  an 
hour  or  two  the  condition  becomes  very  critical.  There  is  sometimes  marked 
stridor  in  respiration.  The  voice  becomes  husky  and  disappears.  The  laryn- 
goscope shows  enormous  swelling  of  the  epiglottis,  which  can  sometimes  be 
felt  with  the  finger  or  even  seen  when  the  tongue  is  strongly  depressed  with  a 
spatula.  The  arj'^-epiglottidean  folds  are  the  seat  of  the  chief  swelling  and 
may  almost  meet  in  the  middle  line.  Occasionally  the  oedema  is  below  the 
true  cords. 

The  diagnosis  is  rarely  difficult,  inasmuch  as  even  without  the  laryngo- 
scope the  swollen  epiglottis  can  be  seen  or  felt  with  the  finger.  The  condition 
is  very  fatal. 

Treatment. — An  ice-bag  should  be  placed  on  the  larynx,  and  the  patient 
given  ice  to  suck.  If  the  symptoms  are  urgent,  the  throat  should  be  sprayed 
with  a  strong  solution  of  cocaine,  and  the  swollen  epiglottis  scarified.  If 
relief  does  not  follow,  tracheotomy  should  immediately  be  performed.  The 
high  rate  of  mortality  is  due  to  the  fact  that  this  operation  is  as  a  rule  too 
long  delayed. 

IV.     SPASMODIC    LARYNGITIS    (Laryngismus  stridulus). 

Spasm  of  the  glottis  is  met  with  in  many  affections  of  the  larynx,  but  there 
is  a  special  disease  in  children  which  has  received  the  above-mentioned  and 
other  names. 

Etiology. — A  purely  nervous  affection,  without  any  inflammatory  condi- 
tion of  the  larynx,  it  occurs  in  children  between  the  ages  of  six  months  and 
three  years,  and  is  most  commonly  seen  in  connection  with  rickets.  As 
Escherich  has  shown,  the  disease  has  close  relations  with  tetany  and  may 
display  many  of  the  accessory  phenomena  of  this  disease.  Often  the  attack 
comes  on  when  the  child  has  been  crossed  or  scolded.  Mothers  sometimes  call 
the  attacks  ^^ passion  fits"  or  attacks  of  "holding  the  breath."    It  was  sup- 


DISEASES  OF  THE  LARYNX.  599 

posed  at  one  time  that  they  were  associated  with  enlargement  of  the  thymus, 
and  the  condition  therefore  received  the  name  of  thymic  asthma. 

The  actual  state  of  the  larynx  during  a  paroxysm  is  a  spasm  of  the 
adductors,  but  the  precise  nature  of  the  influences  causing  it  is  not  yet  known, 
whether  centric  or  reflex  from  peripheral  irritation.  The  disease  is  not  so 
common  in  America  as  in  England. 

Symptoms. — The  attacks  may  come  on  either  in  the  night  or  in  the  day; 
often  just  as  the  child  awakes.  There  is  no  cough,  no  hoarseness,  but  the 
respiration  is  arrested  and  the  child  struggles  for  breath,  the  face  gets  con- 
gested, and  then,  with  a  sudden  relaxation  of  the  spasm,  the  air  is  drawn  into 
the  lungs  with  a  high-pitched  crowing  sound,  which  has  given  to  the  afl ection 
the  name  of  "  child-crowing."  Convulsions  may  occur  during  an  attack  or 
there  may  be  carpo-pedal  spasms.  Death  may,  but  rarely  does,  occur  during 
the  attack.  With  the  cyanosis  the  spasm  relaxes  and  respiration  begins.  The 
attacks  may  recur  with  great  frequency  throughout  the  day. 

Treatment. — The  gums  should  be  carefully  examined  and,  if  swollen  and 
hot,  freely  lanced.  The  bowels  should  be  carefully  regulated,  and  as  these 
children  are  usually  delicate  or  rickety,  nourishing  diet  and  cod-liver  oil 
should  be  given.  By  far  the  most  satisfactory  method  of  treatment  is  the  cold 
sponging.  In  severe  cases,  two  or  three  times  a  day  the  child  should  be  placed 
in  a  warm  bath,  and  the  back  and  chest  thoroughly  sponged  for  a  minute  or 
two  with  cold  water.  Since  learning  this  practice  from  Einger,  at  the  Uni- 
versity Hospital,  London,  I  have  seen  many  cases  in  which  it  proved  success- 
ful. It  may  be  employed  when  the  child  is  in  a  paroxysm,  though  if  the 
attack  is  severe  and  the  lividity  is  great  it  is  much  better  to  dash  cold  water 
into  the  face.  Sometimes  the  introduction  of  the  finger  far  back  into  the 
throat  will  relieve  the  spasm. 

Spasmodic  croup,  believed  to  be  a  functional  spasm  of  the  muscles  of  the 
larynx,  is  an  affection  seen  most  commonly  between  the  ages  of  two  and  five 
years.  According  to  Trousseau's  description,  the  child  goes  to  bed  well,  and 
about  midnight  or  in  the  early  morning  hours  awakes  with  oppressed  breath- 
ing, harsh,  croupy  cough,  and  perhaps  some  huskiness  of  voice.  The  oppres- 
sion and  distress  for  a  time  are  very  serious,  the  face  is  congested,  and  there 
are  signs  of  approaching  cyanosis.  The  attack  passes  off  abruptly,  the  child 
falls  asleep  and  awakes  the  next  morning  feeling  perfectly  well.  These  attacks 
may  be  repeated  for  several  nights  in  succession,  and  usually  cause  great  alarm 
to  the  parents.  Whether  this  is  entirely  a  functional  spasm  is,  I  think,  doubt- 
ful. There  are  instances  in  which  the  child  is  somewhat  hoarse  throughout 
the  day,  and  has  slight  catarrhal  symptoms  and  a  brazen,  croupy  cough.  There 
is  probably  slight  catarrhal  laryngitis  with  it.  These  cases  are  not  infrequently 
mistaken  for  true  croup,  and  parents  are  sometimes  unnecessarily  disturbed 
by  the  serious  view  which  the  physician  takes  of  the  case.  Too  often  the  poor 
child,  deluged  with  drugs,  is  longer  in  recovering  from  the  treatment  than  he 
would  be  from  the  disease.  To  allay  the  spasm  a  whiff  of  chloroform  may  be 
administered,  which  will  in  a  few  moments  give  relief,  or  the  child  may  be 
placed  in  a  hot  bath.  A  prompt  emetic,  such  as  zinc  or  wine  of  ipecac,  will 
usually  relieve  the  spasm,  and  is  specially  indicated  if  the  child  has  overloaded 
the  stomach  through  the  day. 


600  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 


V.     TUBERCULOUS    LARYNGITIS. 

Etiology. — Tubercles  may  arise  primarily  in  the  laryngeal  mucosa,  but  in 
the  great  majority  of  cases  the  afEection  is  secondary  to  pulmonary  tubercu- 
losis, in  which  it  is  met  with  in  a  variable  proportion  of  from  18  to  30  per 
cent.  Laryngitis  may  occur  very  early  in  pulmonary  tuberculosis.  There 
may  be  well-marked  involvement  of  the  larynx  with  signs  of  very  limited 
trouble  at  one  apex.  These  are  cases  which,  in  my  experience,  run  a  very 
unfavorable  course. 

Morbid  Anatomy. — The  mucosa  is  at  first  swollen  ^nd  presents  scattered 
tubercles,  which  seem  to  begin  in  the  neighborhood  of  the  blood-vessels.  By 
their  fusion  small  tuberculous  masses  arise,  which  caseate  and  finally  ulcerate, 
leaving  shallow  irregular  losses  of  substance.  The  ulcers  are  usually  covered 
with  a  grayish  exudation,  and  there  is  a  general  thickening  of  the  mucosa 
about  them,  which  is  particularly  marked  upon  the  arytenoids.  The  ulcers 
may  erode  the  true  cords  and  finally  destroy  them,  and  passing  deeply  may 
cause  perichondritis  with  necrosis  and  occasionally  exfoliation  of  the  carti- 
lages. The  disease  may  extend  laterally  and  involve  the  pharynx,  and  down- 
ward over  the  mucous  membrane,  covering  the  cricoid  cartilage  toward  the 
oesophagus.  Above,  it  may  reach  the  posterior  wall  of  the  pharynx,  and  in 
rare  cases  extend  to  the  fauces  and  tonsils.  The  epiglottis  may  be  entirely 
destroyed.  There  are  rare  instances  in  which  cicatricial  changes  go  on  to  such 
a  degree  that  stenosis  of  the  larynx  is  induced. 

Symptoms. — The  first  indication  is  slight  huskiness  of  the  voice,  which 
finally  deepens  to  hoarseness,  and  in  advanced  stages  there  may  be  complete 
loss  of  voice.  There  is  something  very  suggestive  in  the  early  hoarseness  of 
tuberculous  laryngitis.  The  attention  may  be  directed  to  the  lungs  simply  by 
the  quality  of  the  voice. 

The  cough  is  in  part  due  to  involvement  of  the  larynx.  Early  in  the 
disease  it  is  not  very  troublesome,  but  when  the  ulceration  is  extensive  it 
becomes  husky  and  ineffectual.  Of  the  symptoms,  none  is  more  aggravating 
than  the  dysphagia,  which  is  met  with  particularly  when  the  epiglottis  is 
involved,  and  when  the  ulceration  has  extended  to  the  pharynx.  There  is  no 
more  distressing  or  painful  complication  in  phthisis.  In  instances  in  which 
the  epiglottis  is  in  great  part  destroyed,  with  each  attempt  to  take  food  there 
are  distressing  paroxysms  of  cough,  and  even  of  suffocation. 

With  the  laryngoscope  there  is  seen  early  in  the  disease  a  pallor  of  the 
mucous  membrane,  which  also  looks  thickened  and  infiltrated,  particularly 
that  covering  the  arytenoid  cartilages.  The  ulcers  are  very  characteristic. 
They  are  broad  and  shallow,  with  gray  bases  and  ill-defined  outlines.  The 
vocal  cords  are  infiltrated  and  thickened,  and  ulceration  is  very  common. 

The  diagnosis  is  rarely  difficult,  as  it  is  usually  associated  with  well-marked 
pulmonary  disease.  In  case  of  doubt  the  secretion  from  the  base  of  an  ulcer 
should  be  examined  for  bacilli. 

Treatment.— The  voice  should  not  be  used.  The  ulcers  should  be  sprayed 
and  kept  thorouglily  cleansed  with  a  solution  of  tannic  acid,  nitrate  of  silver, 
or  sulphate  of  zinc.  The  insufflation,  three  times  a  day,  of  a  powder  of  iodo- 
form with  morphia,  after  cleansing  the  ulcers  with  a  spray,  relieves  the  pain 


DISEASES  OF  THE  LARYNX.  601 

in  a  majority  of  the  cases.  Cocaine  (4-per-cent  solution)  applied  with  the 
atomizer  will  often  enable  the  patient  to  swallow  his  food  comfortably.  There 
are,  however,  distressing  cases  of  extensive  laryngeal  and  pharyngeal  ulcera- 
tion in  which  even  cocaine  loses  its  good  effects.  When  the  epiglottis  is  lost 
the  difficulty  in  swallowing  becomes  very  great.  Wolfenden  states  that  this 
may  be  obviated  if  the  patient  hangs  his  head  over  the  side  of  the  bed  and 
sucks  milk  through  a  rubber  tube  from  a  mug  placed  on  the  floor. 

VI.     SYPHILITIC    LARYNGITIS. 

Syphilis  attacks  the  larynx  with  great  frequency.  It  may  result  from 
the  inherited  disease  or  be  a  secondary  or  tertiary  manifestation  of  the  ac- 
quired form. 

Symptoms. — In  secondary  syphilis  there  is  occasionally  erythema  of  the 
larynx,  Avhich  may  go  on  to  definite  catarrh,  but  has  nothing  characteristic. 
The  process  may  proceed  to  the  formation  of  superficial  whitish  ulcers,  usually 
symmetrically  placed  on  the  cords  or  ventricular  bands.  Mucous  patches  and 
condylomata  are  rarely  seen.  The  symptoms  are  practically  those  of  slight 
loss  of  voice  with  laryngeal  irritation,  as  in  the  simple  catarrhal  form. 

The  tertiary  larjoigeal  lesions  are  numerous  and  very  serious.  True  gum- 
mata,  varying  in  size  from  the  head  of  a  pin  to  a  small  nut,  arise  in  the  sub- 
mucous tissue,  most  commonly  at  the  base  of  the  epiglottis.  They  go  through 
the  changes  characteristic  of  these  structures  and  may  either  break  down,  pro- 
ducing extensive  and  deep  ulceration,  or — and  this  is  more  characteristic  of 
syphilitic  laryngitis — in  their  healing  form  a  fibrous  tissue  which  shrinks  and 
produces  stenosis.  The  ulceration  is  apt  to  extend  deeply  and  involve  the  carti- 
lage, inducing  necrosis  and  exfoliation,  and  even  haemorrhage  from  erosion 
of  the  arteries.  OEdema  may  suddenly  prove  fatal.  The  cicatrices  which  fol- 
low the  sclerosis  of  the  gummata  or  the  healing  of  the  ulcers  produce  great 
deformity.  The  epiglottis,  for  instance,  may  be  tied  down  to  the  pharyngeal 
wall  or  to  the  epiglottic  folds,  or  even  to  the  tongue;  and  eventually  a  stenosis 
results,  which  may  necessitate  tracheotomy. 

The  laryngeal  symptoms  of  inherited  syphilis  have  the  usual  course  of 
these  lesions  and  appear  either  early,  within  the  first  five  or  six  months,  or 
after  puberty;  most  commonly  in  the  former  period.  Of  76  cases,  J.  N. 
Mackenzie  found  that  63  occurred  within  the  first  year.  The  gummatous  infil- 
tration leads  to  ulceration,  most  commonly  of  the  epiglottis  and  in  the  ven- 
tricles, and  the  process  may  extend  deeply  and  involve  the  cartilage.  Cica- 
tricial contraction  may  also  occur. 

The  diagnosis  of  syphilis  of  the  larynx  is  rarely  difficult,  since  it  occurs 
most  commonly  in  connection  with  other  symptoms  of  the  disease. 

Treatment. — The  administration  of  constitutional  remedies  is  the  most 
important,  and  under  mercury  and  iodide  of  potassium  the  local  symptoms 
may  rapidly  be  relieved.  The  tertiary  laryngeal  manifestations  are  always 
serious  and  difficult  to  treat.  The  deep  ulceration  is  specially  hard  to  combat, 
and  the  cicatrization  may  necessitate  tracheotomy,  or  the  gradual  dilatation, 
as  practised  bv  Schroetter. 
40  " 


602  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 


C.    DISEASES  OE  THE  BRONCHI. 

I.     ACUTE    BRONCHITIS. 

Acute  catarrhal  inflammation  of  the  bronchial  mucous  membrane  is  a  very 
common  disease,  rarely  serious  in  healthy  adults,  but  very  fatal  in  the  old  and 
in  the  young,  owing  to  associated  pulmonary  complications.  It  is  bilateral 
and  affects  either  the  larger  and  medium  sized  tubes  or  the  smaller  bronchi, 
in  which  case  it  is  known  as  capillary  bronchitis. 

We  shall  speak  only  of  the  former,  as  the  latter  is  part  and  parcel  of 
broncho-pneumonia. 

Etiology. — Acute  bronchitis  is  a  common  sequel  of  catching  cold,  and  is 
often  nothing  more  than  the  extension  downward  of  an  ordinary  coryza.  It 
occurs  most  frequently  in  the  changeable  weather  of  early  spring  and  late 
autumn.  Its  association  with  cold  is  well  indicated  by  the  popular  expression 
"  cold  on  the  chest."  It  may  prevail  as  an  epidemic  apart  from  influenza,  of 
which  it  is  an  important  feature. 

Acute  bronchitis  is  associated  with  many  other  affections,  notably  measles. 
It  is  by  no  means  rare  at  the  onset  of  t^^phoid  fever  and  malaria.  It  is  present 
also  in  asthma  and  whooping-cough.  The  subjects  of  spinal  curvature  are 
specially  liable  to  the  disease.  The  bronchitis  of  Bright's  disease,  gout,  and 
heart-disease  is  usually  a  chronic  form.  It  attacks  persons  of  all  ages,  but 
most  frequently  the  young  and  the  old.  There  are  individuals  who  have  a 
special  disposition  to  bronchial  catarrh,  and  the  slightest  exposure  is  apt  to 
bring  on  an  attack.  Persons  who  live  an  out-of-door  life  are  usually  less  sub- 
ject to  the  disease  than  those  who  follow  sedentary  occupations. 

The  affection  is  probably  microbic,  though  we  have  as  yet  no  definite  evi- 
dence upon  this  point. 

Morbid  Anatomy. — The  mucous  membrane  of  the  trachea  and  bronchi  is 
reddened,  congested,  and  covered  with  mucus  and  muco-pus,  which  may  be 
seen  oozing  from  the  smaller  bronchi,  some  of  which  are  dilated.  The  finer 
changes  in  the  mucosa  consist  in  desquamation  of  the  ciliated  epithelium, 
swelling  and  cedema  of  the  submucosa,  and  infiltration  of  the  tissue  with  leu- 
cocytes.   The  mucous  glands  are  much  swollen. 

Symptoms. — The  symptoms  of  an  ordinary  "  cold  "  accompany  the  onset 
of  an  acute  bronchitis.  The  coryza  extends  to  the  tubes,  and  may  also  affect 
the  lar}-nx.  producing  hoarseness,  which  in  many  cases  is  marked.  A  chill  is 
rare,  but  there  is  invariably  a  sense  of  oppression,  with  heaviness  and  languor 
and  pains  in  the  bones  and  back.  In  mild  cases  there  is  scarcely  any  fever, 
but  in  severer  forms  the  range  is  from  101°  to  103°.  The  bronchial  symptoms 
set  in  with  a  feeling  of  tightness  and  rawness  beneath  the  sternum  and  a 
sansation  of  oppression  in  the  chest.  The  cough  is  rough  at  first,  and  often 
of  a  ringing  character.  It  comes  on  in  paroxysms  which  rack  and  distress 
the  patient  extremely.  During  the  severe  spells  the  pain  may  be  very  intense 
beneath  the  sternum  and  along  the  attachments  of  the  diaphragm.  At  first 
the  cough  is  dry  and  the  expectoration  scanty  and  viscid,  but  in  a  few  days 
the  secretion  becomes  muco-purulent  and  abundant,  and  finally  purulent. 
With  the  loosening  of  the  cough  great  relief  is  experienced.     The  sputum  is 


DISEASES  OF  THE  BRONCHI.  603 

made  up  largely  of  pus-cells,  with  a  variable  number  of  the  large  round 
alveolar  cells,  many  of  which  contain  carbon  grains,  while  others  have  under- 
gone the  myelin  degeneration. 

Physical  Signs. — The  respiratory  movements  are  not  greatly  increased 
in  frequency  unless  the  fever  is  high.  There  are  instances,  however,  in  which 
the  breathing  is  rapid  and  when  the  smaller  tubes  are  involved  there  is 
dyspncBa.  On  palpation  the  bronchial  fremitus  may  often  be  felt.  On  aus- 
cultation in  the  early  stage,  piping  sibilant  rales  are  everywhere  to  be  heard. 
They  are  very  changeable,  and  appear  and  disappear  with  coughing.  With 
the  relaxation  of  the  bronchial  membranes  and  the  greater  abundance  of  the 
secretion,  the  rales  change  and  become  mucous  and  bubbling  in  quality.  The 
bases  of  the  lungs  should  be  carefully  examined  each  day,  particularly  in 
children  and  the  aged. 

Course. — The  course  of  the  disease  depends  on  the  conditions  under  which 
it  arises.  In  healthy  adults,  by  the  end  of  a  week  the  fever  subsides  and  the 
cough  loosens.  In  another  week  or  ten  days  convalescence  is  fully  established. 
In  young  children  the  chief  risk  is  in  the  extension  of  the  process  downward. 
In  measles  and  whooping-cough,  the  ordinary  bronchial  catarrh  is  very  apt  to 
descend  to  the  finer  tubes,  which  become  dilated  and  plugged  with  muco-pus, 
inducing  areas  of  collapse,  and  finally  broncho-pneumonia.  This  extension 
is  indicated  by  changes  in  the  physical  signs.  Usually  at  the  base  the  rales 
are  subcrepitant  and  numerous  and  there  may  be  areas  of  defective  resonance 
and  of  feeble  or  distant  tubular  breathing.  In  the  aged  and  debilitated  there 
are  similar  dangers  if  the  process  extends  from  the  larger  to  the  smaller  tubes. 
In  old  age  the  bronchial  mucosa  is  less  capable  of  expelling  the  mucus,  which 
is  more  apt  to  sag  to  the  dependent  parts  and  induce  dilatation  of  the  tubes 
with  extension  of  the  inflammation  to  the  contiguous  air-cells. 

Diagnosis. — The  diagnosis  of  acute  bronchitis  is  rarely  difficult.  Although 
the  mode  of  onset  may  be  brusque  and  perhaps  simulate  pneumonia,  yet  the 
absence  of  dulness  and  blowing  breathing,  and  the  general  character  of  the 
bronchial  inflammation,  render  the  diagnosis  easy.  About  once  a  year  I  see 
a  case  of  typhoid  fever,  in  which  the  diagnosis  at  first  has  been  acute  bron- 
chitis. The  complication  of  broncho-pneumonia  is  indicated  by  the  greater 
severity  of  the  symptoms,  particularly  the  dyspnoea,  the  changed  color,  and 
the  physical  signs. 

Treatment. — In  mild  cases,  household  measures  suffice.  The  hot  foot- 
bath, or  the  warm  bath,  a  drink  of  hot  lemonade,  and  a  mustard  plaster  on  the 
chest  will  often  give  relief.  For  the  dry,  racking  cough,  the  symptom  most 
complained  of  by  the  patient,  Dover's  powder  is  the  best  remedy.  It  is  a 
popular  belief  that  quinine,  in  full  doses,  will  check  an  oncoming  cold  on  the 
chest,  but  this  is  doubtful.  It  is  a  common  custom  when  persons  feel  the 
approach  of  a  cold  to  take  a  Turkish  bath,  and  though  the  tightness  and 
oppression  may  be  relieved  by  it,  there  is  in  a  majority  of  the  cases  great  risk. 
Some  of  the  severest  cases  of  bronchitis  which  I  have  seen  have  followed  this 
initial  Turkish  bath.  No  doubt,  if  the  person  could  go  to  bed  directly  from 
the  bath,  its  action  would  be  beneficial,  but  there  is  great  risk  of  catching 
"  cold  "  in  going  home  from  the  bath.  Relief  is  obtained  from  the  unpleasant 
sense  of  rawness  by  keeping  the  air  of  the  room  saturated  with  moisture,  and 
in  this  dry  stage  the  old-fashioned  mixture  of  the  wines  of  antimony  and 


604  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

ipecacuanha  with  liquor  ammonii  acetatis  and  nitrous  ether  is  useful.  If  the 
pulse  is  very  rapid,  tincture  of  aconite  may  be  given,  particularly  in  the  case 
of  children.  For  the  cough,  when  dry  and  irritating,  opium  should  be  freely 
used  in  the  form  of  Dover's  powder  or  paregoric.  Of  course,  in  the  very 
young  and  the  aged  care  must  be  exercised  in  the  use  of  opium,  particularly 
if  the  secretions  are  free ;  but  for  the  distressing,  irritative  cough,  which  keeps 
the  patient  awake,  opium  in  some  form  gives  the  only  relief.  As  the  cough 
loosens  and  the  expectoration  is  more  abundant,  the  patient  becomes  more 
comfortable.  In  this  stage  it  is  customary  to  ply  him  with  expectorants  of 
various  sorts.  Though  useful  occasionally,  they  should  not  be  given  as  a 
matter  of  routine.  A  mixture  of  squills,  ammonia,  and  senega  is  a  favorite 
one  with  many  practitioners  at  this  stage. 

In  the  acute  bronchitis  of  children,  if  the  amount  of  secretion  is  large 
and  difficult  to  expectorate,  or  if  there  is  dyspnoea  and  the  color  begins  to 
get  dusky,  an  emetic  (a  tablespoonful  of  ipecac  wine)  shoxdd  be  given  at  once 
and  repeated  if  necessary. 

II.     CHRONIC    BRONCHITIS. 

Etiology. — This  affection  may  follow  repeated  attacks  of  acute  bronchitis, 
but  it  is  most  commonly  met  with  in  chronic  lung  affections,  heart-disease, 
aneurism  of  the  aorta,  gout,  and  renal  disease.  It  is  frequent  in  the  aged; 
the  young  rarely  are  affected.  Climate  and  season  have  an  important  influence. 
It  is  the  winter  cough  of  the  aged,  recurring  with  regularity  as  the  weather 
gets  cold  and  changeable.  Owing  to"  the  more  uniform  heating  of  the  houses,  it 
is  much  less  common  in  Canada  and  in  the  United  States  than  in  England. 

Morbid  Anatomy. — The  bronchial  mucosa  presents  a  great  variety  of 
changes,  depending  somewhat  upon  the  disease  with  which  chronic  bronchitis 
is  associated.  In  some  cases  the  mucous  membrane  is  very  thin,  so  that  the 
longitudinal  bands  of  elastic  tissue  stand  out  prominently.  The  tubes  are 
dilated,  the  muscular  and  glandular  tissues  are  atrophied,  and  the  epithelium 
is  in  great  part  shed. 

In  other  instances  the  mucosa  is  thickened,  granular,  and  infiltrated. 
There  may  be  ulceration,  particularly  of  the  mucous  follicles.  Bronchial  dila- 
tations are  not  uncommon  and  emphysema  is  a  constant  accompaniment. 

Symptoms. — In  the  form  met  with  in  old  men,  associated  with  emphysema, 
gout,  or  heart-disease,  the  chief  symptoms  are  as  follows :  Shortness  of  breath, 
which  may  not  be  noticeable  except  on  exertion.  The  patients  "  puff  and 
blow  "  on  going  up  hill  or  up  a  flight  of  stairs.  This  is  due  not  so  much  to 
the  chronic  bronchitis  itself  as  to  associated  emphysema  or  even  to  cardiac 
weakness.  They  complain  of  no  pain.  The  cough  is  variable,  changing  with 
the  weather  and  with  the  season.  During  the  summer  they  may  remain  free, 
but  each  succeeding  winter  the  cough  comes  on  with  severity  and  persists. 
There  may  be  only  a  spell  in  the  morning,  or  the  chief  distress  is  at  night. 
The  sputum  in  chronic  bronchitis  is  very  variable.  In  cases  of  the  so-called 
dry  catarrh  there  is  no  expectoration.  Usually,  however,  it  is  abundant,  muco- 
purulent, or  distinctly  purulent  in  character.  There  are  instances  in  which 
the  patient  coughs  up  for  years  a  thin  fluid  sputum.  There  is  rarely  fever. 
The  general  health  may  be  good  and  the  disease  may  present  no  serious  fea- 


DISEASES  OF  THE  BRONCHI.  605 

tures  apart  from  the  liability  to  induce  emphysema  and  bronchiectasy.  In 
many  cases  it  is  an  incurable  affection.  Patients  improve  and  the  cough  dis- 
appears in  the  summer  time  only  to  return  during  the  winter  months. 

Physical  Signs. — The  chest  is  usually  distended,  the  movements  are 
limited,  and  the  condition  is  often  that  which  we  see  in  emphysema.  The 
percussion  note  is  clear  or  hyperresonant.  On  auscultation,  expiration  is  pro- 
longed and  wheezy  and  rhonchi  of  various  sorts  are  heard — some  high-pitched 
and  piping,  others  deep-toned  and  snoring.  Crepitant  rales  are  common  at 
the  bases. 

Clinical  Varieties. — The  description  just  given  is  of  the  ordinary  chronic 
bronchitis  which  occurs  in  connection  with  emphysema  and  heart-disease  and 
in  many  elderly  men.  There  are  certain  forms  which  merit  special  descrip- 
tion: (a)  There  is  a  form  of  chkonic  bronchitis  in  women,  which  comes 
on  between  the  ages  of  twenty  and  thirty  and  may  continue  indefinitely  with- 
out serious  impairment  of  the  health.  In  several  cases  the  cough  followed 
influenza,  and  there  may  be  slight  bronchiectasis. 

(&)  Bronchorrhcea. — Excessive  bronchial  secretion  is  met  with  under 
several  conditions.  It  must  not  be  mistaken  for  the  profuse  expectoration  of 
bronchiectasis.  The  secretion  may  be  very  liquid  and  watery — hroncJiorrhoea 
serosa,  and  in  extraordinary  amount.  More  commonly,  it  is  purulent  though 
thin,  and  with  greenish  or  yellow-green  masses.  It  may  be  thick  and  uniform. 
This  profuse  bronchial  secretion  is  usually  a  manifestation  of  chronic  bron- 
chitis, and  may  lead  to  dilatation  of  the  tubes  and  ultimately  to  fetid 
bronchitis.  In  the  young  the  condition  may  persist  for  years  without  impair- 
ment of  health  and  without  apparently  damaging  the  lungs. 

(c)  Putrid  Bronchitis. — Fetid  expectoration  is  met  with  in  connection 
with  bronchiectasis,  gangrene,  abscess,  or  with  decomposition  of  secretions 
within  phthisical  cavities  and  in  an  empyema  which  has  perforated  the 
lung.  There  are  instances  in  which,  apart  from  any  of  these  states,  the 
expectoration  has  a  fetid  character.  The  sputa  are  abundant,  usually  thin, 
grayish-white  in  color,  and  they  separate  into  an  upper  fluid  layer  capped 
with  frothy  mucus  and  a  thick  sediment  in  which  may  sometimes  be  found 
dirty  yellow  masses  the  size  of  peas  or  beans — the  so-called  Dittriclis  plugs. 
The  affection  is  very  rare  apart  from  the  above-mentioned  conditions.  In 
severe  cases  it  leads  to  changes  in  the  bronchial  walls,  pneumonia,  and  often 
to  abscess  or  gangrene.  Metastatic  brain  abscess  has  followed  putrid  bron- 
chitis in  a  certain  number  of  cases. 

{d)  Dry  Catarrh. — The  catarrhe  sec  of  Laennec,  a  not  uncommon  form, 
is  characterized  by  paroxysms  of  coughing  of  great  intensity,  with  little  or 
no  expectoration.  It  is  usually  met  with  in  elderly  persons  with  emphysema, 
and  is  one  of  the  most  obstinate  of  all  varieties  of  bronchitis. 

Treatment. — Eemoval  to  a  southern  latitude  may  prevent  the  onset.  In 
England  the  milder  climate  of  Falmouth,  Torquay,  and  Bournemouth  is 
suitable  for  those  who  cannot  go  elsewhere.  Egypt,  southern  France,  southern 
California,  and  Florida  furnish  winter  climates  in  which  the  subjects  of 
chronic  bronchitis  live  with  the  greatest  comfort.  With  care  chronic  bron- 
chitis may  prove  to  be  the  slight  ailment  that,  as  Oliver  Wendell  Holmes  says, 
promotes  longevity. 

The  first  endeavor  is  to  ascertain,  if  possible,  whether  there  are  constitu- 


606  DISEASES  OF  THE  RESPIRATORY  SYSTEAi. 

tional  or  local  affections  with  which  it  is  associated.  In  many  instances  the 
urine  is  found  to  be  highly  acid,  perhaps  slightly  albuminous,  and  the  arteries 
are  stiff.  In  the  form  associated  with  this  condition,  sometimes  called  gouty 
bronchitis,  the  attacks  seem  related  to  the  defective  renal  elimination,  and  to 
this  condition  the  treatment  should  be  first  directed.  In  other  instances  there 
are  heart-disease  and  emphysema.  In  the  form  occurring  in  old  men  much 
may  be  done  in  the  way  of  prophjdaxis.  There  is  no  doubt  that  with  prudence 
even  in  the  most  changeable  winter  weather  much  may  be  done  to  prevent 
the  onset  of  chronic  bronchitis.  Woollen  undergarments  should  be  used  and 
especial  care  should  be  taken  in  the  spring  months  not  to  change  them  for 
lighter  ones  before  the  warm  weather  is  established. 

Cure  is  seldom  affected  by  medicinal  remedies.  There  are  instances  in 
which  iodide  of  potassium  acts  with  remarkable  benefit,  and  it  should  always 
be  given  a  trial  in  cases  of  paroxysmal  bronchitis  of  obscure. origin.  For  the 
morning  cough,  bicarbonate  of  sodium  (gr.  xv),  chloride  of  sodium  (gr.  v), 
spirits  of  chloroform  (fflv)  in  anise  water  and  taken  with  an  equal  amount 
of  warm  water  will  be  found  useful  (Fowler).  When  there  is  much  sense 
of  tightness  and  fulness  of  the  chest,  the  portable  Turkish  bath  may  be  tried. 
When,  the  secretion  is  excessive  muriate  of  ammonia  and  senega  are  useful. 
Stimulating  expectorants  are  contraindicated.  When  the  heart  is  feeble,  the 
combination  of  digitalis  and  strychnia  is  very  beneficial.  Turpentine,  the  old- 
fashioned  remedy  so  warmly  recommended  by  the  Dublin  physicians,  has  in 
many  quarters  fallen  undeservedly  into  disuse.  Preparations  of  tar,  creosote, 
and  terebene  are  sometimes  useful.  Of  other  balsamic  remedies,  sandal-wood, 
the  compound  tincture  of  benzoin,  copaiba,  balsam  of  Peru  or  tolu  may  be 
used.  Inhalations  of  eucah^tus  and  of  the  spray  of  ipecacuanha  wine  are 
often  very  useful.  If  fetor  be  present,  carbolic  acid  in  the  form  of  spray  (10 
to  20  per  cent  solution)  will  lessen  the  odor,  or  thymol  (1  to  1,000),  but  the 
intratracheal  medication  is  the  most  efficient.  After  the  larjmx  is  ansesthe- 
tized  with  a  4  per  cent  cocaine  solution,  inject  with  suitable  syringe  about 
two  drachms  of  olive  oil,  vsdth  gr.  ^  of  iodoform,  and  gr.  ^  of  morphia  if  there 
is  irritating  cough.  For  urgent  dyspnoea  with  cyanosis,  bleeding  from  the 
arm  gives  most  relief, 

III.     BRONCHIECTASIS. 

Etiology. — The  following  excellent  classification  is  given  by  Barty  King: 

I.  Bronchiolectasis-;  ^i 

I  Chronic 

Chronic  bronchitis 
Broncho-pneumonic 

A.  Pure-(  3.   Chronic  pneumonic 
Pneumonic 
Pleuritic 

B.  Tuberculous 


11.  Bronchiectasis 


C.   Traumatic     - 


'1.  Aneurism 

2.  Tumor 

3.  Foreign  body 
,4.  Syphilis 


DISEASES  OF  THE  BRONCHI.  607 

In  addition  there  is  a  congenital  defect  which  Grawitz  has  described  as  hron- 
chicctasis  universalis. 

Unquestionably  the  weakening  of  the  bronchial  wall  is  the  most  impor- 
tant, probably  the  essential,  factor  in  inducing  bronchiectasy,  since  the  wall 
is  then  not  able  to  resist  the  pressure  of  air  in  severe  spells  of  coughing  and 
in  straining.  In  some  instances  the  mere  weight  of  the  accumulated  secretion 
may  be  sufficient  to  distend  the  terminal  tubules,  as  is  seen  in  compression  of  a 
bronchus  by  aneurism.  Barty  King  lays  great  stress  on  pleural  adherency  as 
a  factor  in  the  initial  dilatation  of  the  tubes.  The  disease  seems  to  have 
increased  in  frequency  since  the  influenza  epidemics  of  the  past  fifteen  years. 
Of  six  consecutive  cases  in  my  wards  in  the  session  of  1904-05  from  every 
one  Boggs  isolated  the  influenza  bacillus. 

Morbid  Anatomy. — Two  chief  forms  of  bronchiectasis  are  recognized — the 
cylindrical  and  the  saccular — which  may  exist  together  in  the  same  lung.  The 
condition  may  be  general  or  partial.  Universal  bronchiectasis  is  always  uni- 
lateral. It  occurs  in  rare  congenital  cases  and  is  occasionally  seen  as  a 
sequence  of  interstitial  pneumonia.  The  entire  bronchial  tree  is  represented 
by  a  series  of  sacculi  opening  one  into  the  other.  The  walls  are  smooth  and 
possibly  without  ulceration  or  erosion  except  in  the  dependent  parts.  The 
lining  membrane  of  the  sacculi  is  usually  smooth  and  glistening.  The  dila- 
tations may  form  large  cysts  iminediately  beneath  the  pleura.  Intervening 
between  the  sacculi  is  a  dense  cirrhotic  lung  tissue.  The  partial  dilatations — 
the  saccular  and  cylindrical — are  common  in  chronic  phthisis,  particularly  at 
the  apex,  in  chronic  pleurisy  at  the  base,  and  in  emphysema.  Here  the  dila- 
tation is  more  commonly  cylindrical,  sometimes  fusiform.  The  bronchial 
mucous  membrane  is  much  involved  and  sometimes  there  is  a  narrowing  of 
the  lumen.  Occasionally  one  meets  with  a  single  saccular  bronchiectasy  in 
connection  with  chronic  bronchitis  or  emphysema.  Some  of  these  look  like 
simple  cysts,  with  smooth  walls,  without  fluid  contents.  Bronchiolectasis  as  an 
acute  condition  may  follow  the  infectious  diseases,  as  in  the  cases  described  by 
Sharkey,  Carr,  and  others.  The  chronic  variety  is  a  sequel  of  bronchitis  in 
old  subjects. 

Histologically  the  bronchi  which  are  the  seat  of  dilatation  show  important 
changes.  In  the  large,  smooth  dilatations  the  cylindrical  is  replaced  by  a 
pavement  epithelium.  The  muscular  layer  is  stretched,  atrophied,  and  the 
fibres  separated;  the  elastic  tissue  is  also  much  stretched  and  separated.  In 
the  large  saccular  bronchiectases  and  in  some  of  the  cylindrical  forms,  due  to 
retained  secretions,  the  lining  membrane  is  ulcerated.  The  contents  of  some 
of  the  larger  bronchiectatic  cavities  are  horribly  fetid. 

Symptoms. — There  are  acute  cases,  usually  the  bronchiolectasis  of  children ; 
but  a  recent  case  in  my  wards  of  the  broncho-pneumonia  form  died  in  six 
weeks  from  the  onset.  The  bronchi  of  the  lower  lobes  were  dilated;  there 
were  areas  of  broncho-pneumonia  and  one  or  two  spots  of  gangrene.  The 
patient  became  hemiplegic,  probably  from  abscess  of  the  brain.  In  the 
limited  dilatations  of  phthisis,  emphysema,  and  chronic  bronchitis,  the  symp- 
toms are  in  great  part  those  of  the  original  disease,  and  the  condition  often 
is  not  suspected  during  life. 

In  extensive  saccular  bronchiectasis  the  characters  of  the  cough  and  expec- 
toration are  distinctive.     The  patient  will  pass  the  greater  part  of  the  day 


608  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

without  any  cough  and  then  in  a  severe  paroxysm  will  bring  up  a  large  quan- 
tity of  sputum.  Ten  of  my  eases  showed  this  symptom.  Of  33  of  my  cases  the 
amount  for  twenty-four  hours  was,  in  2  less  than  100  cc,  in  11  from  100-300 
cc,  in  2  almost  500  cc,  in  7  over  600  cc.  In  one  case  with  over  one  litre 
per  day  the  cavities  found  were  very  small.  Sometimes  change  of  the  posi- 
tion will  bring  on  a  violent  attack,  probably  due  to  the  fact  that  some  of  the 
secretion  flows  from  the  dilatation  to  a  normal  tube.  The  daily  spell  of 
coughing  is  usually  in  the  morning.  The  expectoration  is  in  many  instances 
very  characteristic.  It  is  grayish  or  grayish-brown  in  color,  fluid,  purulent, 
with  a  peculiar  acid,  sometimes  fetid,  odor.  Placed  in  a  conical  glass,  it  sepa- 
rates into  a  thick  granular  layer  below  and  a  thin  mucoid  intervening  layer 
above,  which  is  capped  by  a  brownish  froth.  Microscopically  it  consists  of 
pus-corpuscles,  often  large  crystals  of  fatty  acids,  which  are  sometimes  in 
enormous  numbers  over  the  field  and  arranged  in  bunches.  H^matoidin 
crystals  are  sometimes  present.  Elastic  fibres  are  seldom  found  except  when 
there  is  ulceration  of  the  bronchial  walls.  Tubercle  baccilli  are  not  present. 
In  some  cases,  as  in  10  of  my  series,  the  expectoration  is  very  fetid  and  has  all 
the  characters  of  that  described  under  fetid  bronchitis.  Nummular  expectora- 
tion, such  as  comes  from  phthisical  cavities,  is  not  common.  Hsemorrhage 
occurred  in  14  out  of  35  cases  analyzed  by  Fowler,  in  17  of  my  24  cases, 
slight  in  8,  and  extreme  in  3.  Abscess  of  the  brain  has  in  a  few  instances 
followed  the  bronchiectasis.  Eheumatoid  affections  may  occur,  and  it  is  one 
of  the  conditions  with  which  the  pulmonary  osteo-arthropathy  is  commonly 
associated. 

Diagnosis. — The  diagnosis  is  not  possible  in  a  large  number  of  the  cases. 
In  the  extensive  sacculated  forms,  unilateral  and  associated  with  interstitial 
pneumonia  or  chronic  pleurisy,  the  diagnosis  is  easy.  There  is  contraction  of 
the  side,  which  in  some  instances  is  not  at  all  extreme.  The  cavernous  signs 
may  be  chiefly  at  the  base  and  may  vary  according  to  the  condition  of  the 
cavity,  whether  full  or  empty.  There  may  be  the  most  exquisite  amphoric 
phenomena  and  loud  resonant  rales.  The  condition  persists  for  years  .and  is 
not  inconsistent  with  a  tolerably  active  life.  The  patients  frequently  show 
signs  of  marked  embarrassment  of  the  pulmonary  circulation.  There  is  cya- 
nosis on  exertion,  the  finger-tips  are  clubbed,  and  the  nails  incurved.  A  con- 
dition very  difficult  to  distinguish  from  bronchiectasis  is  a  limited  pleural 
cavity  communicating  with  a  bronchus. 

Treatment. — Medical  treatment  is  not  satisfactor}'',  since  it  is  impossible 
to  heal  the  cavities.  I  have  practised  the  injection  of  antiseptic  fluids  in  some 
instances  with  benefit.  Intratracheal  injections  have  been  very  warmly  recom- 
mended of  late.  With  a  suitable  syringe  a  drachm  may  be  injected  twice  a 
day  of  the  following  solution :  Menthol  10  parts,  guaiacol  2  parts,  olive  oil  88 
parts.  Or  better  still  when  the  odor  is  very  offensive  iodoform  in  olive  oil. 
The  creasote  vapor  bath  may  be  given  in  a  small  room.  The  patient's  eyes 
must  be  protected  with  well-fitting  goggles,  and  the  nostrils  stuffed  with 
cotton-wool.  A  drachm  of  creasote  is  poured  upon  water  in  a  saucer  and 
vaporized  by  placing  the  saucer  over  a  spirit  lamp.  At  first  the  vapor  is  very 
irritating  and  disagreeable,  but  the  patient  gets  used  to  it.  The  bath  should 
be  taken  at  first  every  other  day  for  fifteen  minutes,  then  gradually  increased 
to  an  hour  daily.     The  treatment  should  be  continued  for  three  months.    I 


DISEASES  OF  THE  BRONCHI.  609 

can  recommend  it  as  a  most  satisfactory  metliod  of  treatment.  In  suitable 
cases  drainage  of  the  cavities  may  be  attempted,  particularly  if  the  patient  is  in 
fairly  good  condition.  For  the  fetid  secretion  turpentine  may  be  given,  or  tere- 
bene,  and  inhalations  used  of  carbolic  acid  or  thymol, 

IV.     BRONCHIAL    ASTHMA. 

Asthma  is  a  term  which  has  been  applied  to  various  conditions  associated 
with  dyspnoea — hence  the  names  cardiac  and  renal  asthma — but  its  use  should 
be  limited  to  the  affection  known  as  bronchial  or  spasmodic  asthma. 

Etiology. — All  writers  agree  that  there  is  in  a  majority  of  cases  of  bron- 
chial asthma  a  strong  neurotic  element.  Many  regard  it  as  a  neurosis  in  which, 
according  to  one  view,  spasm  of  the  bronchial  muscles,  according  to  the  other 
turgescence  of  the  mucosa,  results  from  disturbed  innervation,  pneumogastric 
or  vaso-motor.  Of  the  numerous  theories  the  following  are  the  most  im- 
portant : 

(1)  That  it  is  due  to  spasm  of  the  bronchial  muscles,  a  theory  which  has 
perhaps  the  largest  number  of  adherents.  The  original  experiments  of 
C,  J.  B.  Williams,  upon  which  it  is  largely  based,  have  been  confirmed  by 
Brodie. 

(2)  That  the  attack  is  due  to  swelling  of  the  bronchial  mucous  membrane 
— fiuctionary  hypersemia  (Traube),  vaso-motor  turgescence  (Weber),  diffuse 
hypergemic  swelling  (Clark). 

(3)  That  in  many  cases  it  is  a  special  form  of  inflammation  of  the 
smaller  bronchioles — hroncliiolitis  exudativa  (Curschmann).  Other  theories 
which  may  be  mentioned  are  that  the  attack  depends  on  spasm  of  the  dia- 
phragm or  on  reflex  spasm  of  all  the  inspiratory  muscles. 

As  already  mentioned,  the  so-called  hay  fever  is  an  affection  which  has 
many  resemblances  to  bronchial  asthma,  with  which  the  attacks  may  alter- 
nate. In  the  suddenness  of  onset  and  in  many  of  their  features  these  dis- 
eases have  the  same  origin  and  differ  only  in  site,  as  suggested  by  Sir  Andrew 
Clark  and  now  generally  acknowledged  by  specialists.  Making  due  allowance 
for  anatomical  differences,  if  the  structural  changes  occurring  in  the  nasal 
mucous  membrane  during  an  attack  of  hay  fever  were  to  occur  also  in  various 
parts  of  the  bronchial  mucosa,  their  presence  there  would  afford  a  complete 
and  adequate  explanation  of  the  facts  observed  during  a  paroxysm  of  bronchial 
asthma  (Clark).  With  this  statement  I  fully  agree,  but  the  observations  of 
Curschmann  have  directed  attention  to  a  feature  in  asthma  which  has  been 
neglected;  namely,  that  in  a  majority  of  the  cases  it  is  associated  with  an 
exudation,  such  as  might  be  supposed  to  come  from  a  turgescent  mucosa  and 
which  is  of  a  very  characteristic  and  peculiar  character.  The  hypergemia  and 
swelling  of  the  mucosa  and  the  extremely  viscid,  tenacious  mucus  explain  well 
the  hindrance  to  inspiration  and  expiration  and  also  the  quality  of  the  rales. 
An  oedema  of  the  angio-neurotic  type  has  been  described  in  the  hands  and 
arms  in  asthma  (J.  S.  Billings,  Jr.). 

Some  general  facts  with  reference  to  etiology  may  be  mentioned.  The 
affection  sometimes  runs  in  families,  particularly  those  with  irritable  and 
unstable  nervous  systems.  The  attack  may  be  associated  with  neuralgia  or, 
as  Salter  mentions,  even  alternate  with  epilepsy.     Men  are  more  frequently 


610  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

affected  than  women.  The  disease  often  begins  in  cliildhood  and  sometimes 
lasts  until  old  age.  It  may  follow  an  attack  of  whooping-cough.  One  of  its 
most  striking  peculiarities  is  the  bizarre  and  extraordinary  variety  of  circum- 
stances which  at  times  induce  a  paroxysm.  Among  these  local  conditions 
climate  or  atmosphere  are  most  important.  A  person  may  be  free  in  the  city 
and  invariably  suffer  from  an  attack  when  he  goes  into  the  country,  or  into 
one  special  part  of  the  coimtry.  Such  cases  are  by  no  means  uncommon. 
Breathing  the  air  of  a  particular  room  or  a  dusty  atmosphere  may  bring  on 
an  attack.  Odors,  particularly  of  flowers  and  of  hay,  or  emanations  from 
animals,  as  the  horse,  dog,  or  cat,  may  at  once  cause  an  outbreak.  Fright  or 
violent  emotion  of  any  sort  may  bring  on  a  paroxysm.  Uterine  and  ovarian 
troubles  were  formerly  thought  to  induce  attacks  and  may  do  so  in  rare  in- 
stances. Diet,  too,  has  an  important  influence,  and  in  persons  subject  to  the 
disease  severe  paroxysms  may  be  induced  by  overloading  the  stomach,  or  by 
taking  certain  articles  of  food.  Chronic  cases,  in  which  the  attacks  recur  year 
after  year,  gradually  become  associated  with  emphysema,  and  every  fresh 
"  cold  "  induces  a  paroxysm.  And  lastly,  many  cases  of  bronchial  asthma  are 
associated  with  affections  of  the  nose,  particularly  with  hypertrophic  rhinitis 
and  nasal  polypi. 

Briefly  stated  then,  bronchial  asthma  is  a  neurotic  affection,  characterized 
by  hypersemia  and  turgescence  of  the  mucosa  of  the  smaller  bronchial  tubes 
and  a  peculiar  exudate  of  mucin.  The  attacks  may  be  due  to  direct  irritation 
of  the  bronchial  mucosa  or  may  be  induced  reflexly,  by  irritation  of  the  nasal 
mucosa,  and  indirectly,  too,  by  reflex  influences,  from  stomach,  intestines,  or 
genital  organs. 

Symptoms. — Premonitory  sensations  precede  some  attacks,  such  as  chilly 
feelings,  a  sense  of  tightness  in  the  chest,  flatulence,  the  passage  of  a  large 
quantity  of  urine,  or  great  depression  of  spirits.  Nocturnal  attacks  are  com- 
mon. After  a  few  hours'  sleep,  the  patient  is  aroused  with  a  distressing  sense 
of  want  of  breath  and  a  feeling  of  great  oppression  in  the  chest.  Soon  the 
respiratory  efforts  become  violent,  all  the  accessory  muscles  are  brought  into 
play,  and  in  a  few  minutes  the  patient  is  in  a  paroxysm  of  the  most  intense 
dyspnoea.  The  face  is  pale,  the  expression  anxious,  speech  is  impossible,  and 
in  spite  of  the  most  strenuous  inspiratory  efforts  very  little  air  enters  the  lungs. 
Expiration  is  prolonged  and  also  wheezy.  The  number  of  respirations,  how- 
ever, is  not  much  increased.  The  asthmatic  fit  may  last  from  a  few  minutes  to 
several  hours.  When  severe,  the  signs  of  defective  aeration  soon  appear,  the 
face  becomes  bedewed  with  sweat,  the  pulse  is  small  and  quick,  the  extremities 
get  cold,  and  just  as  the  patient  seems  to  be  at  his  worst,  the  breathing  begins 
to  get  easier,  and  often  with  a  paroxysm  of  coughing  relief  is  obtained  and  he 
sinks  exhausted  to  sleep.  The  relief  may  be  but  temporary  and  a  second 
attack  may  soon  come  on.  In  a  majority  of  the  cases  even  in  the  intervals  be- 
tween the  asthmatic  fits  the  respiration  is  somewhat  embarrassed.  The  cough 
is  at  first  very  tight  and  dry  and  the  expectoration  is  tenacious.  Emphysema 
of  the  neck  may  occur  during  the  violent  coughing  spells.  Urticaria  may 
break  out  over  the  whole  body  during  an  attack,  or,  as  in  one  patient,  may 
be  confined  to  the  skin  of  the  interscapular  regions. 

The  PHYSICAL  SIGNS  during  an  attack  are  very  characteristic.  On  inspec- 
tion the  thorax  looks  enlarged,  barrel-shaped,  and  is  fixed,  the  amount  of 


DISEASES  OF  THE  BRONCHI.  611 

expansion  being  altogether  disproportionate  to  the  intensity  of  the  inspiratory 
movements.  The  diaphragm  is  lowered  and  moves  but  slightly.  Inspiration  is 
short  and  quick,  expiration  prolonged.  Percussion  may  not  reveal  any  special 
difference,  but  there  is  sometimes  marked  hyperresonance,  particularly  in 
cases  which  have  had  repeated  attacks. 

On  auscultation,  with  inspiration  and  expiration,  there  are  innumerable 
sibilant  and  sonorous  rales  of  all  varieties,  piping  and  high-pitched,  low-pitched 
and  grave.    Later  in  the  attack  there  are  moist  rales. 

The  sputum  in  bronchial  asthma  is  quite  distinctive,  unlike  that  which 
occurs  in  any  other  affection.  Early  in  the  attack  it  is  brought  up  with  great 
difficulty  and  is  in  the  form  of  rounded  gelatinous  masses,  the  so-called 
"  perles "  of  Laennec.  Though  ball-like,  they  can  be  unfolded  and  really 
represent  moulds  in  mucus  of  the  smaller  tubes.  The  entire  expectoration  may 
be  made  up  of  these  somewhat  translucent-looking  pellets,  floating  in  a  small 
quantity  of  thin  mucus.  Some  of  them  are  opaque.  Often  with  the  naked  eye 
a  twisted  spiral  character  can  be  seen,  particularly  if  the  sputum  is  spread  on 
a  glass  with  a  black  background.  Microscopically,  many  of  these  pellets  have 
a  spiral  structure,  which  renders  them  among  the  most  remarkable  bodies  met 
with  in  sputum.  It  is  not  a  little  curious  that  they  should  have  been  practi- 
cally overlooked  until  described  by  von  Curschmann.  Under  the  microscope 
the  spirals  are  of  two  forms.  In  one  there  is  simply  a  twisted,  spirally  arranged 
filament  of  mucin,  in  which  are  entangled  leucocytes,  the  majority  of  which 
are  eosinophiles.  The  twist  may  be  loose  or  tight.  The  second  form  is  much 
more  peculiar.  In  the  centre  of  a  tightly  coiled  skein  of  mucin  fibrils  with  a 
few  scattered  cells  is  a  filament  of  extraordinary  clearness  and  translucency, 
probably  composed  of  transformed  mucin.  These  spirals  are  doubtless  formed 
in  the  finer  bronchioles  and  constitute  the  product  of  an  acute  bronchiolitis. 
It  is  difficult  to  explain  their  spiral  nature.  I  do  not  know  of  any  observa- 
tions upon  the  course  of  the  currents  produced  by  the  ciliated  epithelium  in 
the  bronchi,  but  it  is  quite  possible  that  their  action  may  be  rotatory,  in  which 
case,  particularly  when  combined  with  spasm  of  the  bronchial  muscles,  it  is 
possible  to  conceive  that  the  mucus  formed  in  the  tube  might  be  compelled 
to  assume  a  spiral  form.  Within  two  or  three  days  the  sputum  changes  entirely 
in  character;  it  becomes  muco-purulent  and  von  Curschmann's  spirals  are  no 
longer  to  be  found.  They  occur  in  all  instances  of  true  bronchial  asthma  in 
the  early  period  of  the  attack.  I  have  never  seen  the  true  spirals  either  in 
bronchitis  or  pneumonia.  There  are,  in  addition,  in  many  cases,  the  pointed, 
octahedral  crystals  described  by  Leyden  and  sometimes  called  asthma  crystals. 
They  are  identical  with  the  crystals  found  in  the  semen  and  in  the  blood  in 
leukaemia.  At  one  time  they  were  supposed,  by  their  irritating  character,  to 
induce  the  paroxysms.  Eosinophiles  in  the  blood  are  enormously  increased 
in  asthma — to  25  or  35  per  cent  of  the  leucocytes,  or  even  to  53.6  per  cent  in 
one  case  (J.  S.  Billings,  Jr.). 

Course. — The  course  of  the  disease  is  very  variable.  In  severe  attacks  the 
paroxysms  recur  for  three  or  four  nights  or  even  more,  and  in  the  intervals 
and  during  the  day  there  may  be  wheezing  and  cough.  Early  in  the  disease 
the  patient  may  be  free  in  the  morning,  without  cough  or  much  distress,  and 
the  attacks  may  appear  at  first  to  be  of  a  purely  nervous  character.  In  the 
long-standing  cases  emphysema  almost  invariably  develops,  and  while  the  pure 


612  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

asthmatic  fits  diminish  in  frequency  the  chronic  bronchitis  and  shortness  of 
breath  become  aggravated. 

We  have  no  knowledge  of  the  morlnd  anatomy  of  true  asthma.  Death  dur- 
ing the  attack  is  unknown.  In  long-standing  cases  the  lesions  are  those  of 
chronic  bronchitis  and  emphysema. 

Treatment. — The  asthmatic  attack  usually  demands  immediate  and  prompt 
treatment,  and  remedies  should  be  administered  wliich  experience  has  shown 
are  capable  of  relieving  the  condition  of  the  bronchial  mucosa.  A  few  whiffs 
of  chloroform  will  produce  prompt  though  temporary  relaxation.  In  a  child 
with  ver}'  severe  attacks,  resisting  all  the  usual  remedies,  the  treatment  by 
chloroform  gave  immediate  and  finally  permanent  relief.  H^-podermic  injec- 
tions of  pilocarpin  (gr.  J)  will  sometimes  relax  the  mucosa  in  the  profuse 
sweating.  Perles  of  nitrite  of  amyl  may  be  broken  on  the  handkerchief  or 
from  two  to  five  drops  of  the  solution  may  be  placed  upon  cotton-wool  and 
inhaled.  Strong  stimulants  given  hot  or  a  dose  of  spirits  of  chloroform  in  hot 
whisk}^  will  sometimes  induce  relaxation.  More  permanent  relief  is  given  by 
the  hypodermic  injection  of  morphia  or  of  morphia  and  cocaine  combined. 
In  obstinate  and  repeatedly  recurring  attacks  this  has  proved  a  ver}^  satisfac- 
tory plan.  The  sedative  antispasmodics,  such  as  belladonna,  henbane,  stra- 
monium, and  lobelia,  may  be  given  in  solution  or  used  in  the  form  of  ciga- 
rettes. Xearly  all  the  popular  remedies  either  in  this  form  or  in  pastilles 
contain  some  plant  of  the  order  solanacece,  with  nitrate  or  chlorate  of  potash. 
Excellent  cigarettes  are  now  manufactured  and  asthmatics  tr}^  various  sorts, 
since  one  form  benefits  one  patient,  another  form  another  patient.  Xitre 
paper  made  with  a  strong  solution  of  nitrate  of  potash  is  very  serviceable. 
Filling  the  room  with  the  fumes  of  this  paper  prior  to  retiring  will  sometimes 
ward  off  a  nocturnal  attack.  I  have  known  several  patients  to  whom  tobacco 
smoke  inhaled  was  quite  as  potent  as  the  prepared  cigarettes. 

Cauterization  of  the  mucous  membrane  of  the  nose  has  given  great  relief, 
particularly  in  cases  with  swelling  and  irritation.  The  use  of  compressed 
air  in  the  pneumatic  cabinet  is  very  beneficial;  oxygen  inhalations  may  also 
be  tried.  In  preventing  the  recurrence  of  the  attacks  there  is  no  remedy  so 
useful  as  iodide  of  potassium,  which  sometimes  acts  like  a  specific.  From 
10  to  20  grains  three  times  a  day  is  usually  sufficient. 

Particular  attention  should  be  paid  to  the  diet  of  asthmatic  patients.  A 
rule  which  experience  generally  compels  them  to  make  is  to  take  the  heavy 
meals  in  the  early  part  of  the  day  and  not  retire  to  bed  before  gastric  diges- 
tion is  completed.  As  the  attacks  are  often  induced  by  flatulency,  the  carbo- 
hydrates should  be  restricted.  Coffee  is  a  more  suitable  drink  than  tea.  In 
respect  to  climate  it  is  very  difficult  to  lay  down  rules  for  astlimatics.  The 
patients  are  often  much  better  in  the  city  than  in  the  country.  The  high  and 
dry  altitudes  are  certainly  more  beneficial  than  the  sea-shore ;  but  in  protracted 
cases,  with  emphysema  as  a  secondary  complication,  the  rarefied  .air  of  high 
altitudes  is  not  advantageous.  In  young  persons  I  have  known  a  residence  for 
six  months  in  Florida  or  southern  California  to  be  followed  by  prolonged 
freedom  from  attacks.     Eg}"pt  is  a  peculiarly  satisfactor}^  winter  climate. 


DISEASES  OF  THE  BRONCHI.  613 

V.     FIBRINOUS    BRONCHITIS. 

(Plastic  or  Croupous  Bronchitis.) 

Definition. — An  acute  or  chronic  affection,  characterized  by  the  formation 
in  certain  of  the  bronchial  tubes  of  fibrinous  casts,  which  are  expelled  in 
paroxysms  of  dyspnoea  and  cough. 

In  several  diseases  fibrinous  moulds  of  the  bronchi  are  formed,  as  in  diph- 
theria (with  extension  into  the  trachea  and  bronchi),  in  pneumonia,  and  occa- 
sionally in  phthisis — conditions  which,  however,  have  nothing  to  do  with  true 
fibrinous  bronchitis.  These  casts  are  not  to  be  confounded  with  the  blood-casts 
which  occur  occasionally  in  haemoptysis. 

Clinical  Description. — Bettman,  in  reporting  a  case  which  occurred  in  Prof. 
Whitridge  Williams's  obstetrical  clinic  at  the  Johns  Hopkins  Hospital,  has 
analyzed  all  the  cases  from  the  literature  since  1869,  grouping  them  into  dif- 
ferent classes.  The  first  and  most  important  is  chronic  idiopathic  fibrinous 
Ironchitis.  It  is  a  rare  affection.  Of  27  cases,  15  were  in  males.  It  is  most 
common  at  the  middle  period  of  life.  The  attacks  may  occur  at  definite  inter- 
vals for  months  or  years.  The  form  and  size  of  the  casts  may  be  identical  at 
each  attack  as  though  each  time  precisely  the  same  bronchial  area  was  in- 
volved. The  expectoration  of  the  casts  is  associated  with  paroxysms  of  dysp- 
noea and  coughing,  which  occur  at  longer  or  shorter  intervals.  Fever  and 
hsemoptysis  may  be  present  during  the  attack.  Physical  signs  usually  indicate 
the  portion  of  the  lung  affected,  as  there  are  suppressed  breath  sounds  and 
numerous  rales  on  coughing.  A  very  dry  rale,  called  the  "  bruit  de  drapeau," 
has  been  described,  caused  by  the  vibration  of  a  loosened  portion  of  the  cast. 

In  five  cases  there  were  skin  lesions.  Tuberculosis  is  sometimes  present. 
Death  occurred  in  only  one  case  of  the  series.  The  casts  are  usually  rolled 
up  and  mixed  with  mucus  and  blood.  When  unrolled  they  are  large  white 
branching  structures.  The  main  stem  may  be  as  thick  as  the  little  finger. 
Prom  the  consistency  and  appearance  they  have  been  described  as  fibrinous, 
but  they  consist  mainly  of  mucin.  On  cross-section  they  show  a  concentrically 
stratified  structure,  with  leucocytes  and  alveolar  epithelium.  Leyden's  crystals 
and  von  Curschinann's  spirals  are  sometimes  found,  and  in  Bettman's  case 
there  were  protozoan-like  bodies. 

There  is  a  very  remarkable  acute  form,  of  which  Bettman  has  collected 
15  cases.  It  comes  on  most  frequently  during  some  fever,  as  typhoid,  pneu- 
monia, or  the  eruptive  fevers.  After  a  preliminary  bronchitis  the  dyspnoea 
increases,  and  then  the  casts  are  coughed  up.  Chills  and  fever  have  been 
present.  Four  of  the  15  cases  proved  fatal,  and  the  casts  were  found  in  situ. 
It  is  much  more  serious  than  the  chronic  form.  There  may  be  casts  expec- 
torated which  have  not  the  arborescent  structure  of  the  true  fibrinous  moulds, 
but  which  come  from  a  single  tube  or  its  bifurcation.  Sometimes  they  are 
very  small  and  "  tail  off  "  into  true  spirals. 

Fibrinous  casts  are  expectorated  in  connection  with  chronic  heart-disease 
(10  cases)  and  in  pulmonary  tuberculosis  (14  cases),  in  the  latter  disease  usu- 
ally late  in  the  course  and  of  unfavorable  moment.  In  the  albuminous  expec- 
toration following  tapping  of  a  pleural  exudate  fibrinous  casts  have  been 
coughed  up. 


614  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

In  hgemoptysis  blood-casts  may  be  expectorated,  and  they  are  not  to  be 
confounded  with  the  casts  of  true  fibrinous  bronchitis  which  may  be  coughed 
up  with  profuse  haemorrhage. 

In  pneumonia  small  fibrinous  plugs  are  not  uncommon  in  the  sputa,  and 
in  a  few  rare  instances  quite  large  moulds  of  the  tubes  may  be  coughed  up. 

The  mycelium  of  Aspergillus  fumigatus  may  form  membranous  casts  in 
the  bronchi.  I  reported  an  instance  of  the  kind  in  which  a  small  partial 
mould  of  this  kind  was  expectorated,  and  there  is  on  record  a  case  in  which 
for  long  periods  membranes  composed  of  this  fungus  were  coughed  up  in 
attacks  of  dyspnoea. 

The  pathology  of  the  disease  is  obscure.  The  membrane  is  identical  with 
that  to  which  the  term  croupous  is  applied,  and  the  obscurity  relates  not  so 
much  to  the  mechanism  of  the  production,  which  is  probably  the  same  as  in 
other  mucous  surfaces,  as  to  the  curious  li;nitation  of  the  affection  to  certain 
bronchial  territories  and  in  the  chronic  form  the  remarkable  recurrence  at 
stated  or  irregular  intervals  throughout  a  period  of  man}^  years. 

In  the  fatal  cases  the  bronchial  mucous  membrane  may  be  found  injected 
or  pale.  In  Biermer's  case  the  epithelial  lining  was  intact  beneath  the  cast, 
but  in  that  of  Kretschy  the  bronchi  were  denuded  of  their  epitheliimi.  Em- 
physema is  almost  invariably  present.  Evidences  of  recent  or  antecedent  pleu- 
risy are  sometimes  found.  Model,  in  an  article  published  from  Baumler's 
clinic,  states  that  tuberculosis  was  present  in  10  out  of  21  autopsies. 

Treatment. — In  the  acute  cases  the  treatment  should  be  that  of  ordinary 
acute  bronchitis.  We  know  of  nothing  which  can  prevent  the  recurrence  of  the 
attacks  in  the  chronic  form.  In  the  uncomplicated  cases  there  is  rarely  any  dan- 
ger during  the  paroxysm,  even  though  the  sjanptoms  may  be  most  distressing 
and  the  dyspnoea  and  cough  very  severe.  Inhalations  of  ether,  steam,  or 
atomized  lime-water  aid  in  the  separation  of  the  membranes.  Waldenberg 
employed  the  last  remedy  with  success  in  one  case.  Ewart  recommends  intra- 
tracheal injections  of  olive  oil.  Pilocarpine  might  be  useful,  as  in  some  in- 
stances it  increases  the  bronchial  secretion.  The  emplo3rment  of  emetics  may 
be  necessary,  and  in  some  cases  they  are  effective  in  promoting  the  removal  of 
the  casts. 

D.    DISEASES  OE  THE  LUNGS. 

I.     CIRCULATORY    DISTURBANCES    IN    THE    LUNGS. 

Congestion. — There  are  two  forms  of  congestion  of  the  lungs — active  and 
passive. 

(1)  Active  Coxgestion  of  the  Luisras. — Much  doubt  and  confusion  still 
exist  on  this  subject.  French  writers,  following  Woillez,  regard  it  as  an  inde- 
pendent primary  affection  (maladie  de  Woillez),  and  in  their  dictionaries  and 
text-books  allot  much  space  to  it.  English  and  American  authors  more  cor- 
rectly regard  it  as  a  symptomatic  affection.  Active  fluxion  to  the  lungs  occurs 
with  increased  action  of  the  heart,  and  when  very  hot  air  or  irritating  sub- 
stances are  inhaled.  In  diseases  which  interfere  locally  with  the  circulation 
the  capillaries  in  the  adjacent  unaffected  portions  may  be  greatly  distended. 
The  importance,  however,  of  this  collateral  fluxion,  as  it  is  called,  is  probably 


DISEASES  OP  THE  LUNGS.  615 

exaggerated.  In  a  whole  series  of  pulmonary  affections  there  is  this  asso- 
ciated congestion — in  pneumonia,  bronchitis,  pleurisy,  and  tuberculosis. 

The  symptoms  of  active  congestion  of  the  lungs  are  by  no  means  definite. 
The  description  given  by  Woillez  and  by  other  French  writers  is  of  an  affec- 
tion which  is  difficult  to  recognize  from  anomalous  or  larval  forms  of  pneu- 
monia. The  chief  symptoms  described  are  initial  chill,  pain  in  the  side,  dysp- 
noea, moderate  cough,  and  temperature  from  101°  to  103°.  The  physical  signs 
are  defective  resonance,  feeble  breathing,  sometimes  bronchial  in  character,  and 
fine  rales.  A  majority  of  clinical  physicians  would  undoubtedly  class  such 
cases  under  inflammation  of  the  lung.  In  many  epidemics  the  abnormal  and 
larval  forms  are  specially  prevalent. 

The  occurrence  of  an  intense  and  rapidly  fatal  congestion  of  the  lung,  fol- 
lowing extreme  heat  or  cold  or  sometimes  violent  exertion,  is  recognized  by 
some  authors.  Renforth,  the  oarsman,  is  said  to  have  died  from  this  cause 
during  the  race  at  Halifax.  Leuf  has  described  cases  in  which,  in  association 
with  drunkenness,  exposure,  and  cold,  death  occurred  suddenly,  or  within 
twenty-four  hours,  the  only  lesion  found  being  an  extreme,  almost  hasmor- 
rhagic,  congestion  of  the  lungs.  It  is  by  no  means  certain  that  in  these  cases 
death  really  occurs  from  pulmonary  congestion  in  the  absence  of  specific  state- 
ments with  reference  to  the  coronary  arteries  and  the  heart. 

(2)  Passive  Congestion. — Two  forms  of  this  may  be  recognized,  the  me- 
chanical and  the  hypostatic. 

(a)  Mechanical  congestion  occurs  whenever  there  is  an  obstacle  to  the 
return  of  the  blood  to  the  heart.  It  is  a  common  event  in  many  affections 
of  the  left  heart.  The  lungs  are  voluminous,  russet  brown  in  color,  cutting 
and  tearing  with  great  resistance.  On  section  they  show  at  first  a  brownish- 
red  tinge,  and  then  the  cut  surface,  exposed  to  the  air,  becomes  rapidly  of  a 
vivid  red  color  from  oxidation  of  the  abundant  hgemoglobin.  This  is  the  con- 
dition known  as  hrown  induration  of  the  lung.  Histologically  it  is  charac- 
terized by  (a)  great  distention  of  the  alveolar  capillaries;  (/3)  increase  in 
the  connective-tissue  elements  of  the  lung;  (y)  the  presence  in  the  alveolar 
walls  of  many  cells  containing  altered  blood-pigment ;  (8)  in  the  alveoli  numer- 
ous epithelial  cells  containing  blood-pigment  in  all  stages  of  alteration,  which 
are  also  found  in  great  numbers  in  the  sputum. 

It  occasionally  happens  that  this  mechanical  hypersemia  of  the  lung  results 
from  pressure  by  tumors.  So  long  as  compensation  is  maintained  the  mechan- 
ical congestion  of  the  lung  in  heart-disease  does  not  produce  any  symptoms, 
but  with  enfeebled  heart  action  the  engorgement  becomes  marked  and  there 
are  dyspnoea,  cough,  and  expectoration,  with  the  characteristic  alveolar  cells. 

{!))  Hypostatic  congestion.  In  fevers  and  adynamic  states  generally,  it  is 
very  common  to  find  the  bases  of  the  lungs  deeply  congested,  a  condition  in- 
duced partly  by  the  effect  of  gravity,  the  patient  lying  recumbent  in  one  pos- 
ture for  a  long  time,  but  chiefly  by  weakened  heart  action.  That  it  is  not  an 
effect  of  gravity  alone  is  shown  by  the  fact  that  a  healthy  person  may  remain 
in  bed  an  indefinite  time  without  its  occurrence.  The  posterior  parts  of  the 
lung  are  dark  in  color  and  engorged  with  blood  and  serum ;  in  some  instances 
to  such  a  degree  that  the  alveoli  no  longer  contain  air  and  portions  of  the  lung 
sink  in  water.  The  terms  splenization  and  hypostatic  pneumonia  have  been 
given  to  these  advanced  grades.    It  is  a  common  affection  in  protracted  cases 


616  DISEASES  OF   THE  RESPIRATORY  SYSTEM. 

of  typhoid  fever  and  in  long  debilitating  illnesses.  In  ascites,  meteorism,  and 
abdominal  tumors  the  bases  of  the  lungs  ma}^  be  compressed  and  congested.  In 
this  connection  must  be  mentioned  the  form  of  passive  congestion  met  with 
in  injury  to,  and  organic  disease  of,  the  brain.  In  cerebral  apoplexy  the  bases 
of  the  lungs  are  deepty  engorged,  not  quite  airless,  but  heavy,  and  on  section 
drip  with  blood  and  serum.  I  have  twice  seen  this  condition  in  an  extreme 
grade  throughout  the  lungs  in  death  from  morphia  poisoning.  In  some  in- 
stances the  lung  tissue  has  a  blackish,  gelatinous,  infiltrated  appearance,  almost 
like  diffuse  pulmonary  apoplex}'.  Occasionally  this  congestion  is  most  marked 
in,  and  even  confined  to,  the  hemiplegic  side.  In  prolonged  coma  the  hypo- 
static congestion  may  be  associated  with  patches  of  consolidation,  due  to  the 
aspiration  of  portions  of  food  into  the  air-passages. 

The  s}Tnptoms  of  hypostatic  congestion  are  not  at  all  characteristic,  and 
the  condition  has  to  be  sought  for  by  careful  examination  of  the  bases  of  the 
lungs,  when  slight  dulness,  feeble,  sometimes  blowing,  breathing  and  liquid 
rales  can  be  detected. 

Teeatmext. — The  treatment  of  congestion  of  the  limgs  is  usually  that 
of  the  condition  with  which  it  is  associated.  In  the  intense  pulmonary  en- 
gorgement, which  may  possibly  occur  primarily,  and  which  is  met  with  in 
heart-disease  and  emphysema,  free  bleeding  should  be  practised.  From  20  to 
30  ounces  of  blood  should  be  taken  from  the  arm,  and  if  the  blood  does  not 
flow  freely  and  the  condition  of  the  patient  is  desperate,  aspiration  of  the 
right  auricle  may  be  performed. 

(Edema. — In  all  forms  of  intense  congestion  of  the  lungs  there  is  a  transu- 
dation of  serum  from  the  engorged  capillaries  chiefly  into  the  air-cells,  but 
also  into  the  alveolar  walls.  Xot  only  is  it  very  frequent  in  congestion,  but 
also  with  inflammation,  with  new  growths,  infarcts,  and  tubercles.  When 
limited  to  the  neighborhood  of  an  affected  part,  the  name  collateral  oedema 
is  sometimes  applied  to  it. 

Acute  cedema  is  met  with:  (1)  in  the  infections;  (2)  in  Bright's  disease; 
(3)  in  heart  disease,  particularly  angina  pectoris,  myocarditis,  and  valve 
lesions;  (4)  in  arterio-sclerosis ;  (5)  pregnancy;  (6)  angio-neurotic  redema, 
and  (7)  as  a  complication  of  the  epileptic  flt.  The  theory  most  generally 
accepted  is  that  of  "Welch,  whose  experiments  seemed  to  indicate  that  pul- 
monar}'  cedema  is  due  to  a  disproportionate  wealaiess  of  the  left  ventricle,  so 
that  the  blood  accumulates  in  the  lung  capillaries  until  transudation  occurs. 
Such  weakness  may  be  brought  about  by  paralysis  or  by  spasm  of  the  left 
ventricle.  Others  regard  is  as  an  effect  of  disturbance  in  the  vasomotor 
mechanism  of  the  lungs. 

Anatomically  the  lung  is  ansemic,  heavy,  sodden,  pits  on  pressure,  and  on 
section  a  large  quantity  of  clear  or  blood-tinged  serum  flows  out.  It  may 
have  in  places  a  gelatinous  aspect. 

Symptoms. — The  onset  is  sudden  with  a  feeling  of  oppression  and  pain 
in  the  chest  and  rapid  breathing  which  soon  becomes  dyspnreic  or  orthopnoeic. 
There  may  be  an  incessant  short  cough  and  a  copious  frothy,  sometimes  blood- 
tinged,  expectoration,  which  may  be  expelled  in  a  gush  from  the  mouth  and 
nose.  The  face  is  pale  and  covered  with  a  cold  sweat;  the  pulse  is  feeble  and 
the  heart's  action  weak.  Over  the  entire  chest  may  be  heard  piping  and 
bubbling  rales.     The  attack  may  be  fatal  in  a  few  hours  or  it  may  persist 


DISEASES  OF  THE  LUNGS.  617 

for  twelve  or  twenty-four  hours  and  then  pass  off.  Steven,  of  Glasgow,  has 
reported  a  case  with  73  attacks  in  two  and  a  half  years.  I  have  seen  this 
recurrent  form  in  angina  pectoris,  each  paroxysm  of  which  was  associated 
with  intense  dyspnoea  and  all  the  features  of  acute  oedema  of  the  lungs. 

Bleeding  should  be  practised  at  once  and  is  often  most  helpful.  Dry 
cupping  may  be  tried.  One  of  my  patients  had  great  relief  from  inhalations 
of  chloroform.  Oxygen  may  be  used.  If  there  is  much  agitation  and  sense 
of  impending  death,  morphia  may  be  given  hypodermically. 

Pulmonary  Hsemorrhage. — This  occurs  in  two  forms — broncho-pulmonary 
hwmorrhage,  sometimes  called  bronchorrhagia,  in  which  the  blood  is  poured 
out  into  the  bronchi  and  is  expectorated,  and  pulmonary  apoplexy  or  pneumor- 
rhagia,  in  which  the  hsemorrhage  takes  place  into  the  air-cells  and  the  lung 
tissue. 

1.  Broncho-pulmonaet  Hemorrhage;  Hemoptysis. — Spitting  of 
blood,  to  which  the  term  haemoptysis  should  be  restricted,  results  from  a  vari- 
ety of  conditions,  among  which  the  following  are  the  most  important:  (a)  In 
young  healthy  persons  haemoptysis  may  occur  without  warning,  and  after  con- 
tinuing for  a  few  days  disappear  and  leave  no  ill  traces.  There  may  be  at 
the  time  of  the  attack  no  physical  signs"  indicating  pulmonary  disease.  In 
such  cases  good  health  may  be  preserved  for  years  and  no  further  trouble 
occur.  These  cases  are  not  very  uncommon,  and  in  spite  of  the  good  health 
tuberculosis  may  be  suspected.  In  Ware's  important  contribution  to  this  sub- 
ject,* of  386  cases  of  haemoptysis  noted  in  private  practice  63  recovered  and 
pulmonary  disease  did  not  subsequently  develop  in  them.  (&)  Hcemoptysis 
in  pulmonary  tuberculosis,  which  is  considered  on  page  325.  (c)  In  con- 
nection with  certain  diseases  of  the  lung,  as  pneumonia  (in  the  initial  stage) 
and  cancer,  occasionally  in  gangrene,  abscess,  and  bronchiectasis,  (d)  In 
many  heart  affections,  particularly  mitral  lesions.  It  may  be  profuse  and 
recur  at  intervals  for  years,  (e)  In  ulcerative  affections  of  the  larynx, 
trachea,  or  bronchi.  Sometimes  the  haemorrhage  is  profuse  and  rapidly  fatal, 
as  when  the  ulcer  erodes  a  large  branch  of  the  pulmonary  artery,  an  accident 
which  I  have  known  to  happen  in  a  case  of  chronic  bronchitis  with  emphy- 
sema. (/)  Aneurism  is  an  occasional  cause  of  hemoptysis.  It  may  be  sudden 
and  rapidly  fatal  when  the  sac  bursts  into  the  air-passages.  Slight  bleeding 
may  continue  for  weeks  or  months,  due  to  pressure  on  the  mucous  membrane 
or  erosion  of  the  lung ;  or  in  some  cases  the  sac  "  weeps  "  through  the  exposed 
laminae  of  fibrin,  (g)  Vicarious  hcemorrhage,  which  occurs  in  rare  instances 
in  cases  of  interrupted  menstruation.  The  instances  are  well  authenticated. 
Flint  mentions  a  case  which  he  had  had  under  observation  for  four  years, 
and  Hippocrates  refers  to  it  in  the  aphorism,  "  Haemoptysis  in  a  woman  is 
removed  by  an  eruption  of  the  menses."  Periodical  hsemoptysis  has  also  been 
met  with  after  the  removal  of  both  ovaries.  Even  fatal  haemorrhage  has 
occurred  from  the  lung  during  menstruation  when  no  lesion  was  found  to 
account  for  it.  (h)  There  is  a  form  of  recurring  hcemoptysis  in  arthritic 
subjects  to  which  Sir  Andrew  Clark  has  called  special  attention  and  which 
also  is  described  by  French  writers.  The  cases  occur  in  persons  over  fifty 
years  of  age  who  usually  present  signs  of  the  arthritic  diathesis.     It  rarely 

*  On  Haemoptysis  as  a  Symptom,  by  John  Ware,  M.D. 


618  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

leads  to  fatal  issue  and  subsides  without  inducing  pulmonary  changes,  (i) 
Hemoptysis  occurs  sometimes  in  malignant  fevers  and  in  purpura  licenwr- 
rliagica.  Lastly,  there  is  endemic  hsemoptysis,  due  to  the  bronchial  fluke,  an 
affection  which  is  confined  to  parts  of  China  and  Japan, 

Symptoms. — Hgemoptysis  sets  in  as  a  rule  suddenly.  Often  without  warn- 
ing the  patient  experiences  a  warm,  saltish  taste  as  the  mouth  fills  with  blood. 
Coughing  is  usually  induced.  There  may  be  only  an  ounce  or  so  brought  up 
before  the  haemorrhage  stops,  or  the  bleeding  may  continue  for  days,  the 
patient  bringing  up  small  quantities.  In  other  instances,  particularly  when 
a  large  vessel  is  eroded  or  an  aneurism  bursts,  the  amount  is  large,  and  the 
patient  after  a  few  attempts  at  coughing  shows  signs  of  suffocation  and  death 
is  produced  by  inundation  of  the  bronchial  system.  Fatal  hsemorrhage  even 
ma}^  occur  into  a  large  cavity  in  a  patient  debilitated  by  phthisis  without  the 
production  of  hsemoptysis.  I  dissected  a  case  of  this  kind  at  the  Philadelphia 
Hospital.  The  blood  from  the  lungs  generally  has  characters  which  render 
it  readily  distinguishable  from  the  blood  which  is  vomited.  It  is  alkaline 
in  reaction,  frothy,  and  mixed  with  mucus,  and  when  coagulation  occurs  air- 
bubbles  are  present  in  the  clot.  Blood-moulds  of  the  smaller  bronchi  are 
sometimes  seen.  Patients  can  usually  tell  whether  the  blood  has  been  brought 
up  by  coughing  or  by  vomiting,  and  in  a  majority  of  cases  the  history  gives 
important  indications.  In  paroxysmal  hsemoptysis  connected  with  menstrual 
disturbances  the  practitioner  should  see  that  the  blood  is  actually  coughed 
up,  since  deception  may  be  practised.  The  spurious  haemoptysis  of  hysteria  is 
considered  with  that  disease.  Naturally,  the  patient  is  at  first  alarmed  at  the 
occurrence  of  bleeding,  but,  unless  very  profuse,  as  when  due  to  rupture  of 
an  aortic  aneurism  in  a  pulmonary  cavity,  the  danger  is  rarely  immedi- 
ate. The  attacks,  however,  are  apt  to  recur  for  a  few  days  and  the  sputa 
may  remain  blood-tinged  for  a  longer  period.  In  the  great  majority  of 
cases  the  hemorrhage  ceases  spontaneously.  It  should  be  remembered  that 
some  of  the  blood  may  be  swallowed  and  produce  vomiting,  and,  after  a  day 
or  two,  the  stools  may  be  dark  in  color.  It  is  not  well  during  an  attack  of 
hsemoptysis  to  examine  the  chest. 

2.  Pulmonary  Apoplexy;  Hemorrhagic  Infarct. — In  this  condition 
the  blood  is  effused  into  the  air-cells  and  interstitial  tissue.  It  is  usually 
diffuse,  the  parenchyma  not  being  broken,  as  is  the  brain  tissue  in  cerebral 
apoplexy.  Sometimes,  in  disease  of  the  brain,  in  septic  conditions,  and  in 
the  malignant  forms  of  fevers,  the  lung  tissue  is  uniformly  infiltrated  with 
blood  and  has,  on  section,  a  black,  gelatinous  appearance. 

As  a  rule,  the  haemorrhage  is  limited  and  results  from  the  blocking  of 
a  branch  of  the  pulmonary  artery  either  \)j  a  thrombus  or  an  embolus.  The 
condition  is  most  common  in  chronic  heart-disease.  Although  the  pulmonary 
arteries  are  terminal  ones,  blocking  is  not  always  followed  by  infarction; 
partly  because  the  wide  capillaries  furnish  sufficient  anastomosis,  and  partly 
because  the  bronchial  vessels  may  keep  up  the  circulation.  The  infarctions 
are  chiefly  at  the  periphery  of  the  lung,  usually  wedge-shaped,  with  the  base 
of  the  wedge  toward  the  surface.  When  recent,  they  are  dark  in  color,  hard 
and  firm,  and  look  on  section  like  an  ordinary  blood-clot.  Gradual  changes 
go  on,  and  the  color  becomes  a  reddish-brown.  The  pleura  over  an  infarct 
is  usually  inflamed.     A  microscopical  section  shows  the  air-cells  to  be  dis- 


DISEASES  OF  THE  LUNGS.  619 

tended  with  red  blood-corpuscles,  which  may  also  be  in  the  alveolar  walls. 
The  infarcts  are  usually  multiple  and  vary  in  size  from  a  walnut  to  an  orange. 
Very  large  ones  may  involve  the  greater  part  of  a  lobe.  In  the  artery  passing 
to  the  affected  territory  a  thrombus  or  an  embolus  is  found.  The  globular 
thrombi,  formed  in  the  right  auricular  appendix,  play  an  important  part 
in  the  production  of  hsemorrhagic  infarction.  In  many  cases  the  source  of 
the  embolus  cannot  be  discovered,  and  the  infarct  may  have  resulted  from 
thrombosis  in  the  pulmonary  artery,  but,  as  before  mentioned,  it  is  not  infre- 
quent to  find  total  obstruction  of  a  large  branch  of  a  pulmonary  artery  without 
haemorrhage  into  the  corresponding  lung  area.  The  further  history  of  an  in- 
farction is  variable.  It  is  possible  that  in  some  instances  the  circulation  is 
re-established  and  the  blood  removed.  More  commonly,  if  the  patient  lives, 
the  usual  changes  go  on  in  the  extravasated  blood  and  ultimately  a  pigmented, 
puckered,  fibroid  patch  results.  Sloughing  may  occur  with  the  formation  of  a 
cavity.  Occasionally  gangrene  results.  In  a  case  at  the  University  Hospital, 
Philadelphia,  a  gangrenous  infarct  ruptured  and  produced  fatal  pneumo- 
thorax. 

The  symptoms  of  pulmonary  apoplexy  are  by  no  means  definite.  The 
condition  may  be  suspected  in  chronic  heart-disease  when  haemoptysis  occurs, 
particularly  in  mitral  stenosis,  but  the  bleeding  may  be  due  to  the  extreme 
engorgement.  When  the  infarcts  are  very  large,  and  particularly  in  the  lower 
lobe,  in  which  they  most  commonly  occur,  there  may  be  signs  of  consolidation 
with  blowing  breathing  and  a  pleuritic  friction. 

Treatment  of  Pulmoistary  Hemorrhage. — The  pressure  within  the 
pulmonary  artery  is  considerably  less  than  that  in  the  aortic  system.  The 
system  is  under  vaso-motor  control,  but  our  knowledge  of  the  mutual  rela- 
tions of  pressure  in  the  aorta  and  in  the  pulmonary  artery,  under  varying 
conditions,  is  still  very  imperfect  (Bradford).  There  may  be  an  influence 
on  the  systemic  blood-pressure  without  any  on  the  pulmonary,  and  the  pres- 
sure in  the  one  may  rise  while  it  falls  in  the  other,  or  it  may  rise  and  fall  in 
both  together.  The  researches  of  Brodie  and  Dixon  indicate  that  drugs  which 
raise  the  peripheral  blood-pressure  by  vaso-constriction  increase  the  total  blood 
in  the  lung.  Thus  ergot,  the  remedy  perhaps  most  commonly  used,  causes  a 
distinct  rise  in  the  pulmonary  blood-pressure,  while  aconite  produces  a  definite 
fall. 

The  anatomical  condition  in  haemoptysis  is  either  hyperaemia  of  the  bron- 
chial mucosa  (or  of  the  lung  tissue)  or  a  perforated  vessel.  In  the  latter  case 
the  patient  often  passes  rapidly  beyond  treatment,  though  there  are  instances 
of  the  most  profuse  haemorrhage,  which  must  have  come  from  a  perforated 
artery  or  a  ruptured  aneurism,  in  which  recovery  has  occurred.  Practically, 
for  treatment,  we  should  separate  these  cases,  as  the  remedies  which  would  be 
applicable  in  the  case  of  congested  and  bleeding  mucosa  would  be  as  much 
out  of  place  in  a  case  of  haemorrhage  from  ruptured  aneurism  as  in  a  cut 
radial  artery.  When  the  blood  is  brought  up  in  large  quantities,  it  is  almost 
certain  either  that  an  aneurism  has  ruptured  or  a  vessel  has  been  eroded.  In 
the  instances  in  which  the  sputa  are  blood-tinged  or'  when  the  blood  is  in 
smaller  quantities,  bleeding  comes  by  diapedesis  from  hyperaemie  vessels.  In 
such  cases  the  haemorrhage  may  be  beneficial  in  relieving  the  congested  blood- 
vessels. 


620  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

The  indications  are  to  reduce  the  frequency  of  the  heart-l^eats  and  to 
lower  the  hlood-pressure.  The  truth,  Das  Blut  ist  ein  ganz  besonderer  Saft, 
is  strikingly  emphasized  by  the  frightened  state  of  the  patient.  Eest  of  the 
body  and  peace  of  the  mind — "  quies,  securitas,  silentium  "  of  Celsus — should 
be  secured.  Turn  the  patient  on  the  affected  side,  if  known,  as  the  regur- 
gitation is  less  apt  to  occur  into  the  bronchi  of  the  sound  lung.  As  Aretseus 
remarks,  in  hgemoptysis  the  patient  despairs  from  the  first,  and  needs  to  be 
strongly  reassured.  Death  is  rarely  due  directly  to  hsemoptysis;  patients  die 
after,  not  of  it  (S.  West).  In  the  majority  of  cases  of  mild  haemoptysis  this 
is  sufficient.  Even  when  the  patient  insists  upon  going  about,  the  bleeding 
may  stop  spontaneously.  The  diet  should  be  light  and  unstimulating.  xllcohol 
should  not  be  used.  The  patient  may,  if  he  wishes,  have  ice  to  suck.  Small 
doses  of  aromatic  sulphuric  acid  may  be  given,  but  unless  the  bleeding  is 
protracted  st)^tic  and  astringent  medicines  are  not  indicated.  For  cough, 
which  is  always  present  and  disturbing,  opiuni  should  be  freely  given,  and 
is  of  all  mediciries  most  serviceable  in  hsemoptysis.  Digitalis  should  not  be 
used,  as  it  raises  the  blood-pressure  in  the  pulmonary  artery.  Aconite,  as  it 
lowers  the  pressure,  may  be  used  when  there  is  much  vascular  excitement. 
Ergot,  tannic  acid,  and  lead,  which  are  so  much  employed,  have  little  or  no 
influence  in  hsemoptysis;  ergot  probabl}^  does  harm.  One  of  the  most  satis- 
factory means  of  lowering  the  blood-pressure  is  purgation,  and  when  the  bleed- 
ing is  protracted  salts  may  be  freely  given.  In  profuse  haemoptysis,  such  as 
comes  from  erosion  of  an  artery  or  the  rupture  of  an  aneurism,  a  fatal  result 
is  common,  and  yet  post-mortem  evidence  shows  that  thrombosis  may  occur 
with  healing  in  a  rupture  of  considerable  size.  The  fainting  induced  by  the 
loss  of  blood  is  probably  the  most  efficient  means  of  promoting  thrombosis, 
and  it  was  on  this  principle  that  formerly  patients  were  bled  from  the  arm, 
or  from  both  arms,  as  in  the  case  of  Laurence  Sterne.  Ligatures,  or  Esmarch's 
bandages,  placed  around  the  legs  may  serve  temporarily  to  cheek  the  bleeding. 
The  ice-bag  on  the  sternum  is  of  doubtful  utility.  In  a  protracted  case  Cayley 
induced  pneumothorax,  but  without  effect. 

Briefly,  then,  we  may  say  that  hemorrhage  from  rupture  of  aneurism  or 
erosion  of  a  blood-vessel  usually  proves  fatal.  The  fainting  induced  by  the  loss 
of  blood  is  beneficial,  and,  if  the  patient  can  be  kept  alive  for  twenty-four 
hours,  a  thrombus  of  sufficient  strength  to  prevent  further  bleeding  may  form. 
The  chief  danger  is  the  inundation  of  the  bronchial  system  with  the  blood,  so 
that  while  the  hasmorrhage  is  profuse  the  cough  should  be  encouraged.  Opium 
should  not  then  be  used,  and  stimulants  should  be  given  with  caution. 

In  the  other  group,  in  which  the  haemorrhage  comes  from  a  congested 
area  and  is  limited,  the  patient  gets  well  if  kept  absolutely  quiet,  and  fatal 
hgemorrhage  probably  never  occurs  from  this  source.  Eest,  reduction  of 
the  blood-pressure  by  minimum  diet,  purging,  if  necessary,  and  the  admin- 
istration of  opium  to  allay  the  cough  are  the  main  indications. 

n.     BRONCHO-PNETJMONLA.    (CapiUary  Bronchitis). 

This  is  essentially  an  inflammation  of  the  terminal  bronchus  and  the  air- 
vesicles  which  make  up  a  pulmonary  lobule,  whence  the  term  broncho-pneu- 
monia.   It  is  also  known  as  lobular,  in  contradistinction  to  lobar  pneumonia. 


DISEASES  OF  THE  LUNGS.  621 

The  term  catarrhal  is  less  applicable.  The  process  begins  usually  with  an 
inflammation  of  the  capillary  bronchi,  which  is  a  condition  rarely,  if  ever, 
found  without  involvement  of  the  lobular  structures,  so  that  it  is  now  custom- 
ary to  consider  the  affections  together.  All  forms  of  broncho-pneumonia 
depend  upon  invasion  of  the  lung  with  microbes,  and  it  would  have  been  more 
consistent  to  place  them  with  lobar  pneumonia  among  the  infectious  dis- 
orders, but  it  is  well  perhaps  to  defer  this  until  the  bacteriology  of  the  different 
varieties  has  been  more  fully  worked  out. 

Etiology. — Broncho-pneumonia  occurs  either  as  a  primary  or  as  a  sec- 
ondary affection.  The  relative  frequency  in  443  cases  is  thus  given  by  Holt: 
Primary,  without  previous  bronchitis,  154;  secondary  (a)  to  bronchitis  of 
larger  tubes,  41;  to  measles,  89;  to  whooping-cough,  66;  to  diphtheria,  47; 
to  scarlet  fever,  7 ;  to  influenza,  6 ;  to  varicella,  2 ;  to  erysipelas,  2 ;  and  to 
acute  ileo-colitis,  19.  The  proportion  of  primary  to  secondary  forms  as  shown 
in  this  list  is  probably  too  low. 

Pkimary  acute  broncho-pneumonia,  like  the  lobar  form,  attacks  chil- 
dren in  good  health,  usually  under  two  years.  The  etiological  factors  are  very 
much  those  of  ordinary  pneumonia,  and  probably  the  pneumococcus  is  more 
often  associated  with  it. 

Secondary  broncho-pneumonia  occurs  in  two  great  groups:  1.  As  a 
sequence  of  the  infectious  fevers — measles,  diphtheria,  whooping-cough,  scar- 
let fever,  and,  less  frequently,  small-pox,  erysipelas,  and  typhoid  fever.  In 
children  it  forms  the  most  serious  complication  of  these  diseases,  and  in 
reality  causes  more  deaths  than  are  due  directly  to  the  fevers.  In  large  cities 
it  ranks  next  in  fatality  to  infantile  diarrhoea.  Following,  as  it  does,  the 
contagious  diseases  which  principally  affect  children,  we  find  that  a  large 
majority  of  cases  occur  during  early  life.  According  to  Morrill's  Boston  sta- 
tistics, it  is  most  fatal  during  the  first  two  years  of  life.  The  number  of  cases 
in  a  community  increases  or  decreases  with  the  prevalence  of  measles,  scarlet 
fever,  and  diphtheria.  It  is  most  prevalent  in  the  winter  and  spring  months. 
In  the  febrile  affections  of  adults  broncho-pneumonia  is  not  very  common. 
Thus  in  typhoid  fever  it  is  not  so  frequent  as  lobar  pneumonia,  though  isolated 
areas  of  consolidation  at  the  bases  are  by  no  means  rare  in  protracted'  cases 
of  this  disease.  In  old  people  it  may  follow  debilitating  causes  of  any  sort, 
and  is  met  with  in  the  course  of  chronic  Bright's  disease  and  various  acute 
and  chronic  maladies. 

2.  In  the  second  division  of  this  affection  are  embraced  the  cases  of 
so-called  aspiration  or  deglutition  pneumonia.  Whenever  the  sensitiveness  of 
the  larynx  is  benumbed,  as  in  the  coma  of  apoplexy  or  ursemia,  minute  par- 
ticles of  food  or  drink  are  allowed  to  pass  the  iima,  and,  reaching  finally  the 
smaller  tubes,  excite  an  intense  inflammation  similar  to  the  vagus  pneumonia 
which  follows  the  section  of  the  pneumogastrics  in  the  dog.  Cases  are  very 
common  after  operations  about  the  mouth  and  nose,  after  tracheotomy,  and 
in  cancer  of  the  larynx  and  oesophagus.  The  aspirated  particles  in  some 
instances  induce  such  an  intense  broncho-pneumonia  that  suppuration  or  even 
gangrene  supervenes.  The  ether  pneumonia,  already  described,  is  often  lobu- 
lar in  type. 

An  aspiration  broncho-pneumonia  may  follow  hemoptysis  (which  has  been 
already  considered),  the  aspiration  of  material  from  a  bronchiectatic  cavity, 


622  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

and  occasionally  the  material  from  an  empyema  which  has  ruptured  into  the 
lung. 

A  common  and  fatal  form  of  broncho-pneumonia  is  that  excited  by  the 
tubercle  bacillus,  which  has  already  been  considered. 

Among  general  predisposing  causes  may  be  mentioned  age.  As  just  noted, 
it  is  prone  to  attack  infants,  and  a  majority  of  cases  of  pneumonia  in  chil- 
dren under  five  years  of  age  are  of  this  form.  Of  370  cases  in  children  under 
five  years  of  age,  75  per  cent  were  broncho-pneumonia  (Holt).  At  the  oppo- 
site extreme  of  life  it  is  also  common,  in  association  with  various  debilitating 
circumstances  and  with  the  chronic  diseases  incident  to  the  old.  In  children, 
rickets  and  diarrhoea  are  marked  predisposing  causes,  and  broncho-pneumonia 
is  one  of  the  most  frequent  post-mortem-room  lesions  in  infants'  homes  and 
foundling  asylums.  The  disease  prevails  most  extensively  among  the  poorer 
classes. 

Morbid  Anatomy. — On  the  pleural  surfaces,  particularly  toward  the  base, 
are  seen  depressed  bluish  or  blue-brown  areas  of  collapse,  between  which  the 
lung  tissue  is  of  a  lighter  color.  Here  and  there  are  projecting  portions  over 
which  the  ^^leura  ma}'  be  slightly  turbid  or  granular.  The  lung  is  fuller  and 
firmer  than  normal,  and,  though  in  great  part  crepitant,  there  can  be  felt 
in  places  throughout  the  substance  solid,  nodular  bodies.  The  dark  depressed 
areas  may  be  isolated  or  a  large  section  of  one  lobe  may  be  in  the  condition 
of  collapse  or  atelectasis.  Gradual  infiation  by  a  blow-pipe  inserted  in  the 
bronchus  will  distend  a  great  majority  of  these  collapsed  areas.  On  section, 
the  general  surface  has  a  dark  reddish  color  and  usually  drips  blood.  Project- 
ing above  the  level  of  the  section  are  lighter  red  or  reddish-gray  areas  repre- 
senting the  patches  of  broncho-pneumonia.  These  may  be  isolated  and  sepa- 
rated from  each  other  by  tracts  of  uninflamed  tissue  or  they  may  be  in  groups ; 
or  the  greater  part  of  a  lobe  may  be  involved.  Study  of  a  favorable  section 
of  an  isolated  patch  shows :  (a)  A  dilated  central  bronchiole  full  of  tenacious 
purulent  mucus.  A  fortunate  section  parallel  to  the  long  axis  may  show  a 
racemose  arrangement — the  alveolar  passages  full  of  muco-pus.  (&)  Sur- 
rounding the  bronchus  for  from  3  to  5  mm.  or  even  more,  an  area  of  grapsh- 
red  consolidation,  usually  elevated  above  the  surface  and  firm  to  the  touch. 
Unlike  the  consolidation  of  lobar  pneumonia,  it  may  present  a  perfectly  smooth 
surface,  though  in  some  instances  it  is  distinctly  granular.  In  a  late  stage  of 
the  disease  small  grayish-white  points  may  be  seen,  which  on  pressure  may  be 
squeezed  out  as  purulent  droplets.  A  section  in  the  axis  of  the  lobule  may 
present  a  somewhat  grape-like  arrangement,  the  stalks  and  stems  represent- 
ing the  bronchioles  and  alveolar  passages  filled  with  a  yellowish  or  grayish- 
white  pus,  while  surrounding  them  is  a  reddish-brown  hepatized  tissue,  (c) 
In  the  immediate  neighborhood  of  this  peribronchial  inflammation  the  tissue 
is  dark  in  color,  smooth,  airless,  at  a  somewhat  lower  level  than  the  hepatized 
portion,  and  differs  distinctly  in  color  and  appearance  from  the  other  por- 
tions of  the  lung.  This  is  the  condition  to  which  the  term  splenization  has 
been  given.  It  really  represents  a  tissue  in  the  early  stage  of  inflamma- 
tion, and  it  perhaps  would  be  as  well  to  give  up  the  use  of  this  term  and 
also  that  of  carnification,  which  is  only  a  more  advanced  stage.  The  con- 
dition of  collapse  probably  always  precedes  this,  and  it  is  difficult  in 
some  instances  to  tell  the  difference,  as  one  shades  into  the  other.     In  fact. 


DISEASES  OF  THE  LUNGS.  623 

collapse,  splenization,  and  carnification  are  but  preliminary  steps  in  broncho- 
pneumonia. 

While,  in  many  cases,  the  areas  of  broncho-pneumonia  present  a  reddish- 
brown  color  and  are  indistinctly  granular,  in  others,  particularly  in  adults,  the 
nodules  may  resemble  more  closely  gray  hepatization  and  the  air-cells  are  filled 
with  a  grayish  muco-purulent  material.  Minute  hgemorrhages  are  sometimes 
seen  in  the  neighborhood  of  the  inflamed  areas  or  on  the  pleural  surfaces. 
Emphysema  is  commonly  seen  at  the  anterior  borders  and  upper  portions  of 
the  lung  or  in  lobules  adjacent  to  the  inflamed  ones.  In  many  cases  following 
diphtheria  and  measles  the  process  is  so  extensive  that  the  greater  part  of  a 
lobe  is  involved,  and  it  looks  like  a  case  of  lobar  hepatization.  It  has  not, 
however,  the  uniformity  of  this  affection,  and  collapsed  dark  strands  may  be 
seen  between  extensive  areas  of  hepatized  tissue. 

There  are  three  groups  of  cases:  (1)  Those  in  which  the  bronchitis  and 
bronchiolitis  are  most  marked,  and  in  which  there  may  be  no  definite  con- 
solidation, and  yet  on  microscopical  examination  many  of  the  alveolar  pas- 
sages and  adjacent  air-cells  appear  filled  with  inflammatory  products.  (3) 
The  disseminated  broncho-pneumonia,  in  which  there  are  scattered  areas  of 
peribronchial  hepatization  with  patches  of  collapse,  while  a  considerable  pro- 
portion of  the  lobe  is  still  crepitant.  This  is  by  far  the  most  common  condi- 
tion. (3)  The  pseudo-lobar  form,  in  which  the  greater  portion  of  the  lobe 
is  consolidated,  but  not  uniformly,  for  intervening  strands  of  dark  congested 
lung  tissue  separate  the  groups  of  hepatized  lobules. 

Microscopically,  the  centre  of  the  bronchus  is  seen  filled  with  a  plug  of 
exudation,  consisting  of  leucocytes  and  swollen  epithelium.  Section  in  the 
long  axis  may  show  irregular  dilatations  of  the  tube.  The  bronchial  wall  is 
swollen  and  infiltrated  with  cells.  Under  a  low  power  it  is  readily  seen  that 
the  air-cells  next  the  bronchus  are  most  densely  filled,  while  toward  the  per- 
iphery the  alveolar  exudation  becomes  less.  The  contents  of  the  air-cells  are 
made  up  of  leucocytes  and  swollen  epithelial  cells  in  varying  proportions. 
Eed  corpuscles  are  not  often  present  and  a  fibrin  network  is  rarely  seen, 
though  it  may  be  present  in  some  alveoli.  In  the  swollen  walls  are  seen  dis- 
tended capillaries  and  numerous  leucocytes.  As  Delafield  has  pointed  out, 
the  interstitial  inflammation  of  the  bronchi  and  alveolar  walls  is  the  special 
feature  of  broncho-pneumonia. 

The  histological  changes  in  the  aspiration  or  deglutition  broncho-pneu- 
monia differ  from  the  ordinary  post-febrile  form  in  a  more  intense  infiltra- 
tion of  the  air-cells  with  leucocytes,  producing  suppuration  and  foci  of  soften- 
ing ;  even  gangrene  may  be  present. 

Bacteriology  of  Broncho-pneumonia. — The  organisms  most  commonly 
found  in  broncho-pneumonia  are  Micrococcus  lanceolatus.  Streptococcus  py- 
ogenes (either  alone  or  with  the  pneumococcus).  Staphylococcus  aureus  et 
alhus,  and  Friedlander's  Bacillus  pneumonice.  The  Klebs-Loefiler  bacillus  is 
not  infrequently  found  in  the  secondary  lesions  of  diphtheria.  Except  the 
pneumococcus  these  microbes  are  rarely  found  in  pure  cultures.  In  the  lobu- 
lar type  the  streptococcus  is  the  most  constant  organism,  in  the  pseudo-lobar 
the  pneumococcus.  Mixed  infections  are  almost  the  rule  in  broncho-pneu- 
monia. 

M.  WoUstein,  in  17  primary  cases,  found  Micrococcus  lanceolatus  alone 


624  DISEASES  OF   THE  RESPIRATORY  SYSTEM. 

in  9,  with  the  streptococcus  in  7.  Of  14  secondary  cases  Micrococcus  lanceo- 
latus  was  found  alone  in  2  and  with  other  organisms  in  9.  The  primary 
form  is  the  result  of  infection  with  the  pneumococcus,  the  secondary  most 
often  with  the  streptococcus. 

Terminations  of  Broncho-pneumonia. —  (1)  In  resolution,  which  when  it 
once  begins  goes  on  more  rapidly  than  in  fibrinous  pneumonia.  Broncho- 
pneumonia of  the  apices,  in  a  child,  persisting  for  three  or  more  weeks, 
particularly  if  it  follows  measles  or  diphtheria,  is  often  tuberculous.  In  these 
instances,  when  resolution  is  supposed  to  be  delayed,  caseation  has  in  reality 
taken  place.  (2)  In  suppuration,  wliich  is  rarely  seen  apart  from  the  aspira- 
tion and  deglutition  forms,  in  which  it  is  extremely  common.  (3)  In  gan- 
grene,  which  occurs  under  the  same  conditions.  (4)  In  fibroid  changes — 
chronic  hroncho-pneumonia — a  rare  termination  in  the  simple,  a  common 
sequence  of  the  tuberculous,  disease.  Formerly  it  was  thought  that  one  of 
the  most  common  changes  in  broncho-pneumonia,  particularly  in  children, 
was  caseation ;  but  this  is  really  a  tuberculous  process,  the  natural  termination 
of  an  originally  specific  broncho-pneumonia.  It  is  of  course  quite  possible 
that  a  broncho-pneumonia,  simple  in  its  origin,  may  subsequentl}^  be  the  seat 
of  infection  by  Bacillus  tuberculosis. 

Symptoms. — The  primary  form  sets  in  abruptly  with  a  chill  or  a  con- 
vulsion. The  child  has  not  had  a  previous  illness,  but  there  may  have  been 
slight  exposure.  The  temperature  rises  rapidly  and  is  more  constant;  the 
physical  signs  are  more  local  and  there  is  not  the  wide-spread  diffuse  catarrh 
of  the  smaller  tubes.  Many  cases  are  mistaken  for  lobar  pneumonia.  In 
others  the  pulmonary  features  are  in  the  background  or  are  overlooked  in 
the  intensit}^  of  the  general  or  cerebral  sjonptoms.  The  termination  is  often 
by  crisis,  and  the  recovery  is  prompt.  The  mortality  of  this  form  is  slight. 
S.  "West  has  called  attention  to  the  importance  of  recognizing  these  primary 
cases  and  to  their  resemblance  in  clinical  features  with  acute  lobar  pneumonia. 
The  secondary  form  begins  usually  as  a  bronchitis  of  the  smaller  tubes.  Much 
confusion  has  arisen  from  the  description  of  capillary  bronchitis  as  a  sepa- 
rate affection,  whereas  it  is  only  a  part,  though  a  primary  and  important  one, 
of  broncho-pneumonia.  At  the  outset  it  may  be  said  that  if  in  convalescence 
from  measles  or  in  whooping-cough  a  child  has  an  accession  of  fever  with 
cough,  rapid  pulse,  and  rapid  breathing,  and  if,  on  auscultation,  fine  rales 
are  heard  at  the  bases,  or  widely  spread  throughout  the  lungs,  even  though 
neither  consolidation  nor  blowing  breathing  can  be  detected,  the  diagnosis 
of  broncho-pneumonia  may  safely  be  made,  I  have  never  seen  in  a  fatal  case 
after  diphtheria  or  measles  a  capillary  bronchitis  as  the  sole  lesion.  The  onset 
is  rarel}^  sudden,  or  with  a  distinct  chill;  but  after  a  day  or  so  of  indisposi- 
tion the  child  gets  feverish  and  begins  to  cough  and  to  get  short  of  breath. 
The  fever  is  extremely  variable;  a  range  of  from  102°  to  104°  is  common. 
The  skin  is  very  dry  and  pungent.  The  cough  is  hard,  distressing,  and  may 
be  painful.  Dyspnoea  gradually  becomes  a  prominent  feature.  Expiration 
may  be  jerky  and  grunting.  The  respirations  may  rise  as  high  as  60  or  even 
80  per  minute.  Within  the  first  forty-eight  hours  the  percussion  resonance  is 
not  impaired;  the  note,  indeed,  may  be  very  full  at  the  anterior  borders  of 
the  lungs.  On  auscultation,  many  rales  are  heard,  chiefly  the  fine  subcrepitant 
variety,  with  sibilant  rhonchi.    There  may  really  be  no  signs  indicating  that 


DISEASES  OF  THE  LUNGS.  625 

the  pareiich3^ma  of  the  lung  is  involved,  and  yet  even  at  this  early  stage,  within 
forty-eight  hours  of  the  onset  of  the  pulmonary  symptoms,  I  have  repeatedly, 
after  diphtheria,  found  scattered  nodules  of  lobular  hepatization.  Northrup, 
in  a  case  in  which  death  occurred  within  the  first  twenty-four  hours,  in  addi- 
tion to  the  extensive  involvement  of  the  smaller  bronchi,  found  the  intra- 
lobular tissue  also  involved  in  places.  The  dyspnoea  is  constant  and  progres- 
sive and  soon  signs  of  deficient  aeration  of  the  blood  are  noted.  The  face 
becomes  a  little  suffused  and  the  finger-tips  bluish.  The  child  has  an  anxious 
expression  and  gradually  enters  upon  the  most  distressing  stage  of  asphyxia. 
At  first  the  urgency  of  the  symptoms  is  marked,  but  soon  the  benumbing  influ- 
ence of  carbon  dioxide  on  the  nerve-centres  is  seen  and  the  child  no  longer 
makes  strenuous  efforts  to  breathe.  The  cough  subsides,  and,  with  a  gradual 
increase  in  lividity  and  a  drowsy  restlessness,  the  right  ventricle  becomes  more 
and  more  distended,  the  bronchial  rales  become  more  liquid  as  the  tubes  fill 
with  mucus,  and  death  occurs  from  heart  paralysis.  These  are  symptoms  of 
a  severe  case  of  broncho-pneumonia,  or  what  the  older  writers  called  suffocative 
catarrh. 

The  PHYSICAL  SIGNS  may  at  first  be  those  of  capillary  bronchitis,  as  indi- 
cated by  the  absence  of  dulness,  the  presence  of  fine  subcrepitant  and  whistling 
rales.  In  many  cases  death  takes  place  before  any  definite  pneumonic  signs 
are  detected.  When  these  exist  they  are  much  more  frequent  at  the  bases, 
where  there  may  be  areas  of  impaired  resonance  or  even  of  positive  dulness. 
When  numerous  foci  involve  the  greater  part  of  a  lobe  the  breathing  may 
become  tubular,  but  in  the  scattered  patches  of  ordinary  broncho-pneumonia, 
following  the  fevers,  the  breathing  is  more  commonly  harsh  than  blowing. 
In  grave  cases  there  is  retraction  of  the  base  of  the  sternum  and  of  the  lower 
costal  cartilages  during  inspiration,  pointing  to  deficient  lung  expansion. 

Diagnosis. — With  lobar  pneumonia  it  may  readily  be  confounded  if  the 
areas  of  consolidation  are  large  and  merged  together.  It  is  to  be  remembered, 
as  Holt's  figures  well  show,  that  broncho-pneumonia  occurs  chiefly  in  children 
under  one  year,  whereas  lobar  pneumonia  is  more  common  after  the  third 
year.  No  writer  has  so  clearly  brought  out  the  difference  between  pneumonia 
at  these  periods  as  Gerhard,*  of  Philadelphia,  whose  papers  on  this  subject 
have  the  freshness  and  accuracy  which  characterized  all  the  writings  of  that 
eminent  physician.  Between  lobar  pneumonia  and  the  secondary  form  of 
broncho-pneumonia  the  diagnosis  is  easy.  The  mode  of  onset  is  essentially 
different  in  the  two  infections,  the  one  developing  insidiously  in  the  course 
or  at  the  conclusion  of  another  disease,  the  other  setting  in  abruptly  in  a 
child  in  good  health.  In  lobar  pneumonia  the  disease  is  almost  always  uni- 
lateral, in  broncho-pneumonia  bilateral.  The  chief  trouble  arises  in  cases  of 
primary  broncho-pneumonia,  which  by  aggregation  of  the  foci  involves  the 
greater  part  of  one  lobe.  Here  the  difficulty  is  very  great,  and  the  physical 
signs  may  be  practically  identical,  but  in  broncho-pneumonia  it  is  much  more 
likely  that  a  lesion,  however  slight,  will  be  found  on  the  other  side. 

A  still  more  difficult  question  to  decide  is  whether  an  existing  broncho- 
pneumonia is  simple  or  tuberculous.  In  many  instances  the  decision  cannot 
be  made,  as  the  circumstances  under  which  the  disease  occurs,  the  mode  of 

*  American  Journal  of  Medical  Sciences,  vols,  xiv  and  xv. 
41 


626  DISEASES  OF   THE  RESPIRATORY  SYSTEM. 

OTiaet.  and  the  physical  signs  may  be  identicah  It  has  often  been  my  expe- 
rience that  a  case  has  been  sent  do\m  from  the  children's  ward  to  the  dead- 
house  -with  the  diagnosis  of  post-febrile  broncho-pneumonia  in  which  there 
was  no  suspicion  of  the  existence  of  tuberculosis;  but  on  section  there  were 
found  tuberculous  bronchial  glands  and  scattered  areas  of  broncho-pneumonia, 
some  of  which  were  distinctly  caseous,  while  others  showed  signs  of  softening. 
I  have  already  spoken  fully  of  this  in  the  section  on  tuberculosis,  but  it  is 
well  to  emphasize  the  fact  that  there  are  many  cases  of  broncho-pneumonia 
in  children  wliich  time  alone  enables  us  to  distinguish  from  tuberculosis.  The 
existence  of  extensive  disease  at  the  apices  or  central  regions  is  a  suggestive 
indication,  and  signs  of  softening  may  be  detected.  In  the  vomited  matter, 
wliich  is  brought  up  after  severe  spells  of  coughing,  sputum  may  be  picked 
out  and  elastic  tissue  and  bacilli  detected. 

It  is  a  superfluous  refinement  to  make  a  diagnosis  between  capillary  bron- 
chitis and  catarrhal  pneumonia,  for  the  two  conditions  are  part  and  parcel 
of  the  same  disease.  In  simple  bronchitis  involving  the  larger  tulles  urgent 
dyspnoea  and  pulmonary  distress  are  rarely  present  and  the  rales  are  coarser 
and  more  sibilant.  It  must  not  be  forgotten  that,  as  in  lobar  pneumonia, 
cerebral  s^Tuptoms  may  mask  the  true  nature  of  the  disease,  and  may  even 
lead  to  the  diagnosis  of  meningitis.  I  recall  more  than  one  instance  in 
which  it  could  not  be  satisfactorily  determined  whether  the  infant  had  tuber- 
culous meningitis  or  a  cerebral  complication  of  an  acute  pulmonary  affection. 

Prognosis. — In  the  primary  form  the  outlook  is  good.  In  children  en- 
feebled by  constitutional  disease  and  prolonged  fevers  broncho-pneumonia  is 
terribly  fatal,  but  in  cases  coming  on  in  connection  with  whooping-cough  or 
after  measles  recovery  may  take  place  in  the  most  desperate  cases.  It  is  in 
this  disease  that  the  truth  of  the  old  maxim  is  shown — '"  Xever  despair  of 
a  sick  child.*^  The  death-rate  in  children  under  five  has  been  variously  esti- 
mated at  from  30  to  50  per  cent.  After  diphtheria  and  measles  thin,  wiry 
children  seem  to  stand  broncho-pneumonia  much  better  than  fat,  flabby  ones. 
In  adults  the  aspiration  or  deglutition  pneumonia  is  a  very  fatal  disease. 

Prophylaxis. — Much  can  be  done  to  reduce  the  probabilit}'  of  attack  after 
feljrile  affections.  Thus,  in  the  convalescence  from  measles  and  whooping- 
cough,  it  is  very  important  that  the  child  should  not  be  exposed  to  cold, 
particularly  at  night,  when  the  temperature  of  the  room  naturally  falls.  In 
"  nocturnal  visit  to  the  nursery — sometimes,  too,  I  am  sorry  to  say,  to  a 
children's  hospital — ^how  often  one  sees  children  almost  naked,  having  kicked 
aside  the  bedclothes  and  having  the  night-clothes  up  about  the  arms !  The 
use  of  light  flannel  "  combinations  "  obviates  this  nocturnal  chill,  which  is, 
I  am  sure,  an  important  factor  in  the  colds  and  pulmonary  affections  of  young 
children,  both  in  private  houses  and  in  institutions.  The  catarrhal  troubles 
of  the  nose  and  throat  should  be  carefully  attended  to,  and  during  fevers 
the  mouth  should  be  washed  two  or  three  times  a  day  with  an  antiseptic 
solution. 

Treatment. — The  frequency  and  the  seriousness  of  broncho-pneumonia 
render  it  a  disease  which  taxes  to  the  utmost  the  resources  of  the  prac- 
titioner. There  is  no  acute  pulmonary  affection  over  which  he  at  times  so 
greatly  despairs.  On  the  other  hand,  there  is  not  one  in  which  he  will  be 
more  gratified  in  saving  cases  which  have  seemed  past  all  succor.     The  gen- 


DISEASES  OF  THE  LUNGS.  627 

eral  arrangements  should  receive  special  attention.  The  room  should  be  kept 
at  an  even  temperature — about  65°  to  68° — and  the  air  should  be  kept  moist 
with  vapor. 

At  the  outset  the  bowels  should  be  opened  by  a  mild  purge,  either  castor 
oil  or  small  doses  of  calomel,  one-twelfth  to  one-sixth  of  a  grain  hourly  until 
a  movement  is  obtained,  and  care  should  be  taken  throughout  the  attack 
to  secure  a  daily  movement.  The  common  saline  fever  mixture  of  citrate 
of  potash,  liquor  ammonii  acetatis,  and  aromatic  spirits  of  ammonia  may  be 
given  every  two  or  three  hours.  If  the  disease  comes  on  abruptly  with  high 
fever,  minim  or  minim  and  a  half  doses  of  the  tincture  of  aconite  may  be 
given  with  it.  The  pain,  the  distressing  symptoms,  and  the  incessant  cough 
often  demand  opium,  which  must  of  course  be  used  with  care  and  judgment 
in  the  case  of  young  children,  but  which  is  certainly  not  contra-indicated  and 
may  be  usefully  given  in  the  form  of  paregoric.  Blisters  are  now  rarely  if 
ever  employed,  and  even  the  jacket  poultice  has  gone  out  of  fashion.  For 
the  latter,  however,  I  confess  to  a  strong  prejudice,  and  when  lightly  made 
and  frequently  changed  it  undoubtedly  gives  great  relief.  Much  more  com- 
monly we  now  see,  both  in  private  and  in  hospital  practice,  the  jacket  of 
cotton-batting.  Ice-poultices  to  the  chest  may  be  used  and  do  good.  The  diet 
should  consist  of  milk,  broths,  and  egg  albumen.  Milk  often  curds  and  is  dis- 
agreeable. Egg-white  is  particularly  suitable  and  very  acceptable  when  given 
in  cold  water  with  a  little  sugar.  It  forms,  indeed,  an  excellent  medium  for 
the  administration  of  the  stimulants.  If  the  pulse  shows  signs  of  failing,  it  is 
best  to  begin  early  with  brandy.  As  in  all  febrile  affections  of  children,  cold 
water  should  be  constantly  at  the  bedside,  and  the  child  should  be  encour- 
aged to  drink  freely.  With  these  measures,  in  many  cases  the  disease  pro- 
gresses to  a  favorable  termination,  but  too  often  other  and  more  serious 
symptoms  arise.  Cough  becomes  more  distressing,  dyspnoea  increases,  the 
ominous  rattling  of  the  mucus  can  be  heard  in  the  tubes,  the  child's  color  is 
not  so  good,  and  there  is  greater  restlessness.  Under  these  circumstances 
stimulant  expectorants — ammonia,  squills,  and  senega — ^may  be  given.  To- 
gether they  make  a  very  disagreeable  dose  for  a  young  child,  particularly  with 
the  carbonate  of  ammonia.  The  aromatic  spirits  of  ammonia  is  somewhat 
better.  If  the  carbonate  is  employed,  it  must  be  given  in  small  doses,  not 
more  than  a  grain  to  an  infant  of  eighteen  months.  If  the  child  has  increas- 
ing difficulty  in  getting  up  the  mucus,  an  emetic  should  be  given — either  the 
wine  of  ipecac,  or,  if  necessary,  tartar  emetic.  There  is  no  necessity,  how- 
ever, to  keep  the  child  constantly  nauseated.  Enough  should  be  given  to  cause 
prompt  emesis,  and  the  benefit  results  in  the  expulsion  of  the  mucus  from 
the  larger  tubes.  In  this  stage,  too,  strychnine  is  undoubtedly  helpful  in 
stimulating  the  depressed  respiratory  centre.  Inhalations  of  oxygen  may  be 
employed,  sometimes  with  great  benefit. 

With  rapid  failure  of  the  heart,  loud  mucous  rattles  in  the  throat,  and 
increasing  lividity,  every  measure  should  be  used  to  arouse  the  child  and 
excite  coughing.  Alternate  douches  of  hot  and  cold  water,  electricity,  and 
hypodermic  injections  of  ether  may  be  tried.  For  the  reduction  of  tempera- 
ture, particularly  if  cerebral  symptoms  are  prominent,  there  is  nothing  so 
satisfactory  as  the  wet  pack  or  the  cold  bath.  In  the  case  of  children,  when 
the  latter  is  used  it  should  be  graduated,  beginning  with  a  temperature  whicli 


628  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

is  pleasantly  warm  and  gradually  reducing  it  to  75°  or  80°.  Even  when  the 
temperature  is  not  high,  the  cerebral  symptoms  are  greatly  relieved  by  the  bath 
or  the  pack. 

m.     CHRONIC    INTERSTITIAL    PNEUMONIA. 

(Cirrliosis  of  the  Lung — Fibroid  Phthisis.) 

A  fibroid  change  may  have  its  starting-point  in  the  tissue  about  the  bronchi 
and  blood-vessels,  the  interlobular  septa,  the  alveolar  walls,  or  in  the  pleura. 
So  diverse  are  the  forms  and  so  varied  the  conditions  under  which  this  change 
occurs  that  a  proper  classification  is  extremely  difficult.  "We  may  recognize, 
however,  two  chief  forms — the  locals  involving  only  a  limited  area  of  the  lung 
substance,  and  the  diffuse,  invading  either  both  lungs  or  an  entire  organ. 

Etiology. — Local  fibroid  change  in  the  lungs  is  common.  It  is  a  constant 
accompaniment  of  tubercle,  in  the  evolution  of  which  interstitial  changes  play 
a  very  important  role.  In  tumors,  abscess,  gummata,  hydatids,  and  emphy- 
sema it  also  occurs.  Fibroid  processes  are  frequently  met  with  at  the  apices  of 
the  lung  and  may  be  due  either  to  a  limited  healed  tuberculosis,  to  fibroid 
induration  in  consequence  of  pigment,  or,  in  a  few  instances,  may  result  from 
thickening  of  the  pleura. 

Diffuse  ixterstitial  pxeuiloxia  is  met  with :  1.  As  a  sequence  of  acute 
fibrinous  pneumonia.  Although  extremely  rare,  this  is  recognized  as  a  possible 
termination.  From  unknown  causes  resolution  fails  to  take  place.  Organiza- 
tion goes  on  in  the  fibrinous  plugs  "wdthin  the  air-cells  and  the  alveolar  walls 
become  greatly  thickened  by  a  new  growth,  first  of  nuclear  and  subsequently 
of  fibrillated  connective  tissue.  Macroscopically  there  is  produced  a  smooth, 
gra}dsh,  homogeneous  tissue  which  has  the  peculiar  translucency  of  all  new- 
formed  connective  tissue.  This  has  been  called  gray  induration.  A  majority 
of  the  cases  terminate  within  a  few  months,  but  instances  which  have  been  fol- 
lowed from  the  outset  are  very  rare. 

2.  Chronic  Broncho-Pneumonia. — The  relation  of  broncho-pneumonia  to 
cirrhosis  of  the  lung  has  been  specially  studied  by  Charcot,  who  states  that  it 
may  follow  the  acute  or  subacute  form  of  this  disease,  particularly  in  children. 
The  fibrosis  extends  from  the  bronchi,  which  are  usually  found  dilated.  Bron- 
chiectasis itself  may  be  followed  by  fibrosis  of  the  lung.  The  alveolar  walls 
are  thickened  and  the  lobules  converted  into  firm  grayish  masses,  in  which 
there  is  no  trace  of  normal  lung  tissue.  This  process  may  go  on  and  involve 
an  entire  lobe  or  even  the  whole  lung.  Many  of  these  cases  are  tuberculous 
from  the  outset. 

3.  Meurogenous  Interstitial  Pneumonia. — Charcot  applies  this  term  to 
that  form  of  cirrhosis  of  the  lung  which  follows  invasion  from  the  pleura. 
Doubt  has  been  expressed  by  some  winters  whether  this  really  occurs.  While 
Wilson  Fox  is  probably  correct  in  questioning  whether  an  entire  lung  can 
become  cirrhosed  by  the  gradual  invasion  from  the  pleura,  there  can  be  no 
doubt  that  there  are  instances  of  primitive  dry  pleurisy,  which,  as  Sir  Andrew 
Clark  has  pointed  out.  gradually  compresses  the  lung  and  at  the  same  time 
leads  to  interstitial  cirrhosis.  This  may  be  due  in  part  to  the  fibroid  change 
which  follows  prolonged  compression.    In  some  cases  there  seems  to  be  a  dis- 


DISEASES  OF   THE  LUNGS.  629 

tinct  connection  between  the  greatly  thickened  pleura  and  the  dense  strands 
of  fibrous  tissue  passing  from  it  into  the  lung  substance.  Instances  occur  in 
which  one  lobe  or  the  greater  part  of  it  presents,  on  section,  a  mottled  appear- 
ance, owing  to  the  increased  thickness  of  the  interlobar  septa — a  condition 
which  may  exist  without  a  trace  of  involvement  of  the  pleura.  In  many  other 
eases,  however,  the  extension  seems  to  be  so  definitely  associated  with  pleurisy 
that  there  is  no  doubt  as  to  the  causal  connection  between  the  two  processes. 
In  these  instances  the  lung  is  removed  with  great  difficulty,  owing  to  the  thick- 
ness and  close  adhesion  of  the  pleura  to  the  chest  wall. 

4.  Chronic  interstitial  pneumonia,  due  to  inhalation  of  dust,  which  is 
considered  in  a  separate  section. 

5.  Syphilis  of  the  lung  presents  the  features  of  a  chronic  fibrosis  of  the 
organ  (see  p.  273). 

6.  Indurative  changes  in  the  lung  may  follow  the  compression  by  aneurism 
or  new  growth  or  the  irritation  of  a  foreign  body  in  a  bronchus. 

Morbid  Anatomy. — There  are  two  chief  forms,  the  massive  or  lobar  and 
the  insular  or  broncho-pneumonic  form.  In  the  massive  type  the  disease  is 
unilateral ;  the  chest  of  the  affected  side  is  sunken,  deformed,  and  the  shoulder 
much  depressed.  On  opening  the  thorax  the  heart  is  seen  drawn  far  over 
to  the  affected  side.  The  unaffected  lung  is  emphysematous  and  covers  the 
greater  portion  of  the  mediastinum.  It  is  scarcely  credible  in  how  small  a 
space,  close  to  the  spine,  the  cirrhosed  lung  may  lie.  The  adhesions  between 
the  pleural  membranes  may  be  extremely  dense  and  thick,  particularly  in 
the  pleurogenous  cases;  but  when  the  disease  has  originated  in  the  lung  there 
may  be  little  thickening  of  the  pleura.  The  organ  is  airless,  firm,  and  hard. 
It  strongly  resists  cutting,  and  on  section  shows  a  grayish  fibroid  tissue  of 
variable  amonntj  through  which  pass  the  blood-vessels  and  bronchi.  The  latter 
may  be  either  slightly  or  enormously  dilated.  There  are  instances  in  which 
the  entire  lung  is  converted  into  a  series  of  bronchiectatic  cavities  and  the 
cirrhosis  is  apparent  only  in  certain  areas  or  at  the  root.  The  tuberculous 
cases  can  usually  be  differentiated  by  the  presence  of  an  apical  cavity,  not 
bronchiectatic,  often  large,  and  the  other  lung  almost  invariably  shows  tuber- 
culous lesions.  Aneurisms  of  the  pulmonary  artery  are  not  infrequent  in  the 
cavities.  The  other  lung  is  always  greatly  enlarged  and  emphysematous.  The 
heart  is  hypertrophied,  particularly  the  right  ventricle,  and  there  may  be 
marked  atheromatous  changes  in  the  vessels.  An  amyloid  condition  of  the 
viscera  is  found  in  some  cases. 

In  the  broncho-pneumonic  form  the  areas  are  smaller,  often  centrally 
placed,  and  most  frequently  in  the  lower  lobes.  They  are  deeply  pigmented, 
show  dilated  bronchi,  and  when  multiple  are  separated  by  emphysematous 
lung  tissue. 

A  reticular  form  of  fibrosis  of  the  lung  has  been  described  by  Percy  Kidd 
and  W.  McCollum,  in  which  the  lungs  are  intersected  by  grayish  fibroid 
strands  following  the  lines  of  the  interlobular  septa. 

Symptoms  and  Course. — The  disease  is  essentially  chronic,  extending  over 
a  period  of  many  years,  and  when  once  the  condition  is  established  the  health 
may  be  fairly  good.  In  a  well-marked  case  the  patient  complains  only  of  his 
chronic  cough,  perhaps  a  slight  shortness  of  breath.  In  other  respects  he  is 
quite  well,  and  is  usually  able  to  do  light  work.     The  cases  are  commonly 


630  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

regarded  as  phthisical,  though  there  may  be  scarcely  a  symptom  of  that  affec- 
tion except  the  cough.  There  are  instances,  however,  of  fibroid  phthisis  which 
camiot  be  distinguished  from  cirrhosis  of  the  lung  except  by  the  presence  of 
tubercle  bacilli  in  the  expectoration.  As  the  bronchi  are  usually  dilated,  the 
symptoms  and  physical  signs  may  be  those  of  bronchiectasis.  The  cough  is 
paroxysmal  and  the  expectoration  is  generally  copious  and  of  a  muco-purulent 
or  sero-purulent  nature.  It  is  sometimes  fetid.  Hajmorrhage  is  by  no  means 
infrequent,  and  occurred  in  more  than  one-half  of  the  cases  anal3^zed  by 
Bastian.  Walking  on  the  level  and  in  the  ordinary  affairs  of  life  the  patient 
may  show  no  shortness  of  breath,  but  in  the  ascent  of  stairs  and  on  exertion 
there  may  be  d^^spnoea. 

Physical  Sigxs. — Inspection. — The  affected  side  of  the  chest  is  immo- 
bile, retracted,  and  shrunken,  and  contrasts  in  a  striking  way  with  the  volu- 
minous healthy  one.  The  intercostal  spaces  are  obliterated  and  the  ribs  may 
even  overlap.  The  shoulder  is  drawn  down  and  from  behind  it  is  seen  that 
the  spine  is  bowed.  The  muscles  of  the  shoulder-girdle  are  wasted.  The  heart 
is  greatly  displaced,  being  drawn  over  by  the  shrinkage  of  the  lung  to  the 
affected  side.  When  the  left  lung  is  affected  there  may  be  a  large  area  of 
visible  impulse  in  the  second,  third,  and  fourth  interspaces.  Mensuration 
shows  a  great  diminution  in  the  affected  side,  and  with  the  saddle-tape  the 
expansion  may  be  seen  to  be  negative.  The  percussion  note  varies  with  the 
condition  of  the  bronchi.  It  may  be  absolutely  flat,  particularly  at  the  base 
or  at  the  apex.  In  the  axilla  there  may  be  a  flat  t}Tapany  or  even  an  am- 
phoric note  over  a  large  sacculated  bronchus.  On  the  opposite  side  the  per- 
cussion note  is  usually  hj-perresonant.  On  auscultation  the  breath-sounds  have 
either  a  cavernous  or  amphoric  quality  at  the  apex,  and  at  the  base  are  feeble, 
with  mucous,  bubbling  rales.  The  voice-sounds  are  usually  exaggerated. 
Cardiac  murmurs  are  not  uncommon,  particularly  late  in  the  disease,  when 
the  right  heart  fails.  These  are,  of  course,  the  physical  signs  of  the  disease 
when  it  is  well  established.  They  naturally  vary  considerably,  according  to 
the  stage  of  the  process.  The  disease  is  essentially  chronic,  and  may  persist 
for  fifteen  or  twenty  years.  Death  occurs  sometimes  from  hemorrhage,  more 
commonly  from  gradual  failure  of  the  right  heart  with  dropsy,  and  occasion- 
ally from  amyloid  degeneration  of  the  organs. 

Diagnosis. — The  diagnosis  is  never  difficult.  It  may  be  impossible  to  say, 
without  a  clear  liistory,  whether  the  origin  is  pleuritic  or  pneumonic.  Between 
cases  of  this  kind  and  fibroid  phthisis  it  is  not  always  easy  to  discriminate,  as 
the  conditions  may  be  almost  identical.  When  tuberculosis  is  present,  how- 
ever, even  in  long-standing  cases,  bacilli  are  usually  present  in  the  sputa,  and 
there  may  be  signs  of  disease  in  the  other  lung. 

Treatment. — It  is  only  for  an  intercurrent  affection  or  for  an  aggravation 
of  the  cough  that  the  patient  seeks  relief.  Xothing  can  be  done  for  the  con- 
dition itself.  When  possible  the  patient  should  live  in  a  mild  climate,  and 
should  avoid  exposure  to  cold  and  damp.  A  distressing  feature  in  some  cases 
is  the  putrefaction  of  the  contents  of  the  dilated  tubes,  for  which  the  same 
measures  may  be  used  as  in  fetid  bronchitis. 


DISEASES  OF  THE  LUNGS,  631 


rV.     PNEUMONOKONIOSIS. 

Definition. — Under  this  term,  introduced  by  Zenker,  are  embraced  those 
forms  of  fibrosis  of  the  lung  due  to  the  inhalation  of  dusts  in  various  occupa- 
tions. They  have  received  various  names,  according  to  the  nature  of  the  in- 
haled particles — antliracosis,  or  coal-miner's  disease;  siderosis,  due  to  the 
inhalation  of  metallic  dusts,  particularly  iron;  clialicosis,  due  to  the  inhala- 
tion of  mineral  dusts,  producing  the  so-called  stone-cutter's  phthisis,  or  the 
"  grinder's  rot "  of  the  Sheffield  workers. 

Etiology. — The  dust  particles  inhaled  into  the  lungs  are  dealt  with  exten- 
sively by  the  ciliated  epithelium  and  by  the  phagocytes,  which  exist  normally 
in  the  respiratory  organs.  The  ordinary  mucous  corpuscles  take  in  a  large 
number  of  the  particles,  which  fall  upon  the  trachea  and  main  bronchi.  The 
cilia  sweep  the  mucus  out  to  a  point  from  which  it  can  be  expelled  by  cough- 
ing. It  is  doubtful  if  the  particles  ever  reach  the  air-cells,  but  the  swollen 
alveolar  cells  (in  which  they  are  in  numbers)  probably  pick  them  up  on  the 
way.  The  mucous  and  the  alveolar  cells  are  the  normal  respiratory  scavengers. 
In  dwellers  in  the  country,  in  which  the  air  is  pure,  they  are  able  to  prevent 
the  access  of  dust  particles  to  the  lung  tissue,  so  that  even  in  adults  these 
organs  present  a  rosy  tint,  very  different  from  the  dark,  carbonized  appear- 
ance of  the  lungs  of  dwellers  in  cities.  When  the  impurities  in  the  air  are 
very  abundant,  a  certain  proportion  of  the  dust  particles  escapes  these  cells 
and  penetrates  the  mucosa,  reaching  the  lymph  spaces,  where  they  are  attacked 
at  once  by  the  cells  of  the  connective-tissue  stroma,  which  are  capable  of 
ingesting  and  retaining  a  large  quantity.  In  coal-miners,  coal-heavers,  and 
others  whose  occupations  necessitate  the  constant  breathing  of  a  very  dusty 
atmosphere  even  these  forces  are  insufficient.  Vansteenberghe  and  Grysez 
have  demonstrated  that  pulmonary  anthracosis  may  be  induced  by  passing 
an  emulsion  of  china  ink  into  the  stomach  of  an  animal  through  a  catheter. 
From  a  long  series  of  experiments  they  conclude  that  anthracosis  is  due  to 
the  intestinal  absorption  of  carbon  particles  arrested  in  the  nose  and  pharynx, 
and  then  swallowed.  Their  experiments  further  show  that  both  the  tracheal 
and  intestinal  routes  are  used — through  the  former  the  particles  reach  the 
bronchi  and  external  portions  of  the  alveoli,  through  the  latter  the  parenchyma 
of  the  lung.  Occasionally  in  anthracosis  the  carbon  grains  reach  the  general 
circulation,  and  the  coal  dust  is  found  in  the  liver  and  spleen.  As  Weigert 
has  shown,  this  occurs  when  the  densely  pigmented  bronchial  glands  closely 
adhere  to  the  pulmonary  veins,  through  the  walls  of  which  the  carbon  particles 
pass  to  the  general  circulation.  The  lung  tissue  has  a  remarkable  tolerance 
for  these  particles;  but  by  constant  exposure  a  limit  is  reached,  and  there  is 
brought  about  a  very  definite  pathological  condition,  an  interstitial  sclerosis. 
In  coal-miners  this  may  occur  in  patches,  even  before  the  lung  tissue  is  uni- 
formly infiltrated  with  the  dust.  In  others  it  appears  only  after  the  entire 
organs  have  become  so  laden  that  they  are  dark  in  color,  and  an  ink-like 
juice  flows  from  the  cut  surface.  The  lungs  of  a  miner  may  be  black  through- 
out and  yet  show  no  local  lesions  and  be  everywhere  crepitant. 

Morbid  Anatomy. — The  particles  of  carbon  are  found  deposited  in  large 
numbers  in  the  follicxilar  cords  of  the  tracheal  and  bronchial  glands  and 


632  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

of  the  peri-bronchial  and  peri-arterial  lymph  nodules,  and  in  these  they  finally 
excite  proliferation  of  the  connective-tissue  elements.  It  is  by  no  means  un- 
common to  find  in  persons  whose  lungs  are  only  moderately  carbonized  the 
bronchial  glands  sclerosed  and  hard.  In  anthracosis  the  fibroid  changes  usu- 
ally begin  in  the  peri-bronchial  lymph  tissue,  and  in  the  early  stage  of  the 
process  the  sclerosis  may  be  largely  confined  to  these  regions.  A  Nova  Scotian 
miner,  aged  thirty-six,  died  under  my  care,  at  the  Montreal  General  Hospital, 
of  black  small-pox,  after  an  illness  of  a  few  days.  In  his  lungs  (externally 
coal-black)  there  were  round  and  linear  patches  ranging  in  size  from  a  pea 
to  a  hazel-nut,  of  an  intensely  black  color,  airless  and  firm,  and  surrounded 
by  a  crepitant  tissue,  slate-gray  in  color.  In  the  centre  of  each  of  these  areas 
was  a  small  bronchus.  Many  of  them  were  situated  just  beneath  the  pleura, 
and  formed  typical  examples  of  limited  fibroid  broncho-pneumonia.  In  addi- 
tion there  is  usually  thickening  of  the  alveolar  walls,  particularly  in  certain 
areas.  By  the  gradual  coalescence  of  these  fibroid  patches  large  portions  of 
the  lung  may  be  converted  into  firm  areas  of  cirrhosis,  grayish-black  in  the 
case  of  the  coal-miner,  steel-gray  in  the  case  of  the  stone-worker.  In  the 
case  of  a  Cornish  miner,  aged  sixty-three,  who  died  under  my  care,  one  of 
these  fibroid  areas  measured  18  by  6  cm.  and  4.5  cm.  in  depth. 

A  second  important  factor  in  these  cases  is  chronic  bronchitis,  which  is 
present  in  a  large  proportion  and  really  causes  the  chief  symptoms.  A  third 
is  the  occurrence  of  emphysema,  which  is  almost  invariably  associated  with 
long-standing  cases  of  pneumonokoniosis.  With  the  changes  so  far  described, 
unless  the  cirrhotic  area  is  unusually  extensive,  the  case  may  present  the 
features  of  chronic  bronchitis  with  emphysema,  but  finally  another  element 
comes  into  play.  In  the  fibroid  areas  softening  occurs,  probably  a  process  of 
necrosis  similar  to  that  by  which  softening  is  produced  in  fibro-myomata  of 
the  uterus.  At  first  these  are  small  and  contain  a  dark  liquid.  Charcot  calls 
them  ulceres  du  poumon.  They  rarely  attain  a  large  size  unless  a  communica- 
tion is  formed  with  the  bronchus,  in  which  case  they  may  become  converted 
into  suppurating  cavities. 

Anthracosis  and  Tuberculosis. — In  the  Pennsylvania  anthracite  district 
tuberculosis  is  relatively  less  common  among  the  miners,  the  figures  for 
ten  years  at  Scranton  for  male  adults  being  3.37  per  cent  in  mine  workers,  9.97 
per  cent  in  those  of  other  occupations  (Wainwright).  Goldman  in  Germany, 
Oliver  and  Trotter  in  England,  all  agree  upon  the  comparative  rarity  of  tuber- 
culosis among  coal  miners.  Though  this  may  be  attributed  in  part  to  the 
improved  ventilation  of  the  mines,  it  has  also  probably  something  to  do 
with  the  less  favorable  soil  offered  to  the  bacilli  in  a  lung  infiltrated  with 
coal  dust. 

The  siderosis  induced  by  the  oxide  of  iron  causes  an  interstitial  pneumonia 
similar  to  anthracosis.  Workers  in  brass  and  in  bronze  are  liable  to  a  like 
affection. 

Chalicosis,  due  to  the  deposit  of  particles  of  silex  and  alumina,  is  found 
in  the  makers  of  mill-stones,  particularly  the  French  mill-stones,  and  also  in 
knife  and  axe  grinders  and  stone-cutters.  Anatomically,  this  form  is  char- 
acterized by  the  production  of  nodules  of  various  sizes,  which  are  cut  with  the 
greatest  difficulty  and  sometimes  present  a  curious  grayish,  even  glittering, 
crystalloid  appearance. 


DISEASES  OF  THE  LUNGS.  633 

Workers  in  flax  and  in  cotton,  and  grain-shovellers  are  also  subject  to 
these  chronic  interstitial  changes  in  the  lungs.  In  all  these  occupations,  as 
shown  by  CIreenhow,  to  whose  careful  studies  we  owe  so  much  of  our  knowl- 
edge of  these  diseases,  the  condition  of  the  lung  may  ultimately  be  almost 
identical. 

Symptoms. — The  symptoms  do  not  come  on  until  the  patient  has  worked 
for  a  variable  number  of  years  in  the  dusty  atmosphere.  As  a  rule  there  are 
cough  and  failing  health  for  a  prolonged  period  of  time  before  complete  disa- 
bility. The  coincident  emphysema  is  responsible  in  great  part  for  the  short- 
ness of  breath  and  wheezy  condition  of  these  patients.  The  expectoration  is 
usually  muco-purulent,  often  profuse,  and  in  anthracosis  very  dark  in  color — 
the  so-called  "black  spit,"  while  in  chalicosis  there  may  be  seen  under  the 
microscope  the  bright  angular  particles  of  silica. 

Even  when  there  are  physical  signs  of  cavity,  tubercle  bacilli  are  not  neces- 
sarily, and  indeed  in  my  experience  are  not  usually  present.  It  is  remarkable 
for  how  long  a  time  a  coal-miner  may  continue  to  bring  up  sputum  laden  with 
coal  particles  even  when  there  are  signs  only  of  a  chronic  bronchitis.  Many 
of  the  particles  are  contained  in  the  cells  of  the  alveolar  epithelium.  In  these 
instances  it  appears  that  an  attempt  is  made  by  the  leucocytes  to  rid  the  lungs 
of  some  of  the  carbon  grains. 

The  diagnosis  of  the  condition  is  rarely  difficult;  the  expectoration  is  usu- 
ally characteristic.  It  must  always  be  borne  in  mind  that  chronic  bronchitis 
and  emphysema  form  essential  parts  of  the  process  and  that  in  late  stages 
there  may  be  tuberculous  infection. 

The  treatment  of  the  condition  is  practically  that  of  chronic  bronchitis 
and  emphysema. 

V.     EMPHYSEMA. 

Definition. — The  condition  in  which  the  infundibular  passages  and  the 
alveoli  are  dilated  and  the  alveolar  walls  atrophied. 

A  practical  division  may  be  made  into  compensatory,  hypertrophic,  and 
atrophic  forms,  the  acute  vesicular  emphysema,  and  the  interstitial  forms. 
The  last  two  do  not  in  reality  come  under  the  above  definition,  but  for  con- 
venience they  may  be  considered  here. 

I.  Compensatory  Emphysema. 

Whenever  a  region  of  the  lung  does  not  expand  fully  in  inspiration,  either 
another  portion  of  the  lung  must  expand  or  the  chest  wall  sink  in  order  to 
occupy  the  space.  The  former  almost  invariably  occurs.  We  have  already 
mentioned  that  in  broncho-pneumonia  there  is  a  vicarious  distention  of  the 
air- vesicles  in  the  adjacent  healthy  lobules,  and  the  same  happens  in  the 
neighborhood  of  tuberculous  areas  and  cicatrices.  In  general  pleural  adhe- 
sions there  is  often  compensatory  emphysema,  particularly  at  the  anterior 
margins  of  the  lung.  The  most  advanced  example  of  this  form  is  seen  in 
cirrhosis,  when  the  unaffected  lung  increases  greatly  in  size,  owing  to  disten- 
tion of  the  air-vesicles.  A  similar  though  less  marked  condition  is  seen  in 
extensive  pleurisy  with  effusion  and  in  pneumothorax. 

At  first,  this  distention  of  the  air-vesicles  is  a  simple  physiological  process 
42 


634  DISEASES  OF  THE  RESPtRATORY  SYSTEM. 

and  the  alveolar  T^^alls  are  stretelied  but  not  atrophied.  Ultimately,  however, 
in  many  cases  they  waste  and  the  contiguous  air-cells  fuse,  producing  true 
emphysema. 

II.  Hypekteophic  Emphysema. 

The  large-lunged  emphysema  of  Jenner,  also  known  as  substantive  or 
idiopathic  emph3'sema,  is  a  well-marked  clinical  affection,  characterized  by 
enlargement  of  the  lungs,  due  to  distention  of  the  air-cells  and  atrophy 
of  their  walls,  and  clinically  by  imperfect  aeration  of  the  blood  and  more  or 
less  marked  dyspnoea. 

Etiology. — Emphysema  is  the  result  of  persistently  high  intra-alveolar 
tension  acting  upon  a  congenitally  weak  lung  tissue.  Strongly  in  favor  of 
the  view  that  the  nutritive  change  in  the  air-cells  is  the  primary  factor,  is  the 
markedly  hereditary  character  of  the  disease  and  the  frequency  with  which  it 
starts  early  in  life.  To  James  Jackson,  Jr.,  of  Boston,  we  owe  the  first  obser- 
vations on  the  hereditary  character  of  emphysema.  Working  under  Louis'  di- 
rection, he  found  that  in  18  out  of  28  cases  one  or  both  parents  were  affected. 

In  childhood,  it  may  follow  recurring  asthmatic  attacks  due  to  adenoid 
vegetations.  It  may  occur,  too,  in  several  members  of  the  same  family.  We 
are  still  ignorant  as  to  the  nature  of  this  congenital  pulmonary  weakness. 
Cohnheim  thinks  it  probably  due  to  a  defect  in  the  development  of  the  elastic- 
tissue  fibres — a  statement  which  is  borne  out  by  Eppinger's  observations. 

Heightened  pressure  within  the  air-cells  may  be  due  to  forcible  inspira- 
tion or  expiration.  Much  discussion  has  taken  place  as  to  the  part  played  by 
these  two  acts  in  the  production  of  the  disease.  The  inspiratory  theory  was 
advanced  by  Laennec  and  subsequently  modified  by  Gairdner,  who  held  that 
in  chronic  bronchitis  areas  of  collapse  were  induced,  and  compensatory  dis- 
tention took  place  in  the  adjacent  lobules.  This  unquestionably  does  occur 
in  the  vicarious  or  compensatory  emphysema,  but  it  probably  is  not  a  factor 
of  much  moment  in  the  form  now  under  consideration.  The  expiratory  theory, 
which  was  supported  by  Mendelssohn  and  Jenner,  accounts  for  the  condition 
in  a  much  more  satisfactor}'-  way.  In  all  straining  efforts  and  violent  attacks 
of  coughing,  the  glottis  is  closed  and  the  chest  walls  are  strongly  compressed 
by  muscular  efforts,  so  that  the  strain  is  thrown  upon  those  parts  of  the  lung 
least  protected,  as  the  apices  and  the  anterior  margins,  in  which  we  always 
find  the  emphysema  most  advanced.  The  sternum  and  costal  cartilages  grad- 
ually yield  to  the  heightened  intrathoracic  pressure  and  are,  in  advanced  cases, 
pushed  forward,  giving  the  characteristic  rotundity  to  the  thorax. 

Freuivid's  Theory. — A  primary  disease  of  the  costal  cartilages — a  chronic 
hyperplasis  with  premature  ossification  is  believed  to  bring  about  gradually 
a  state  of  rigid  dilatation  of  the  chest,  to  which  the  emphysema  is  secondary. 
Eecent  observations  make  it  probable  that  there  is  a  group  of  cases  in  which 
such  changes  occur  in  young  persons,  particularly  in  the  cartilages  of  the  first 
three  ribs.  Xiemeyer  says  that  he  had  met  with  a  few  such  cases,  and  there 
have  been  reported  recently  instances  in  which  the  cartilages  increased  in  size 
and  stood  out  prominently.  For  such  a  condition  what  is  now  called  Freund's 
operation  (of  resection)  would  be  indicated. 

Of  other  etiological  factors  occupation  is  the  most  important.  The  dis- 
ease is  met  with  in  players  on  wind  instruments,  in  glass-blowers,  and  in 


DISEASES  OF  THE  LUNGS.  635 

occupations  necessitating  heavy  lifting  or  straining.  Whooping-cough  and 
bronchitis  play  an  important  role^  not  so  much  in  the  changes  which  they 
induce  in  the  bronchi  as  in  consequence  of  the  prolonged  attacks  of 
coughing. 

Morbid  Anatomy. — The  thorax  is  capacious,  usually  barrel-shaped,  g,nd 
the  cartilages  are  calcified.  On  removal  of  the  sternum,  the  anterior  medias- 
tinum is  found  completely  occupied  by  the  margins  of  the  lungs,  and  the 
pericardial  sac  may  not  be  visible.  The  organs  are  very  large  and  have  lost 
their  elasticity,  so  that  they  do  not  collapse  either  in  the  thorax  or  when  placed 
on  the  table.  The  pleura  is  pale  and  there  is  often  an  absence  of  pigment, 
sometimes  in  patches,  termed  by  Yhchow  albinism  of  the  lung.  To  the  touch 
they  have  a  peculiar,  downy,  feathery  feel,  and  pit  readily  on  pressure.  This 
is  one  of  the  most  marked  features.  Beneath  the  pleura  greatly  enlarged  air- 
vesicles  may  be  readily  seen.  They  vary  in  size  from  .5  to  3  mm.,  and  irregu- 
lar bullas,  the  size  of  a  walnut  or  larger,  may  project  from  the  free  margins. 
The  best  idea  of  the  extreme  rarefaction  of  the  tissue  is  obtained  from  sec- 
tions of  a  lung  distended  and  dried.  At  the  anterior  margins  the  structure 
may  form  an  irregular  series  of  air-chambers,  resembling  the  frog's  lung.  On 
careful  inspection  with  the  hand-lens,  remnants  of  the  interlobular  septa  or 
even  of  the  alveoli  may  be  seen  on  these  large  emphysematous  vesicles.  Though 
general,  the  distention  is  more  marked,  as  a  rule,  at  the  anterior  margins,  and 
is  often  specially  marked  at  the  inner  surface  of  the  lobe  near  the  root,  where 
in  extreme  cases  air-spaces  as  large  as  a  hen's  egg  may  sometimes  be  found. 
Microscopically  there  is  seen  atrophy  of  the  alveolar  walls,  by  which  is  pro- 
duced the  coalescence  of  neighboring  air-cells.  In  this  process  the  capillary 
network  disappears  before  the  walls  are  completely  atrophied.  The  loss  of 
the  elastic  tissue  is  a  special  feature.  It  is  stated,  indeed,  that  in  certain 
cases  there  is  a  congenital  defect  in  the  development  of  this  tissue.  The  epi- 
thelium of  the  air-cells  undergoes  a  fatty  change,  but  the  large  distended  air- 
spaces retain  a  pavement  layer. 

The  bronchi  show  important  changes.  In  the  larger  tubes  the  mucous 
membrane  may  be  rough  and  thickened  from  chronic  bronchitis;  often  the 
longitudinal  lines  of  submucous  elastic  tissue  stand  out  prominently.  In 
the  advanced  cases  many  of  the  smaller  tubes  are  dilated,  particularly  when, 
in  addition  to  emphysema,  there  are  peri-bronchial  fibroid  changes.  Bron- 
chiectasis is  not,  however,  an  invariable  accompaniment  of  emphysema,  but, 
as  Laennec  remarks,  it  is  difficult  to  understand  why  it  is  not  more  common. 
Of  associated  morbid  changes  the  most  important  are  found  in  the  heart. 
The  right  chambers  are  dilated  and  hypertrophied,  the  tricuspid  orifice  is 
large,  and  the  valve  segments  are  often  thickened  at  the  edges.  In  advanced 
cases  the  cardiac  hypertrophy  is  general.  The  pulmonary  artery  and  its 
branches  may  be  wide  and  show  marked  atheromatous  changes. 

The  changes  in  the  other  organs  are  those  commonly  associated  with  pro- 
•  longed  venous  congestion.  Pneumothorax  may  follow  the  rupture  of  an  em- 
phj^sematous  bleb. 

Symptoms. — The  disease  may  be  tolerably  advanced  before  any  special 
symptoms  occur.  A  child,  for  instance,  may  be  somewhat  short  of  breath  on 
going  up-stairs  or  may  be  unable  to  run  and  play  as  other  children  without 
great  discomfort;  or,  perhaps,  has  attacks  of  slight  lividity.    Doubtless  much 


636  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

depends  upon  the  completeness  of  cardiac  compensation.  When  this  is  per- 
fect^ there  may  be  no  special  interruption  of  the  pulmonary  circulation  and, 
except  with  violent  exertion,  there  is  no  interference  with  the  aeration  of  the 
blood.  In  well-marked  cases  the  following  are  the  most  important  symptoms : 
Dyspnoea^  which  may  be  felt  only  on  slight  exertion,  or  may  be  persistent,  and 
aggravated  by  intercurrent  attacks  of  bronchitis.  The  respirations  are  often 
harsh  and  wheez}^  and  expiration  is  distinct^  prolonged. 

Cyanosis  of  an  extreme  grade  is  more  common  in  emphysema  than  in 
other  affections  with  the  exception  of  congenital  heart-disease.  So  far  as  I 
know  it  is  the  only  disease  in  which  a  patient  may  be  able  to  go  about  and 
even  to  walk  into  the  hospital  or  consulting-room  with  a  lividity  of  startling 
intensity.  The  contrast  between  the  extreme  cyanosis  and  the  comparative 
comfort  of  the  patient  is  very  striking.  In  other  affections  of  the  heart  and 
lungs  associated  with  a  similar  degree  of  cyanosis  the  patient  is  invariably  in 
bed  and  usually  in  a  state  of  orthopnoea.  One  condition  must  be  here  referred 
to,  viz.,  the  extraordinary  cyanosis  in  cases  of  poisoning  by  aniline  products, 
which  is  in  most  part  due  to  the  conversion  of  the  hsemoglobin  into  methtemo- 
globin. 

Bronchitis  with  associated  cough  is  a  frequent  symptom  and  often  the 
direct  cause  of  the  pulmonary  distress.  The  contrast  between  emphysematous 
patients  in  the  winter  and  summer  is  marked  in  this  respect.  In  the  latter 
they  may  be  comfortable  and  able  to  attend  to  their  work,  but  with  the  cold 
and  changeable  weather  they  are  laid  up  with  attacks  of  bronchitis.  Finally, 
in  fact,  the  two  conditions  become  inseparable  and  the  patient  has  persistently 
more  or  less  cough.  The  acute  bronchitis  may  produce  attacks  not  unlike 
asthma.  In  some  instances  this  is  true  spasmodic  asthma,  with  which  emphy- 
sema is  frequently  associated. 

As  age  advances,  and  with  successive  attacks  of  bronchitis,  the  condition 
grows  slowly  worse.  In  hospital  practice  it  is  common  to  admit  patients  over 
sixty  with  well-marked  signs  of  advanced  emphysema.  The  affection  can 
generall}^  be  told  at  a  glance — the  rounded  shoulders,  barrel  chest,  the  thin 
yet  oftentimes  muscular  form,  and  sometimes,  I  think,  a  very  characteristic 
facial  expression. 

There  is  another  group,  however,  of  younger  patients  from  twenty-five  to 
forty  years  of  age  who,  winter  after  winter,  have  attacks  of  intense  cyanosis  in 
consequence  of  an  aggravated  bronchial  catarrh.  On  inquiry  we  find  that  these 
patients  have  been  short-breathed  from  infancy,  and  they  belong,  I  believe, 
to  a  category  in  which  there  has  been  a  primary  defect  of  structure  in  the 
lung  tissue. 

Physical  Signs. — Inspection. — The  thorax  is  markedly  altered  in  shape; 
the  antero-posterior  diameter  is  increased  and  may  be  even  greater  than  the 
lateral,  so  that  the  chest  is  barrel-shaped.  The  appearance  is  somewhat  as  if 
the  chest  was  in  a  permanent  inspiratory  position.  The  sternum  and  costal 
cartilages  are  prominent.  The  lower  zone  of  the  thorax  looks  large  and  the- 
intercostal  spaces  are  much  widened,  particularly  in  the  hypochondriac  regions. 
The  sternal  fossa  is  deep,  the  clavicles  stand  out  with  great  prominence,  and 
the  neck  looks  shortened  from  the  elevation  of  the  thorax  and  the  sternum. 
A  zone  of  dilated  venules  may  be  seen  along  the  line  of  attachment  of  the  dia- 
phragm.    Though  this  is  common  in  emphysema,  it  is  by  no  means  peculiar 


DISEASES  OF  THE  LUNGS.  637 

to  it  or  indeed  to  any  special  affection.  Andrew,  of  Bartholomew's  Hospital, 
and,  according  to  Duckworth,  Laycock  called  attention  to  it. 

The  curve  of  the  spine  is  increased  and  the  back  is  remarkably  rounded, 
so  that  the  scapula  seem  to  be  almost  horizontal.  Mensuration  shows  the 
rounded  form  of  the  chest  and  the  very  slight  expansion  on  deep  inspiration. 
The  respiratory  movements,  which  may  look  energetic  and  forcible,  exercise 
little  or  no  influence.  The  chest  does  not  expand,  but  there  is  a  general  ele- 
vation. The  inspiratory  effort  is  short  and  quick ;  the  expiratory  movement  is 
prolonged.  There  may  be  retraction  instead  of  distention  in  the  upper  abdom- 
inal region  during  inspiration,  and  there  is  sometimes  seen  a  transverse  curve 
crossing  the  abdomen  at  the  level  of  the  twelfth  rib.  The  apex  beat  of  the 
heart  is  not  visible,  and  there  is  usually  marked  pulsation  in  the  epigastric 
region.    The  cervical  veins  stand  out  prominently  and  may  pulsate. 

Palpation. — The  vocal  fremitus  is  somewhat  enfeebled  but  not  lost.  The 
apex  beat  can  rarely  be  felt.  There  is  a  marked  shock  in  the  lower  sternal 
region  and  very  distinct  pulsation  in  the  epigastrium.  Percussion  gives 
greatly  increased  resonance,  full  and  drum-like — what  is  sometimes  called 
hyperresonance.  The  note  is  not  often  distinctly  tympanitic  in  quality.  The 
percussion  note  is  greatly  extended,  the  heart  dulness  may  be  obliterated,  the 
upper  limit  of  liver  dulness  is  greatly  lowered,  and  the  resonance  may  extend 
to  the  costal  margin.  Behind,  a  clear  percussion  note  extends  to  a  much  lower 
level  than  normal.    The  level  of  splenic  dulness,  too,  may  be  lowered. 

On  auscultation  the  breath-sounds  are  usually  enfeebled  and  may  be 
masked  by  bronchitic  rales.  The  most  characteristic  feature  is  the  prolonga- 
tion of  the  expiration,  and  the  normal  ratio  may  be  reversed — 4  to  1  instead 
of  1  to  4.  It  is  often  wheezy  and  harsh  and  associated  with  coarse  rales  and 
sibilant  rhonchi.  It  is  said  that  in  interstitial  emphysema  there  may  be  a 
friction  sound  heard,  not  unlike  that  of  pleurisy.  The  heart-sounds  are  usu- 
ally feeble  but  clear;  in  advanced  cases,  when  there  is  marked  cyanosis,  a 
tricuspid  regurgitant  murmur  may  be  heard.  Accentuation  of  the  pulmonary 
second  sound  may  be  present. 

Course. — The  course  of  the  disease  is  slow  but  progressive,  the  recurring 
attacks  of  bronchitis  aggravating  the  condition.  Death  may  occur  from  inter- 
current pneumonia,  either  lobar  or  lobular,  and  dropsy  may  supervene  from 
cardiac  failure.  Occasionally  death  results  from  overdistention  of  the  heart, 
with  extreme  cyanosis.  Duckworth  has  called  attention  to  the  occasional 
occurrence  of  fatal  haemorrhage  in  emphysema.  In  an  old  emphysematous 
patient  at  the  Montreal  General  Hospital  death  followed  the  erosion  of  a  main 
branch  of  the  pulmonary  artery  by  an  ulcer  near  the  bifurcation  of  the  trachea. 

Treatment. — Practicall}^,  the  measures  mentioned  in  connection  with  bron- 
chitis should  be  employed.  In  children  with  asthma  and  emphysema  the  nose 
should  be  carefully  examined.  No  remedy  is  known  which  has  any  influence 
over  the  progress  of  the  condition  itself.  Bronchitis  is  the  great  danger  of 
these  patients,  and  therefore  when  possible  they  should  live  in  an  equable 
climate.  The  cases  do  well  in  southern  California  and  in  Egypt.  In  conse- 
quence of  the  venous  engorgement  they  are  liable  to  gastric  and  intestinal  dis- 
turbance, and  it  is  particularly  important  to  keep  the  bowels  regulated  and  to 
avoid  flatulency  which  often  seriously  aggravates  the  dyspnoea.  Patients  who 
come  into  the  hospital  in  a  state  of  urgent  dyspnoea  and  lividity,  with  great 


638  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

engorgement  of  the  veins,  particularly  if  the)^  are  young  and  vigorous,  should 
be  bled  freely.  Inhalation  of  oxygen  may  be  used.  Strychnine  will  be  found 
specially  useful.  Breathing  of  compressed  air  in  a  pneumatic  cabinet  gives 
temporary  relief.  Eesection  of  the  first  costal  cartilage  or  of  the  first  three 
cartilages  on  either  side  has  been  practised  (Freund's  operation).  It  is  not 
likely  to  be  of  any  benefit  in  the  aged  in  whom  the  condition  is  established, 
but  in  a  special  group  in  the  young  in  which  the  primary  trouble  appears  to 
be  in  the  cartilages — what  has  been  called  Freund's  Disease — the  operation 
may  be  tried,  though  it  is  not  without  risks. 

III.  Atrophic  Emphysema. 

A  senile  change,  called  by  Sir  William  Jenner  small-lunged  emphysema,  is 
really  a  primary  atrophy  of  the  lung,  coming  on  in  advanced  life,  and  scarcely 
constitutes  a  special  affection.  It  occurs  in  "  withered-looking  old  persons  " 
who  ma}"  perhaps  have  had  a  winter  cough  and  shortness  of  breath  for  years. 
In  striking  contrast  to  the  essential  hypertrophic  emphysema,  the  chest  is  small 
and  the  ribs  obliquely  placed.  The  thoracic  muscles  are  usually  atrophied. 
The  lung  presents  a  remarkable  appearance,  being  converted  into  a  series  of 
large  vesicles,  on  the  walls  of  which  the  remnants  of  air-cells  may  be  seen. 

IV.  Acute  Yesiculae  Emphysema. 

TTlien  death  occurs  from  bronchitis  of  the  smaller  tubes,  when  strong 
inspiratory  efforts  have  been  made,  the  lungs  are  large  in  volume  and  the  air- 
cells  are  much  distended.  Clinicall}^,  this  condition  may  occur  rapidly  in 
cases  of  cardiac  asthma  and  angina  pectoris.  The  area  of  pulmonary  reso- 
nance is  much  increased,  and  on  auscultation  there  are  heard  everywhere 
piping  rales  and  prolonged  expiration.  A  similar  condition  may  follow  pres- 
sure on  the  vagi. 

V.  Interstitial  Emphysema. 

Beads  of  air  are  seen  in  the  interlobular  and  subpleural  tissue,  sometimes 
forming  large  bulls  beneath  the  pleura.  A  rare  event  is  rupture  close  to  the 
root  of  the  lung,  and  the  passage  of  air  along  the  trachea  into  the  subcuta- 
neous tissues  of  the  neck.  After  tracheotomy  just  the  reverse  may  occur  and 
the  air  may  pass  from  the  tracheotomy  wound  along  the  windpipe  and  bronchi 
and  appear  beneath  the  surface  of  the  pleura.  From  this  interstitial  emphy- 
sema spontaneous  pneumothorax  may  arise  in  healthy  persons. 

VI.     GANGRENE    OF    THE    LUNG. 

Etiology. — Gangrene  of  the  lung  is  not  an  affection  per  se,  but  occurs  in 
a  variety  of  conditions  when  necrotic  areas  undergo  putrefaction.  It  is  not 
easy  to  say  why  sphacelus  should  occur  in  one  case  and  not  in  another,  as 
the  germs  of  putrefaction  are  always  in  the  air-passages,  and  yet  necrotic 
territories  rarely  become  gangrenous.  Total  obstruction  of  a  pulmonary 
artery,  as  a  rule,  causes  infarction,  and  the  area  shut  off  does  not  often, 
though  it  may,  sphacelate.  Another  factor  would  seem  to  be  necessary — 
probably  a  lowered  tissue  resistance,  the  result  of  general  or  local  causes.     It 


DISEASES  OF  THE  LUNGS.  639 

is  met  A\dth  (1)  as  a  sequence  of  lobar  pneumonia.  This  rarely  occurs  in  a 
previously  healthy  person — more  commonly  in  the  debilitated  or  in  the  dia- 
betic subject,  (3)  Gangrene  is  very  prone  to  follow  the  aspiration  pneumonia, 
since  the  foreign  particles  rapidly  undergo  putrefactive  changes.  Of  a  similar 
nature  are  the  cases  of  gangrene  due  to  perforation  of  cancer  of  the  oesophagus 
into  the  lung  or  into  the  bronchus.  (3)  The  putrid  contents  of  a  bronchiec- 
tatic,  more  commonly  of  a  tuberculous,  cavity  may  excite  gangrene  in  the 
neighboring  tissues.  The  pressure  bronchiectasis  following  aneurism  or  tumor 
may  lead  to  extensive  sloughing.  (4)  Gangrene  may  follow  simple  embolism 
of  the  pulmonary  artery.  More  commonly,  however,  the  embolus  is  derived 
from  a  part  which  is  mortified  or  comes  from  a  focus  of  bone  disease.  In 
typhus  and  in  typhoid  fever  gangrene  of  the  lung  may  follow  thrombosis  of  one 
of  the  larger  branches  of  the  pulmonary  artery.  A  case  occurred  in  my  wards 
in  October,  1897,  in  connection  with  a  typhoid  septicaemia.  Typhoid  bacilli 
were  isolated  from  the  lung.  Lastly,  gangrene  of  the  lung  may  occur  in  con- 
ditions of  debility  during  convalescence  from  protracted  fever — occasionally, 
indeed,  without  our  being  able  to  assign  any  reasonable  cause. 

Morbid  Anatomy. — Laennec,  who  first  accurately  described  pulmonary 
gangrene,  recognized  a  diffuse  and  a  circumscribed  form.  The  former,  though 
rare,  is  sometimes  seen  in  connection  with  pneumonia,  more  rarely  after  oblit- 
eration of  a  large  branch  of  the  pulmonary  artery.  It  may  involve  the  greater 
part  of  a  lobe,  and  the  lung  tissue  is  converted  into  a  horribly  offensive  green- 
ish-black mass,  torn  and  ragged  in  the  centre.  In  the  circumscribed  form  there 
is  well-marked  limitation  between  the  gangrenous  area  and  the  surrounding  tis- 
sue. The  focus  may  be  single  or  there  may  be  two  or  more.  The  lower  lobe 
is  more  commonly  affected  than  the  upper,  and  the  peripheral  more  than  the 
central  portion  of  the  lung.  A  gangrenous  area  is  at  first  uniformly  greenish- 
brown  in  color ;  but  softening  rapidly  takes  place  with  the  formation  of  a  cavity 
with  shreddy,  irregular  walls  and  a  greenish,  offensive  fluid.  The  lung  tissue 
in  the  immediate  neighborhood  shows  a  zone  of  deep  congestion,  often  consoli- 
dation, and  outside  this  an  intense  oedema.  In  the  embolic  cases  the  plugged 
artery  can  sometimes  be  found.  When  rapidly  extending,  vessels  may  be 
opened  and  a  copious  haemorrhage  ensue.  Perforation  of  the  pleura  is  not 
uncommon.  The  irritating  decomposing  material  usually  excites  the  most 
intense  bronchitis.  Embolic  processes  are  not  infrequent.  There  is  a  remark- 
able association  in  some  cases  between  circumscribed  gangrene  of  the  lung  and 
abscess  of  the  brain.  It  has  been  referred  to  under  the  section  on  bron- 
chiectasis. 

Symptoms  and  Course. — Usually  definite  symptoms  of  local  pulmonary 
disease  precede  the  characteristic  features  of  gangrene.  These,  of  course,  are 
very  varied,  depending  on  the  nature  of  the  trouble.  The  sputum  is  very  char- 
acteristic. It  is  intensely  fetid — usually  profuse — and,  if  expectorated  into 
a  conical  glass,  separates  into  three  layers — a  greenish-brown,  heavy  sediment ; 
an  intervening  thin  liquid,  which  sometimes  has  a  greenish  or  a  brownish  tint ; 
and,  on  top,  a  thick,  frothy  layer.  Spread  on  a  glass  plate,  the  shreddy  dehris 
of  lung  tissue  can  readily  be  picked  out.  Even  large  fragments  of  lung  may 
be  coughed  up.  Robertson,  of  Onancock,  Va.,  sent  me  one  several  centimetres 
in  length,  which  had  been  expectorated  by  a  lad  of  eighteen,  who  had  severe 
gangrene  and  recovered.     Microscopically,  elastic  fibres  are  found  in  abun- 


640  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

dance,  with  granular  matter,  pigment  grains,  fatty  crystals,  bacteria,  and 
leptothrix.  It  is  stated  that  elastic  tissue  is  sometimes  absent,  but  I  have 
never  met  with  such  an  instance.  The  peculiar  plugs  of  sputum  which  occur 
in  bronchiectasis  are  not  found.  Blood  is  often  present,  and,  as  a  rule,  is  much 
altered.  The  sputum  has,  in  a  majority  of  the  cases,  an  intensely  fetid  odor, 
which  is  communicated  to  the  breath  and  may  permeate  the  entire  room.  It 
is  much  more  offensive  than  in  fetid  bronchitis  or  in  abscess  of  the  lung.  The 
fetor  is  particularly  marked  when  there  is  free  communication  between  the 
gangrenous  cavities  and  the  bronchi.  On  several  occasions  I  have  found,  post 
mortem,  localized  gangrene,  which  had  been  unsuspected  during  life,  and  in 
which  there  had  been  no  fetor  of  the  breath. 

The  physical  signs,  when  extensive  destruction  has  occurred,  are  those 
of  cavity,  but  the  limited  circumscribed  areas  may  be  difficult  to  detect. 
Bronchitis  is  always  present. 

Among  the  general  symptoms  may  be  mentioned  fever,  usually  of  moderate 
grade ;  the  pulse  is  rapid,  and  very  often  the  constitutional  depression  is  severe. 
But  the  only  special  features  indicative  of  gangrene  are  the  sputa  and  the 
fetor  of  the  breath.  The  patient  generally  sinks  from  exhaustion.  Fatal 
hemorrhage  may  ensue. 

Treatment. — The  treatment  of  gangrene  is  very  unsatisfactory.  The  indi- 
cations, or  course,  are  to  disinfect  the  gangrenous  area,  but  this  is  often  impos- 
sible. An  antiseptic  spray  of  carbolic  acid  may  be  employed.  A  good  plan 
is  for  the  patient  to  use  over  the  mouth  and  nose  an  inhaler,  which  may  be 
charged  with  a  solution  of  carbolic  acid  or  with  guaiacol;  the  latter  drug  has 
also  been  used  hypodermically,  with,  it  is  said,  happy  results  in  removing  the 
odor.  If  the  signs  of  cavity  are  distinct  an  attempt  should  be  made  to  cleanse 
it  by  direct  injections  of  an  antiseptic  solution.  If  the  patient's  condition  is 
good  and  the  gangrenous  region  can  be  localized,  surgical  interference  may  be 
indicated.  Successful  cases  have  been  reported.  The  general  condition  of 
the  patient  is  always  such  as  to  demand  the  greatest  care  in  the  matter  of 
diet  and  nursing, 

VII.     ABSCESS    OF    THE    LUNG. 

Etiology. — Suppuration  occurs  in  the  lung  under  the  following  conditions : 
(1)  As  a  sequence  of  inflammation,  either  lobar  or  lobular.  Apart  from  the 
purulent  infiltration  this  is  unquestionably  rare,  and  even  in  lobar  pneumonia 
the  abscesses  are  of  small  size  and  usually  involve,  as  Addison  remarked,  sev- 
eral points  at  the  same  time.  On.  the  other  hand,  abscess  formation  is 
extremely  frequent  in  the  deglutition  and  aspiration  forms  of  lobular  pneu- 
monia. After  wounds  of  the  neck  or  operations  upon  the  throat,  in  suppura- 
tive disease  of  the  nose  or  larynx,  occasionally  even  of  the  ear  (Volkmann), 
infective  particles  reach  the  bronchial  tubes  by  aspiration  and  excite  an  intense 
inflammation  which  often  ends  in  abscess.  Cancer  of  the  oesophagus,  perfo- 
rating the  root  of  the  lung  or  into  the  bronchi,  may  produce  extensive  suppura- 
tion. The  abscesses  vary  in  size  from  a  walnut  to  an  orange,  and  have  ragged 
and  irregular  walls,  and  purulent,  sometimes  necrotic,  contents. 

(2)  Embolic,  so-called  metastatic,  abscesses,  the  result  of  infective  emboli, 
are  extremely  common  in  pj^mia.     They  may  be  numerous  and  present  very 


DISEASES  OF   THE  LUNGS.  641 

definite  characters.  As  a  rule  they  are  superficial,  beneath  the  pleura,  and 
often  wedge-shaped.  At  first  firm,  grayish-red  in  color,  and  surrounded  by  a 
zone  of  intense  hypersemia,  suppuration  soon  follows  with  the  formation  of  a 
definite  abscess.  The  pleura  is  usually  covered  with  greenish  lymph,  and  per- 
foration sometimes  takes  place  with  the  production  of  pneumothorax. 

( 3 )  Perforation  of  the  lung  from  without,  lodgment  of  foreign  bodies,  and, 
in'  the  right  lung,  perforation  from  abscess  of  the  liver  or  a  suppurating  echino- 
coccus  cyst  are  occasional  causes  of  pulmonary  abscess. 

(4)  Suppurative  processes  play  an  important  part  in  chronic  pulmonary 
tuberculosis,  many  of  the  symptoms  of  which  are  due  to  them. 

Symptoms. — Abscess  following  pneumonia  is  easily  recognized  by  an  aggra- 
vation of  the  general  symptoms  and  by  the  physical  signs  of  cavity  and  the 
characters  of  the  expectoration.  Embolic  abscesses  can  not  often  be  recognized, 
and  the  local  symptoms  are  generally  masked  in  the  general  pygemic  manifes- 
tations. The  characters  of  the  sputum  are  of  great  importance  in  determining 
the  presence  of  abscess.  The  odor  is  offensive,  yet  it  rarely  has  the  horrible 
fetor  of  gangrene  or  of  putrid  bronchitis.  In  the  pus  fragments  of  lung  tissue 
can  be  seen,  and  the  elastic  tissue  may  be  very  abundant.  The  presence  of  this 
with  the  physical  signs  rarely  leaves  any  question  as  to  the  nature  of  the 
trouble.  Embolic  cases  usually  run  a  fatal  course.  Eecovery  occasionally 
occurs  after  pneumonia.  In  a  case  following  typhoid  fever  which  I  saw  at 
the  Garfield  Hospital,  Kerr  removed  two  ribs  and  found  free  in  the  pus  of 
a  localized  empyema  a  sequestered  piece  of  lung,  the  size  of  the  palm  of  the 
hand,  which  had  sloughed  off  clearly  from  the  lower  lobe.  The  patient  made 
a  good  recovery. 

Medicinal  treatment  is  of  little  avail  in  abscess  of  the  lung.  When  well 
defined  and  superficial,  an  attempt  should  always  be  made  to  open  and  drain 
it.    A  number  of  successful  cases  have  already  been  treated  in  this  way. 

VIII.     NEW    GROWTHS    IN    THE    LUNGS. 

Etiology  and  Morbid  Anatomy. — While  primary  tumors  are  rare,  second- 
ary growths  are  not  uncommon. 

Carcinoma  is  the  most  common  primary  form.  Endothelium  and  sarcoma 
are  less  frequently  met  with. 

The  secondary  growths  may  be  of  various  forms.  Most  commonly  they 
follow  tumors  in  the  digestive  or  genito-urinary  organs  or  on  the  breast;  not 
infrequently  also  tumors  of  the  bone.  There  may  be  scirrhus,  epithelioma, 
colloid,  melano-sarcoma,  fibroma,  enchondroma,  or  osteoma.  The  lungs  may 
be  extensively  involved  in  Hodgkin's  disease. 

Primary  cancer  or  sarcoma  usually  involves  only  one  lung.  The  second- 
ary growths  are  distributed  in  both.  The  primary  growth  generally  forms  a 
large  mass,  which  may  occupy  the  greater  part  of  a  lung.  Necrosis  and  cavity 
formation  may  occur.  In  the  diffuse  cancerous  growth  the  condition  may 
resemble  a  tuberculous  pneumonia.  A  miliary  type  of  growth  has  been  de- 
scribed. Occasionally  the  secondary  growths  are  solitary  and  confined  chiefly 
to  the  pleura.  The  metastatic  growths  are  nearly  always  disseminated.  Occa- 
sionally they  occupy  a  large  portion  of  the  pulmonary  tissue.  In  a  case  of 
colloid  cancer  secondary  to  cancer  of  the  pancreas,  I  found  both  lungs  volu- 


642  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

minous,  heavy,  only  slightly  crepitant,  and  occupied  by  circular  translucent 
masses,  varying  in  size  from  a  pea  to  a  large  walnut. 

There  are  numerous  accessory  lesions  in  the  pulmonary  new  growths. 
There  ma}'  be  pleurisy,  either  cancerous  or  sero-fibrinous.  The  efEusion  may 
be  hemorrhagic,  but  in  200  cases  of  cancer,  primary  or  secondary,  of  the 
lungs  and  pleura  analyzed  by  Moutard-Martin,  hsemorrhagic  effusion  occurred 
in  only  12  per  cent.  The  tracheal  and  bronchial  glands  are  usually  affected, 
the  cervical  glands  not  infrequently,  and  occasionally  even  the  inguinal. 

The  disease  is  most  common  in  the  middle  period  of  life.  The  primary 
cancer  is  much  more  frequent  in  men  (73  per  cent,  Passler),  but  secondary 
cancer  is  much  more  common  in  women.  The  conditions  which  predispose  to 
it  are  quite  unknown.  It  is  a  remarkable  fact  that  the  workers  in  the  Sclmee- 
berg  cobalt  mines  are  very  liable  to  primary  cancer  of  the  lungs.  It  is  stated 
that  in  this  region  a  considerable  proportion  of  all  deaths  in  persons  over 
forty  are  due  to  this  disease. 

Symptoms. — The  clinical  features  of  neoplasms  of  the  lungs  are  by  no 
means  distinctive,  particularly  in  the  case  of  primary  growths.  The  patient 
may,  indeed,  as  noted  by  Walshe,  present  no  symptoms  pointing  to  intra- 
thoracic disease.  Among  the  more  important  symptoms  are  pain,  particularly 
when  the  pleura  is  involved ;  dyspnoea,  which  is  apt  to  be  paroxysmal  when  due 
to  pressure  upon  the  trachea ;  cough,  which  may  be  dry  and  painful  and  accom- 
panied by  the  expectoration  of  a  dark  mucoid  sputum.  This  so-called  prime- 
Juice  expectoration,  which  was  present  10  times  in  18  cases  of  primary  cancer 
of  the  lung,  was  thought  by  Stokes  to  be  of  great  diagnostic  value. 

In  many  instances  there  are  signs  of  compression  of  the  large  veins,  pro- 
ducing lividity  of  the  face  and  upper  extremities,  or  occasionally  of  only  one 
arm.  Compression  of  the  trachea  and  bronchi  may  give  rise  to  urgent 
dyspnoea.  The  heart  may  be  pushed  over  to  the  opposite  side.  The  pneumo- 
gastric  and  recurrent  laryngeal  nerves  are  occasionally  involved  in  the 
growth. 

Physical  Sigxs. — The  patient,  according  to  Walshe,  usually  lies  on  the 
affected  side.  On  inspection  this  side  may  be  enlarged  and  immobile  and  the 
intercostal  spaces  are  obliterated.  This  is  more  commonly  due  to  the  effusion 
than  to  the  growth  itself.  The  external  tymph-glands  may  be  enlarged,  par- 
ticularly the  clavicular.  The  signs,  on  percussion  and  auscultation,  are  varied, 
depending  much  upon  the  presence  or  absence  of  fluid.  Signs  of  consolidation 
are,  of  course,  present;  the  tactile  fremitus  is  absent  and  the  breath-sounds 
are  usually  diminished  in  intensity.  Occasionally  there  is  t}^ical  bronchial 
breathing.  Among  other  sj^mptoms  may  be  mentioned  fever,  which  is  present 
in  a  certain  number  of  cases.  Emaciation  is  not  necessarily  extreme.  The 
duration  of  the  disease  is  from  six  to  eight  months.  Occasionally  it  runs  a 
very  acute  course,  as  noted  by  Cars  well.  Cases  are  reported  in  which  death 
occurred  in  a  month  or  six  weeks,  and  in  one  instance  (Jaccoud)  the  patient 
died  in  a  week  from  the  onset  of  the  symptoms. 

Diagnosis. — In  secondary  growths  this  is  not  difiicult.  The  occurrence 
of  pulmonary  sjTnptoms  within  a  year  or  two  after  the  removal  of  a  cancer 
of  the  breast,  or  after  the  amputation  of  a  limb  for  osteo-sarcoma,  or  the  onset 
of  similar  symptoms  in  connection  with  cancer  of  the  liver,  or  of  the  uterus, 
or  of  the  rectum,  would  be  extremely  suggestive.    In  primary  cases  the  uni- 


DISEASES  OF  THE  PLEURA.  643 

lateral  involvement,  the  anomalous  character  of  the  physical  signs,  the  occur- 
rence of  prune-juice  expectoration,  the  progressive  wasting,  and  the  secondary 
involvement  of  the  cervical  glands  are  the  important  points  in  the  diagnosis. 


E.    DISEASES  OF  THE  PLEURA. 

I.  ACUTE    PLEURISY. 

Anatomically,  the  eases  may  he  divided  into  dry  or  adhesive  pleurisy  and 
pleurisy  with  effusion.  Another  classification  is  into  primary  or  secondary 
forms.  According  to  the  course  of  the  disease,  a  division  may  be  made  into 
acute  and  chronic  pleurisy,  and  as  it  is  impossible,  at  present,  to  group  the 
various  forms  etiologically,  this  is  perhaps  the  most  satisfactory  division.  The 
following  forms  of  acute  pleurisy  may  be  considered : 

I.  Fibrinous  or  Plastic  Pleurisy. 

In  this  the  pleural  membrane  is  covered  by  a  sheeting  of  lymph  of  variable 
thickness,  which  gives  it  a  turbid,  granular  appearance,  or  the  fibrin  may 
exist  in  distinct  layers.  It  occurs  (1)  as  an  independent  affection,  following 
cold  or  exposure.  This  form  of  acute  plastic  pleurisy  without  fluid  exudate 
is  not  common  in  perfectly  healthy  individuals.  Cases  are  met  with,  however, 
in  which  the  disease  sets  in  with  the  usual  symptoms  of  pain  in  the  side  and 
slight  fever,  and  there  are  the  physical  signs  of  pleurisy  as  indicated  by  the  fric- 
tion. After  persisting  for  a  few  days,  the  friction  murmur  disappears  and  no 
exudation  occurs.  Union  takes  place  between  the  membranes,  and  possibly  the 
pleuritic  adhesions  which  are  found  in  such  a  large  percentage  of  all  bodies 
examined  after  death  originate  in  these  slight  fibrinous  pleurisies. 

Fibrinous  pleurisy  occurs  (2)  as  a  secondary  process  in  acute  diseases  of 
the  lung,  such  as  pneumonia,  which  is  always  accompanied  by  a  certain  amount 
of  pleurisy,  usually  of  this  form.  Cancer,  abscess,  and  gangrene  also  cause 
plastic  pleurisy  when  the  surface  of  the  lung  becomes  involved.  This  condition 
is  specially  associated  in  a  large  number  of  cases  with  tuberculosis.  Pleural 
pain,  stitch  in  the  side,  and  a  dry  cough,  with  marked  friction  sounds  on  aus- 
cultation are  the  initial  phenomena  in  many  instances  of  phthisis.  The  signs 
are  usually  basic,  but  Burney  Yeo  has  recently  called  attention  to  the  fre- 
quency with  which  they  occur  at  the  apex. 

II.  Sero-fibrinous  Pleurisy. 

In  a  majority  of  cases  of  inflammation  of  the  pleura  there  is,  with  the 
fibrin,  a  variable  amount  of  fluid  exudate,  which  produces  the  condition  known 
as  pleurisy  with  effusion. 

Etiology. — Of  194  cases  in  flfteen  years  in  my  wards,  there  were  161  males 
and  33  females.  Under  twenty  years  of  age  there  were  20  patients;  18  were 
over  sixty  years  of  age.  The  greatest  number  was  in  the  fifth  decade,  59. 
Cold  acts  as  a  predisposing  agent,  which  permits  the  action  of  various  micro- 
organisms. We  have  not  yet,  however,  brought  all  the  acute  pleurisies  into 
the  category  of  microbic  affections,  and  the  fact  remains  that  pleurisy  does 
follow  with  great  rapidity  a  sudden  wetting  or  a  chill.     A  majority  of  the 


644  DISEASES    OF  THE  RESPIRATORY  SYSTEM. 

cases  are  tuberculous.  This  view  is  based  upon:  (1)  Post-mortem  evidence. 
Tubercles  have  been  found  in  acute  cases,  thought  to  have  been  rheumatic  or 
due  to  cold.  (2)  The  not  infrequent  presence  of  tuberculous  lesions,  often 
latent,  in  the  lung  or  elsewhere.  (3)  The  character  of  the  exudate.  If  coagu- 
lated and  the  eoagulum  digested  and  centrifugalized  (Inoscopy),  tubercle 
bacilli  are  frequenth^  found.  Injected  into  a  guinea  pig,  in  amounts  of  15  cc. 
or  more,  tuberculosis  followed  in  62  per  cent  (Eiehhorst).  The  cyto-diagnosis 
shows  that  as  in  other  tuberculous  exudates  the  mono-nuclear  leucocytes  pre- 
dominate. (4)  The  tuberculin  reaction  is  given  in  a  considerable  percentage 
of  the  cases.  (5)  The  subsequent  history.  Of  90  eases  of  acute  pleurisy 
which  had  been  under  the  observation  of  H.  I.  Bowditch  between  1849  and 
1879,  32  died  of  or  had  phthisis.  Among  130  patients  with  primary  pleurisy 
with  effusion,  followed  for  a  period  of  seven  years  by  Hedges,  40  per  cent 
became  tuberculous. 

Of  300  uncomplicated  cases  of  pleural  effusion  in  the  Massachusetts  Gen- 
eral Hospital,  followed  by  E.  C.  Cabot,  the  subsequent  history  was  ascertained 
in  221 ;  followed  five  years  until  death  or  phthisis,  117 ;  well  after  five  years,  96. 

In  172  of  our  cases  of  pleurisy  with  effusion  Hamman  got  reports  from  88 ; 
of  these  48  were  living  and  well,  30  later  became  tuberculous,  in  2  the  result 
was  questionable,  and  8  died  of  other  diseases.  Twelve  of  the  88  had  tubercle 
bacilli  in  the  sputum  while  in  the  hospital  without  discoverable  pulmonary 
lesion;  3  of  the  12  are  living  and  well;  in  8  the  signs  became  well  marked; 
one  died  of  unkno^vn  cause.  Hamman  has  collected  562  cases  (including  our 
ovm)  in  wliich  the  subsequent  history  was  sought ;  of  these  167,  29.7  per  cent, 
became  tuberculous. 

Bacteriology  of  Acute  Pleurisy. — From  a  bacteriological  standpoint  we  may 
recognize  three  groups  of  cases,  caused  by  the  tubercle  bacillus,  the  pneumo- 
coccus,  and  the  streptococcus,  respectively. 

Bacillus  tuberculosis  is  present  in  a  very  large  proportion  of  all  cases 
of  primary  or  so-called  idiopathic  pleurisy.  The  exudate  is  usually  sterile 
on  cover-slips  or  in  the  culture  and  inoculation  tests  made  in  the  ordinary 
way,  as  the  bacilli  are  very  scanty.  It  has  been  demonstrated  clearly  that 
a  large  amount  of  the  exudate  must  be  taken  to  make  the  test  complete,  either 
in  cultures  or  in  the  inoculation  of  animals.  Eiehhorst  found  that  more  than 
62  per  cent  were  demonstrated  as  tuberculous  when  as  much  as  15  cc.  of  the 
exudate  was  inoculated  into  test  animals,  while  less  than  10  per  cent  of  the 
cases  showed  tuberculosis  when  only  1  cc.  of  the  exudate  was  used.  This  is  a 
point  to  which  observers  should  pay  very  special  attention.  Le  Damany  has 
recently  in  55  primary  pleurisies  demonstrated  the  tuberculous  character  of 
all  but  4.  He  has  used  large  quantities  of  the  fluid  for  his  inoculation 
experiments. 

The  pneumocoecus  pleurisy  is  almost  always  secondary  to  a  focus  of  inflam- 
mation in  the  lung.  It  may,  however,  be  primary.  The  exudate  is  usually 
purulent  and  the  outlook  is  very  favorable. 

The  streptococcus  pleurisy  .is  the  tj^ical  septic  form  which  may  occur 
either  from  direct  infection  of  the  pleura  through  the  lung  in  broncho-pneu- 
monia, or  in  cases  of  streptococcus  pneumonia;  in  other  instances  it  follows 
infection  of  more  distant  parts.  The  acute  streptococcus  pleurisy  is  the  most 
serious  and  fatal  of  all  forms. 


DISEASES  OF  THE  PLEURA.  645 

Among  other  bacteria  which  have  been  found  are  the  staphylococcus.  Fried- 
lander's  bacillus,  the  typhoid  bacillus,  and  the  diphtheria  bacillus. 

Morbid  Anatomy. — In  sero-fibrinous  pleurisy  the  serous  exudate  is  abun- 
dant and  the  fibrin  is  found  on  the  pleural  surfaces  and  scattered  through 
the  fluid  in  the  form  of  flocculi.  The  proportions  of  these  constituents  vary 
a  great  deal.  In  some  instances  there  is  very  little  membranous  fibrin;  in 
others  it  forms  thick,  creamy  layers  and  exists  in  the  dependent  part  of  the 
fluid  as  whitish,  curd-like  masses.  The  fluid  of  sero-fibrinous  pleurisy  is  of 
a  lemon  color,  either  clear  or  slightly  turbid,  depending  on  the  number  of 
formed  elements.  In  some  instances  it  has  a  dark-brown  color.  The  micro- 
scopical examination  of  the  fluid  shows  leucocytes,  occasional  swollen  cells, 
which  may  possibly  be  derived  from  the  pleural  endothelium,  shreds  of  fibril- 
lated  fibrin,  and  a  variable  number  of  red  blood-corpuscles.  On  boiling,  the 
fluid  is  found  to  be  rich  in  albumin.  Sometimes  it  coagulates  spontaneously. 
Its  composition  closely  resembles  that  of  blood-serum.  Cholesterin,  uric  acid, 
and  sugar  are  occasionally  found.  The  amount  of  the  effusion  varies  from 
"I  to  4  litres.  The  lung  in  acute  sero-fibrinous  pleurisy  is  more  or  less  com- 
pressed. If  the  exudation  is  limited  the  lower  lobe  alone  is  atelectatic ;  but  in 
an  extensive  effusion  which  reaches  to  the  clavicle  the  entire  lung  will  be  found 
lying  close  to  the  spine,  dark  and  airless,  or  even  bloodless — i.  e.,  carnified. 

In  large  exudations  the  adjacent  organs  are  displaced;  the  liver  is  depressed 
and  the  heart  dislocated.  With  reference  to  the  position  of  the  heart,  the  fol- 
lowing statements  may  be  made:  (1)  Even  in  the  most  extensive  left-sided 
exudation  there  is  no  rotation  of  the  apex  of  the  heart,  which  in  no  case  was 
to  the  right  of  the  mid-sternal  line;  (2)  the  relative  position  of  the  apex  and 
base  is  usually  maintained;  in  some  instances  the  apex  is  lifted,  in  others  the 
whole  heart  lies  more  transversely;  (3)  the  right  chambers  of  the  heart  occupy 
the  greater  portion  of  the  front,  so  that  the  displacement  is  rather  a  definite 
dislocation  of  the  mediastinum,  with  the  pericardium,  to  the  right,  than  any 
special  twisting  of  the  heart  itself;  (4)  the  kink  or  twist  in  the  inferior  vena 
cava  described  by  Bartels  was  not  present  in  any  of  my  cases. 

For  a  discussion  of  the  physics  of  cardiac  displacement  see  Calvert,  Johns 
Hophins  Hospital  Bulletin,  1907. 

Symptoms. — Prodromes  are  not  uncommon,  but  the  disease  may  set  in 
abruptly  with  a  chill,  followed  by  fever  and  a  severe  pain  in  the  side.  In 
very  many  cases,  however,  the  onset  is  insidious,  particularly  in  children  and 
in  elderly  persons.  A  little  dyspnoea  on  exertion  and  an  increasing  pallor 
may  be  the  only  features.  Washbourn  has  called  attention  to  the  frequency 
with  which  the  pneumococcus  pleurisy  sets  in  with  the  features  of  pneumonia. 
The  pain  in  the  side  is  the  most  distressing  symptom,  and  is  usually  referred  to 
the  nipple  or  axillary  regions.  It  must  be  remembered,  however,  that  pleuritic 
pain  may  be  felt  in  the  abdomen  or  low  down  in  the  back,  particularly  when 
the  diaphragmatic  surface  of  the  pleura  is  involved.  It  is  lancinating,  sharp, 
and  severe,  and  is  aggravated  by  cough.  At  this  early  stage,  on  auscultation, 
sometimes  indeed  on  palpation,  a  dry  friction  rub  can  be  detected.  The  fever 
.rarely  rises  so  rapidly  as  in  pneumonia,  and  does  not  reach  the  same  grade. 
A  temperature  of  from  102°  to  103°  is  an  average  pyrexia.  It  may  drop  to 
normal  at  the  end  of  a  week  or  ten  days  without  the  appearance  of  any  definite 
change  in  .the  physical  signs,  or  it  may  persist  for  several  weeks.     The  tem- 


646  DISEASES  OF   THE  RESPIRATORY  SYSTEM. 

perature  of  the  affected  is  higher  than  that  of  the  sound  side.  Cough  is  an 
early  symptom  in  acute  pleurisy,  but  is  rarely  so  distressing  or  so  frequent 
as  in  pneumonia.  There  are  instances  in  which  it  is  absent.  The  expectora- 
tion is  usually  slight  in  amount,  mucoid  in  character,  and  occasionally  streaked 
with  blood. 

At  the  outset  there  may  be  dyspnoea,  due  partly  to  the  fever  and  partly 
to  the  pain  in  the  side.  Later  it  results  from  the  compression  of  the  lung, 
particularly  if  the  exudation  has  taken  place  rapidly.  When,  however,  the 
fluid  is  effused  slowly,  one  lung  may  be  entirely  compressed  without  inducing 
shortness  of  breath,  except  on  exertion,  and  the  patient  will  lie  quietly  in  bed 
without  evincing  the  slightest  respiratory  distress.  When  the  effusion  is  large 
the  patient  usually  prefers  to  lie  upon  the  affected  side. 

Physical  Signs. — Inspection  shows  some  degree  of  immobility  on  the 
affected  side,  depending  upon  the  amount  of  exudation ;  and  in  large  effusions 
an  increase  in  volume,  which  may  appear  to  be  much  more  than  it  really 
is  as  determined  by  mensuration.  The  intercostal  depressions  are  obliterated. 
In  right-sided  effusions  the  apex  beat  may  be  lifted  to  the  fourth  interspace 
or  be  pushed  beyond  the  left  nipple,  or  may  even  be  seen  in  the  axilla.  When 
the  exudation  is  on  the  left  side,  the  heart's  impulse  may  not  be  visible;  but 
if  the  effusion  is  large  it  is  seen  in  the  third  and  fourth  spaces  on  the  right 
side,  and  sometimes  as  far  out  as  the  nipple,  or  even  beyond  it. 

Palpation  enables  us  more  successfully  to  determine  the  deficient  move- 
ments on  the  affected  side,  and  the  obliteration  of  the  intercostal  spaces,  and 
more  accurately  to  define  the  position  of  the  heart's  impulse.  In  simple  sero- 
fibrinous effusion  there  is  rarely  any  cfidema  of  the  chest  walls.  It  is  scarcely 
ever  possible  to  obtain  fluctuation.  Tactile  fremitus  is  greatly  diminished  or 
abolished.  If  the  effusion  is  slight  there  may  be  only  enfeeblement.  The 
absence  of  the  voice  vibrations  in  effusions  of  any  size  constitutes  one  of  the 
most  valuable  of  physical  signs.  In  children  there  may  be  much  effusion  with 
retention  of  fremitus.  In  rare  cases  the  vibrations  may  be  communicated  to 
the  chest  walls  through  localized  pleural  adhesions. 

Mensuration. — With  the  cyrtometer,  if  the  effusion  is  excessive,  a  differ- 
ence of  from  half  an  inch  to  an  inch,  or  even,  in  large  effusions,  an  inch  and 
a  half,  may  be  found  between  the  two  sides.  Allowance  must  be  made  for  the 
fact  that  the  right  side  is  naturally  larger  than  the  left.  With  the  saddle-tape 
the  difference  in  expansion  between  the  two  sides  can  be  conveniently  measured. 

Percussion. — Early  in  the  disease,  there  may  be  no  alteration  in  the  note, 
but  vsdth  the  gradual  accumulation  of  the  fluid  the  resonance  becomes  defec- 
tive, and  finally  gives  place  to  absolute  flatness.  From  day  to  day  the  gradual 
increase  in  height  of  the  fluid  may  be  studied.  In  a  pleuritic  effusion 
rising  to  the  fourth  rib  in  front,  the  percussion  signs  are  usually  very  sug- 
gestive. In  the  subclavicular  region  the  attention  is  often  aroused  at  once 
by  a  tympanitic  note,  the  so-called  Skoda's  resonance,  which  is  heard  perhaps 
more  commonly  in  this  situation  with  pleural  effusion  than  in  any  other  con- 
dition. It  shades  insensibly  into  a  flat  note  in  the  lower  mammary  and 
axillary  regions.  Skoda's  resonance  may  be  obtained  also  behind,  just  above 
the  limit  of  effusion.  The  dulness  has  a  peculiarly  resistant,  wooden  quality, 
differing  from  that  of  pneumonia  and  readily  recognized  by  skilled  fingers. 
It  has  long  been  known  that  when  the  patient  is  in  the  erect  posture  the 


DISEASES  OF  THE  PLEURA.  647 

upper  line  of  diilness  is  not  horizontal,  but  is  higher  behind  than  it  is  in  front, 
forming  a  parabola.  The  curve  marking  the  intersection  of  the  plane  of  con- 
tact of  lung  and  fluid  with  the  chest  wall  is  known  as  "  Ellis's  line  of  flat- 
ness," which  Garland  has  verified  clinically  and  by  animal  experiments.  With 
medium-sized  effusions  this  line  begins  lowest  behind,  advances  upward  and 
forward  in  a  letter- S  curve  to  the  axillary  region,  whence  it  proceeds  in  a 
straight  decline  to  the  sternum.  This  curve  is  demonstrable  only  wheii  the 
patient  is  in  the  erect  position.  Grocco,  in  1902,  called  attention  to  the  ex- 
istence in  pleural  effusion  of  a  triangular  area  of  relative  dulness,  along  the 
spine,  on  the  side  opposite  to  the  pleurisy,  in  width  from  2  to  5  cm.,  and 
with  the  apex  upward.  It  can  be  demonstrated  in  a  large  majority  of  all 
cases,  particularly  in  the  young  and  in  thin  persons.  It  is  due  to  the  bulg- 
ing of  the  mediastinum,  by  the  fluid,  across  the  middle  line,  the  anatomical 
possibility  of  which  has  been  pointed  out  by  Calvert. 

On  the  right  side  the  dulness  passes  without  change  into  that  of  the  liver. 
On  the  left  side  in  the  nipple  line  it  extends  to  and  may  obliterate  Traube's 
semilunar  space.  If  the  effusion  is  moderate,  the  phenomenon  of  movable 
dulness  may  be  obtained  by  marking  carefully,  in  the  sitting  posture,  the  upper 
limit  in  the  mammary  region,  and  then  in  the  recumbent  posture,  noting  the 
change  in  the  height  of  dulness.  This  infallible  sign  of  fluid  can  not  always 
be  obtained.  In  very  copious  exudation  the  dulness  may  reach  the  clavicle 
and  even  extend  beyond  the  sternal  margin  of  the  opposite  side. 

Auscultation. — Early  in  the  disease  a  friction  rub  can  usually  be  heard, 
which  disappears  as  the  fluid  accumulates.  It  is  a  to-and-fro  dry  rub,  close 
to  the  ear,  and  has  a  leathery,  creaking  character.  There  is  another  pleural 
friction  sound  which  closely  resembles,  and  is  scarcely  to  be  distinguished 
from,  the  fine  crackling  crepitus  of  pneumonia.  This  may  be  heard  at  the 
commencement  of  the  disease,  and  also,  as  pointed  out  in  1844  by  Mac- 
Donnell,  Sr.,  of  Montreal,  when  the  effusion  has  receded  and  the  pleural  layers 
come  together  again. 

With  even  a  slight  exudation  there  is  weakened  or  distant  breathing. 
Often  inspiration  and  expiration  are  distinctly  audible,  though  distant,  and 
have  a  tubular  quality.  Sometimes  only  a  puffing  tubular  expiration  is  heard, 
which  may  have  a  metallic  or  amphoric  quality.  Loud  resonant  rales  accom- 
panying this  may  forcibly  suggest  a  cavity.  These  pseudo-cavernous  signs  are 
met  with  more  frequently  in  children,  and  often  lead  to  error  in  diagnosis. 
Above  the  line  of  dulness  the  breath-sounds  are  usually  harsh  and  exaggerated, 
and  may  have  a  tubular  quality. 

The  vocal  resonance  is  usually  diminished  or  absent.  The  whispered 
voice  is  said  to  be  transmitted  through  a  serous  and  not  through  a  purulent 
exudate  (Baccelli's  sign).  This  author  advises  direct  auscultation  in  the 
antero-lateral  region  of  the  chest.  There  may,  however,  be  intensification — 
bronchophony.  The  voice  sometimes  has  a  curious  nasal,  squeaking  character, 
which  was  termed  by  Laennec  cegophony,  from  its  supposed  resemblance  to  the 
bleating  of  a  goat.  In  typical  form  this  is  not  common,  but  it  is  by  no  means 
rare  to  hear  a  curious  twang-like  quality  in  the  voice,  particularly  at  the  outer 
angle  of  the  scapula. 

In  the  examination  of  the  heart  in  cases  of  pleuritic  effusion  it  is  well 
to  bear  in  mind  that  when  the  apex  of  the  heart  lies  beneath  the  sternum 


648  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

there  may  be  no  impulse.  The  determination  of  the  situation  of  the  organ 
may  rest  with  the  position  of  maximum  loudness  of  the  sounds.  Over  the 
displaced  organ  a  systolic  murmur  may  be  heard.  When  the  lappet  of  lung 
over  the  pericardium  is  involved  on  either  side  there  may  be  a  pleuro-peri- 
cardial  friction.  Emerson  has  looked  over  for  me  the  histories  of  89  cases 
of  acute  pleurisy  with  effusion  in  which  the  blood  counts  were  made  before 
the  temperature  reached  normal.  Only  26  had  a  leucocytosis  between  10,000 
and  15,000;  one  only  above  15,000.  In  12  of  the  cases  the  count  was  below 
5,000.  ' 

Course. — The  course  of  acute  sero-iibrinous  pleurisy  is  very  variable.  After 
persisting  for  a  week  or  ten  days  the  fever  subsides,  the  cough  and  pain  dis- 
appear, and  a  slight  effusion  may  be  quickly  absorbed.  In  cases  in  which 
the  effusion  reaches  as  high  as  the  fourth  rib  recovery  is  usually  slower. 
Many  instances  come  under  observation  for  the  first  time,  after  two  or  three 
weeks'  indisposition,  with  the  fluid  at  a  level  with  the  clavicle.  The  fever 
may  last  from  ten  to  twenty  days  without  exciting  anxiety,  though,  as  a  rule, 
in  ordinary  pleurisy  from  cold,  as  we  say,  the  temperature  in  cases  of  moderate 
severity  is  normal  within  eight  or  ten  days.  Left  to  itself  the  natilral  tend- 
ency is  to  resorption;  but  this  may  take  place  very  slowly.  With  the  absorp- 
tion of  the  fluid  there  is  a  redux-f  riction  crepitus,  either  leathery  and  creaking 
or  crackling  and  rale-like,  and  for  months,  or  even  longer,  the  defective  reso- 
nance and  feeble  breathing  are  heard  at  the  base.  Eare  modes  of  termination 
are  perforation  and  discharge  through  the  lung,  and  externally  through  the 
chest  wall,  examples  of  which  have  been  recorded  by  Sahli. 

The  immediate  prognosis  in  pleurisy  with  effusion  is  good.  Of  320  cases 
at  St.  Bartholomew's  Hospital,  only  6.1  per  cent  died  before  leaving  the  hos- 
pital (Hedges). 

A  sero-fibrinous  exudate  may  persist  for  months  without  change,  particu- 
larly in  tuberculous  cases,  and  will  sometimes  reaccumulate  after  aspiration 
and  resist  all  treatment.  After  persistence  for  more  than  twelve  months,  in 
spite  of  repeated  tapping,  a  serous  effusion  was  cured  by  incision  without 
deformity  of  the  chest  (S.  West).  When  one  pleura  is  full  and  the  heart 
is  greatly  dislocated,  the  condition,  although  in  a  majority  of  cases  producing 
remarkably  little  disturbance,  is  not  without  risk.  Sudden  death  may  occur, 
and  its  possibility  under  these  circumstances  should  always  be  considered.  I 
have  seen  two  instances — one  in  right  and  the  other  in  left  sided  effusion — 
both  due,  apparently,  to  syncope  following  slight  exertion,  such  as  getting 
out  of  bed.  In  neither  case,  however,  was  the  amount  of  fluid  excessive.  Weil, 
who  has  studied  carefully  this  accident,  concludes  as  follows:  (1)  That  it  may 
be  due  to  thrombosis  or  embolism  of  the  heart  or  pulmonary  artery,  oedema  of 
the  opposite  lung,  or  degeneration  of  the  heart  muscle;  (2)  such  alleged  causes 
as  mechanical  impediment  to  the  circulation,  owing  to  dislocation  of  the  heart 
or  twisting  of  the  great  vessels,  require  further  investigation.  Death  may 
occur  without  any  premonitory  symptoms. 

III.  Purulent  Pleueist  (Empyema). 

Etiology. — Pus  in  the  pleura  is  due  to  (a)  infection  from  within,  as  a 
rule  directly  from  a  patch  of  pneumonia  or  a  septic  focus  due  to  the  pneumo- 
coccus  or  the  pus  organisms,  in  some  cases  a  tuberculous  broncho-pneumonia; 


DISEASES  OF   THE  PLEURA.  649 

(6)  involvement  from  without,  as  in  fracture  of  a  rib,  penetrating  wound, 
disease  of  oesophagus,  etc. 

It  frequently  follows  the  infectious  diseases,  particularly  scarlet  fever.  It 
is  very  often  latent,  and  due  to  undiscovered  foci  of  lobar  or  lobular  pneu- 
monia. It  is  common  in  children,  more  in  boys  than  in  girls  and  between 
the  ages  of  one  and  five  and  eight  and  nine  (Bythell). 

The  pneumococcus  is  the  most  common  organism,  then  the  ordinary  pus 
organisms  and  the  tubercle  bacilli.  The  pneumococcus  has  been  found  and  in 
rare  cases  the  influenza  bacillus,  and  even  psorosperms. 

Morbid  Anatomy. — On  opening  an  empyema  post  mortem,  we  usually  find 
that  the  effusion  has  separated  into  a  clear,  greenish-yellow  serum  above  and 
the  thick,  cream-like  pus  below.  The  fluid  may  be  scarcely  more  than  turbid, 
with  flocculi  of  fibrin  through  it.  In  the  pneumococcus  empyema  the  pus  is 
usually  thick  and  creamy.  It  usually  has  a  heavy,  sweetish  odor,  but  in  some 
instances — ^particularly  those  following  wounds — it  is  fetid.  In  cases  of  gan- 
grene of  the  lung  or  pleura  the  pus  has  a  horribly  stinking  odor.  Microscop- 
ically it  has  the  characters  of  ordinary  pus.  The  pleural  membranes  are  greatly 
thickened,  and  present  a  grayish-white  layer  from  1  to  2  mm.  in  thickness.  On 
the  costal  pleura  there  may  be  erosions,  and  in  old  cases  fistulous  communica- 
tions are  common.  The  lung  may  be  compressed  to  a  very  small  limit,  and  the 
visceral  pleura  also  may  show  perforations. 

Symptoms. — Purulent  pleurisy  may  begin  abruptly,  with  the  symptoms 
already  described.  More  frequently  it  comes  on  insidiously  in  the  course  of 
other  diseases  or  follows  an  ordinary  sero-fibrinous  pleurisy.  There  may  be  no 
pain  in  the  chest,  very  little  cough,  and  no  dyspnoea,  unless  the  side  is  very  full. 
Symptoms  of  septic  infection  are  rarely  wanting.  If  in  a  child,  there  is  a  grad- 
ually developing  pallor  and  weakness ;  sweats  occur,  and  there  is  irregular  fever. 
A  cough  is  by  no  means  constant.  The  leucocytes  are  usually  much  increased ; 
in  one  fatal  case  they  numbered  115,000  per  cubic  millimetre. 

Physical  Signs. — Practically  they  are  those  already  considered  in  pleu- 
risy with  effusion.  There  are,  however,  one  or  two  additional  points  to  be  men- 
tioned. In  empyema,  particularly  in  children,  the  disproportion  between  the 
sides  may  be  extreme.  The  intercostal  spaces  may  not  only  be  obliterated,  but 
may  bulge.  ISTot  infrequently  there  is  oedema  of  the  chest  walls.  The  network 
of  subcutaneous  veins  may  be  very  distinct.  It  must  not  be  forgotten  that  in 
children  the  breath-sounds  may  be  loud  and  tubular  over  a  purulent  effusion 
of  considerable  size.  Whispered  pectoriloquy  is  usually  not  heard  in  empyema 
(Baccelli's  sign).  The  dislocation  of  the  heart  and  the  displacement  of  the 
liver  are  more  marked  in  empyema  than  in  sero-fibrinous  effusion — probably,  as 
Senator  suggests,  owing  to  the  greater  weight  of  the  fluid. 

A  curious  phenomenon  associated  generally  with  empyema,  but  sometimes 
occurring  in  the  sero-fibrinous  exudate,  is  pulsating  pleurisy^,  first  described  by 
MacDonnell,  Sr.,  of  Montreal.  In  95  cases  collected  by  Sailer  it  was  much 
more  frequent  in  males  than  in  females.  In  38  there  was  a  tumor;  that  is, 
empyema  necessitatis.  In  all  but  one  case  the  fluid  was  purulent.  Pneumo- 
thorax may  be  present.  There  are  two  groups  of  cases,  the  intrapleural  pul- 
sating pleurisy  and  the  pulsating  empyema  necessitatis,  in  which  there  is  an 
external  pulsating  tumor.  No  satisfactory  explanation  has  been  offered  how 
the  heart  impulse  is  thus  forcibly  communicated  through  the  effusion. 


650  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

Empyema  is  a  chronic  affection,  which  in  a  few  instances  terminates  natu- 
rally in  recovery,  but  a  majority  of  cases,  if  left  alone,  end  in  death.  The  fol- 
lowing are  some  modes  of  natural  cure:  (a)  By  absorption  of  the  fluid.  In 
small  effusions  this  may  take  place  gradually.  The  chest  wall  sinks.  The 
pleural  layers  become  greatly  thickened  and  enclose  between  them  the  inspis- 
sated pus,  in  which  lime  salts  are  gradually  deposited.  Such  a  condition  may 
be  seen  once  or  twice  a  year  in  the  post-mortem  room  of  any  large  hospital. 
(&)  By  perforation  of  the  lung.  Although  in  this  event  death  may  take  place 
rapidl}^,  by  suffocation,  as  Aretseus  says,  yet  in  cases  in  which  it  occurs  grad- 
ually recovery  may  follow.  Since  1873,  when  I  saw  a  case  of  this  kind  in 
Traube's  clinic,  and  heard  his  remarks  on  the  subject,  I  have  seen  a  number 
of  instances  of  the  kind  and  can  corroborate  his  statement  as  to  the  favorable 
termination  of  many  of  them.  Empyema  may  discharge  either  by  opening  into 
the  bronchus  and  forming  a  fistula,  or,  as  Traube  pointed  out,  by  producing 
necrosis  of  the  pulmonary  pleura,  sufficient  to  allow  the  soaking  of  the  pus 
through  the  spongy  lung  tissue  into  the  bronchi.  In  the  first  way  pneumo- 
thorax usually,  though  not  always,  develops.  In  the  second  way  the  pus  is 
discharged,  without  formation  of  pneumothorax.  Even  with  a  bronchial  fistula 
recovery  is  possible,  (c)  By  perforation  of  the  chest  wall — empyema  necessi- 
tatis. This  is  by  no  means  an  unfavorable  method,  as  many  cases  recover.  The 
perforation  may  occur  an^'where  in  the  chest  wall,  but  is,  as  Cruveilhier  re- 
marked, more  common  in  front.  It  may  be  am-^'here  from  the  third  to  the 
sixth  interspace,  usuaUy,  according  to  Marshall,  in  the  fifth.  It  may  perforate 
in  more  than  one  place,  and  there  may  be  a  fistulous  communication  which 
opens  into  the  pleura  at  some  distance  from  the  external  orifice.  The  tumor, 
when  near  the  heart,  may  pulsate.  The  discharge  may  persist  for  years.  In 
Copeland's  Dictionary  is  mentioned  an  instance  of  a  Bavarian  physician  who 
had  a  pleural  fistula  for  thirteen  years  and  enjoyed  fairly  good  health. 

An  empyema  may  perforate  the  neighboring  organs,  the  oesophagus,  peri- 
tonseum,  pericardium,  or  the  stomach.  A  remarkable  sequel  is  a  pleuro-cesoph- 
ageal  fistula,  of  which  cases  have  been  reported  by  A^oelcker,  Thursfield,  and 
myself.  In  my  case  there  was  a  fistulous  communication  through  the  chest 
wall.  Very  remarkable  cases  are  those  which  pass  down  the  spine  and  along 
the  psoas  into  the  iliac  fossa,  and  simulate  a  psoas  or  lumbar  abscess. 

IV.  Tuberculous  Pleurisy. 

This  has  already  been  considered  (p.  308),  and  the  symptoms  and  physical 
signs  do  not  require  any  description  other  than  that  already  given  in  connec- 
tion with  the  sero-fibrinous  and  purulent  forms. 

V.  Other  A^arieties  of  Pleueisy. 

Haemorrhagic  Pleurisy. — A  bloody  effusion  is  met  with  under  the  follow- 
ing conditions:  {a)  In  the  pleurisy  of  asthenic  states,  such  as  cancer,  Brighfs 
disease,  and  occasionally  in  the  malignant  fevers.  It  is  interesting  to  note  the 
frequency  with  which  hajmorrhagic  pleurisy  is  found  in  cirrhosis  of  the  liver. 
It  occurred  in  the  very  patient  in  whom  Laennec  first  accurately  described 
this  disease.  While  this  may  be  a  simple  ha?morrhagic  pleurisy,  in  a  majority 
of  the  cases  which  I  have  seen  it  has  been  tuberculous.     (6)  Tuberculous  pleu- 


DISEASES  OF  THE  PLEURA.  651 

risy,  in  which  the  bloody  effusion  may  result  from  the  rupture  of  newly  formed 
vessels  in  the  soft  exudate  accompanying  the  eruption  of  miliary  tubercles,  or 
it  may  come  from  more  slowly  formed  tubercles  in  a  pleurisy  secondary  to 
extensive  pulmonary  disease,  (c)  Cancerous  pleurisy,  whether  primary  or  sec- 
ondary, is  frequently  hsemorrhagic.  (d)  Occasionally  hsemorrhagic  exudation 
is  met  with  in  perfectly  healthy  individuals,  in  whom  there  is  not  the  slight- 
est suspicion  of  tuberculosis  or  cancer.  In  one  such  case,  a  large,  able-bodied 
man,  the  patient  was  to  my  knowledge  healthy  and  strong  eight  years  after- 
ward. And,  lastly,  it  must  be  remembered  that  during  aspiration  the  lung 
may  be  wounded  and  blood  in  this  way  get  mixed  with  the  sero-fibrinous  exu- 
date. The  condition  of  haBmorrhagic  pleurisy  is  to  be  distinguished  from 
hsemothorax,  due  to  the  rupture  of  aneurism  or  the  pressure  of  a  tumor  on  the 
thoracic  veins. 

Diaphragmatic  Pleurisy. — The  inflammation  may  be  limited  partly  or 
chiefly  to  the  diaphragmatic  surface.  This  is  often  a  dry  pleurisy,  but  there 
may  be  effusion,  either  sero-fibrinous  or  purulent,  which  is  circumscribed  on 
the  diaphragmatic  surface.  In  these  cases  the  pain  is  low  in  the  zone  of  the 
diaphragm  and  may  simulate  that  of  acute  abdominal  disease.  It  may  be 
intensified  by  pressure  at  the  point  of  insertion  of  the  diaphragm  at  the  tenth 
rib.  The  diaphragm  is  fixed  and  the  respiration  is  thoracic  and  short.  Andral 
noted  in  certain  cases  severe  dyspnoea  and  attacks  simulating  angina.  As 
mentioned,  the  effusion  is  usually  plastic,  not  serous.  Serous  or  purulent  effu- 
sions of  any  size  limited  to  the  diaphragmatic  surface  are  extremely  rare. 
Intense  subjective  with  trifling  objective  features  are  always  suggestive  of  dia- 
phragmatic pleurisy. 

Encysted  Pleurisy. — The  effusion  may  be  circumscribed  by  adhesions  or 
separated  into  two  or  more  pockets  or  loculi,  which  communicate  with  each 
other.  This  is  most  common  in  empyema.  In  these  cases  there  have  usu- 
ally been,  at  different  parts  of  the  pleura,  multiple  adhesions  by  which  the 
fluid  is  limited.  In  other  instances  the  recent  false  membranes  may  encapsu- 
late the  exudation  on  the  diaphragmatic  surface,  for  example,  or  the  part  of 
the  pleura  posterior  to  the  mid-axillary  line.  The  condition  may  be  very  puz- 
zling during  life,  and  present  special  difficulties  in  diagnosis.  In  some  cases 
the  tactile  fremitus  is  retained  along  certain  lines  of  adhesion.  The  explora- 
tory needle  should  be  freely  used. 

Interlobar  Pleurisy  forms  an  interesting  and  not  uncommon  variety.  In 
nearly  every  instance  of  acute  pleurisy  the  interlobar  serous  surfaces  are  also 
involved  and  closely  agglutinated  together,  and  sometimes  the  fluid  is  encysted 
between  them.  In  this  position  tubercles  are  to  be  carefully  looked  for.  In 
a  case  of  this  kind  following  pneumonia  there  was  between  the  lower  and 
upper  and  middle  lobes  of  the  right  side  an  enormous  purulent  collection, 
which  looked  at  first  like  a  large  abscess  of  the  lung.  These  collections  may 
perforate  the  bronchi^  and  the  cases  present  special  difficulties  in  diagnosis. 

Diagnosis  of  Pleurisy. 

Acute  plastic  pleurisy  is  readily  recognized.  In  the  diagnosis  of  pleu- 
ritic effusion  the  first  question  is.  Does  a  fluid  exudate  exist  ?  the  second.  What 
is  its  nature?  In  large  effusions  the  increase  in  the  size  of  the  affected  side, 
the  immobility,  the  absence  of  tactile  fremitus,  together  with  the  displace- 


652  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

ment  of  organs,  give  infallible  indications  of  the  presence  of  fluid.  The  chief 
difficulty  arises  in  effusions  of  moderate  extent,  when  the  dulness,  the  pres- 
ence of  bronchophon}^,  and,  perhaps,  tubular  breathing  may  simulate  pneu- 
monia. The  chief  points  to  be  borne  in  mind  are :  (a)  Differences  in  the  onset 
and  in  the  general  characters  of  the  two  affections,  more  particularly  the 
initial  chill,  the  higher  fevei,  more  urgent  dyspnoea,  and  the  rusty  expectora- 
tion, which  characterize  pneumonia.  As  already  mentioned,  some  of  the  cases 
of  pneumococcus  pleurisy  set  in  like  pneumonia,  (h)  Certain  physical  signs 
. — the  more  wooden  character  of  the  dulness,  the  greater  resistance,  and  the 
marked  diminution  or  the  absence  of  tactile  fremitus  in  pleurisy.  The  aus- 
cultatory signs  may  be  deceptive.  It  is  usually,  indeed,  the  persistence  of 
tubular  breathing,  particularly  the  high-pitched,  even  amphoric  expiration, 
heard  in  some  cases  of  pleurisy,  which  has  raised  the  doubt.  The  intercostal 
spaces  are  more  commonly  obliterated  in  pleuritic  effusion  than  in  pneumonia. 
As  already  mentioned,  the  displacement  of  organs  is  a  very  valuable  sign. 
Nowadays  with  the  hypodermic  needle  the  question  is  easily  settled.  A  sepa- 
rate small  syringe  with  a  capacity  of  two  drachms  should  be  reserved  for 
exploratory  purposes,  and  the  needle  should  be  longer  and  firmer  than  in  the 
ordinary  hypodermic  instrument.  With  careful  preliminary  disinfection  the 
instrument  can  be  used  with  impunity,  and  in  cases  of  doubt  the  exploratory 
puncture  should  be  made  without  hesitation.  Pneumothorax  is  an  occasional 
sequence.  The  hypodermic  needle  is  especially  useful  in  those  eases  in  which 
there  are  pseudo-cavernous  signs  at  the  base.  In  cases,  too,  of  massive  pneu- 
monia, in  which  the  bronchi  are  plugged  with  fibrin,  if  the  patient  has  not 
been  seen  from  the  outset,  the  diagnosis  may  be  impossible  without  it. 

On  the  left  side  it  may  be  difficult  to  differentiate  a  very  large  .pericardial 
from  a  pleural  effusion.  The  retention  of  resonance  at  the  base,  the  presence 
of  Skoda's  resonance  toward  the  axilla,  the  absence  of  dislocation  of  the  heart- 
beat to  the  right  of  the  sternum,  the  feebleness  of  the  pulse  and  of  the  heart- 
sounds,  and  the  urgency  of  the  dyspnoea,  out  of  all  proportion  to  the  extent 
of  the  effusion,  are  the  chief  points  to  be  considered.  Unilateral  hydrothorax, 
which  is  not  at  all  uncommon  in  heart-disease,  presents  signs  identical  with 
those  of  sero-fibrinous  effusion.  Certain  tumors  -within  the  chest  may  simu- 
late pleural  effusion.  It  should  be  remembered  that  many  intrathoracic 
growths  are  accompanied  by  exudation.  Malignant  disease  of  the  lung  and 
of  the  pleura  and  hydatids  of  the  pleura  produce  extensive  dulness,  with  sup- 
pression of  the  breath-sounds,  simulating  closely  effusion. 

On  the  right  side,  abscess  of  the  liver  and  Iwdatid  cysts  may  rise  high  into 
the  pleura  and  produce  dulness  and  enfeebled  breathing.  Often  in  these  cases 
there  is  a  friction  sound,  which  should  excite  suspicion,  and  the  upper  outline 
of  the  dulness  is  sometimes  plainly  convex.  In  a  case  of  cancer  of  the  kidney 
the  growth  involved  the  diaphragm  very  early,  and  for  months  there  were  signs 
of  pleurisy  before  our  attention  was  directed  to  the  kidney.  In  all  these 
instances  the  exploratory  puncture  should  be  made. 

The  second  question,  as  to  the  nature  of  the  fluid,  is  quickly  decided  by 
the  use  of  the  needle.  The  persistent  fever,  the  occurrence  of  sweats,  a  leuco- 
cytosis,  and  the  increase  in  the  pallor  suggest  the  presence  of  pus.  In  chil- 
dren the  complexion  is  often  sallow  and  earthy.  In  protracted  cases,  even  in 
children,  when  the  general  symptoms  and  the  appearance  of  the  patient  have 


.       DISEASES  OF  THE  PLEURA.  653 

been  most  strongly  suggestive  of  pus,  the  syringe  has  withdrawn  clear  fluid. 
On  the  other  hand,  effusions  of  short  duration  may  be  purulent,  even  when 
the  general  symptoms  do  not  suggest  it.  The  following  statement  may  be 
made  with  reference  to  the  prognostic  import  of  the  bacteriological  examina- 
tion of  the  aspirated  fluid :  The  presence  of  the  pneumococcus  is  of  favorable 
significance,  as  such  cases  usually  get  well  rapidly,  even  with  a  single  aspira- 
tion. The  streptococcus  empyema  is  the  most  serious  form,  and  even  after  a 
free  drainage  the  patient  may  succumb  to  a  general  septicaemia.  A  sterile  fluid 
indicates  in  a  majority  of  instances  a  tuberculous  origin. 

Treatment. 

At  the  onset  the  severe  pain  may  demand  leeches,  which  usually  give  relief, 
but  a  hypodermic  of  morphia  is  more  effective.  The  Paquelin  cautery  may  be 
lightly  but  freely  applied.  It  is  well  to  administer  a  mercurial  or  saline  purge. 
Fixing  the  side  by  careful  strapping  with  long  strips  of  adhesive  plaster,  which 
should  pass  well  over  the  middle  line,  drawn  tightly  and  evenly,  gives  great 
relief,  and  I  can  corroborate  the  statement  of  F.  T.  Eoberts  as  to  its  efficacy. 
Cupping,  wet  or  dry,  is  now  seldom  employed.  Blisters  are  of  no  special  service 
in  the  acute  stages,  although  they  relieve  the  pain.  The  ice-bag  may  be  used 
as  in  pneumonia.  The  open-air  treatment  should  be  begun  early,  as  a  majority 
of  the  cases  are  tuberculous.  Medicines  are  rarely  required.  A  Dover's  pow- 
der may  be  given  at  night.    Mercurials  are  not  indicated. 

When  the  effusion  has  taken  place,  mustard  plasters  or  iodine,  producing 
slight  counter-irritation,  appear  useful,  particularly  in  the  later  stages.  Iodide 
of  potassium  is  of  doubtful  benefit.  By  some  the  salicylates  are  believed  to  be 
of  special  efficacy;  but  the  drug  treatment  of  the  disease  is  most  unsatisfac- 
tory. The  dry  diet  and  frequent  saline  purges  (given  in  concentrated  form 
before  breakfast  in  Hay's  method)  may  be  tried.  Recently  it  has  been  advised 
to  use  a  salt-free  diet. 

Early  and  if  necessary  repeated  aspiration  of  the  fluid  is  the  most  satis- 
factory method  of  treatment.  The  results  obtained  by  Delafield  in  300  cases 
treated  by  early  aspiration  (Am.  Jour,  of  the  Medical  Sciences,  1900)  have 
never  been  equalled  by  any  other  method.  The  credit  of  introducing  aspira- 
tion in  pleuritic  effusions  is  due  to  Morrill  Wyman,  of  Cambridge,  Mass.,  and 
Henry  I.  Bowditch,  of  Boston.  Years  prior  to  Dieulaf  oy's  work,  aspiration  was 
in  constant  use  at  the  Massachusetts  General  Hospital  and  was  advocated 
repeatedly  by  Bowditch.  As  the  question  is  one  of  some  historical  interest,  I 
give  Bowditch's  conclusions  concerning  aspiration,  expressed  more  than  fifty- 
five  years  ago,  and  which  practically  represent  the  opinion  of  to-day:  "  (1) 
The  operation  is  perfectly  simple,  but  slightly  painful,  and  can  be  done  with 
ease  upon  any  patient  in  however  advanced  a  stage  of  the  disease.  (3)  It 
should  be  performed  forthwith  in  all  cases  in  which  there  is  complete  filling 
up  of  one  side  of  the  chest.  (3)  He  had  determined  to  use  it  in  any  case  of 
even  moderate  effusion  lasting  more  than  a  few  weeks  and  in  which  there 
should  seem  to  be  a  disposition  to  resist  ordinary  modes  of  treatment.  (4) 
He  urged  this  practice  upon  the  profession  as  a  very  important  measure  in 
practical  medicine;  believing  that  by  this  method  death  may  frequently  be 
prevented  from  ensuing  either  by  sudden  attack  of  dyspnoea  or  subsequent 
phthisis,  and,  finally,  from  the  gradual  wearing  out  of  the  powers  of  life  or 


654  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

inability  to  absorb  the  fluid.''  When  the  fluid  reaches  to  tlie  clavicle  the  indi- 
cation for  aspiration  is  imperative.  Fever  is  not  a  contra-indication ;  indeed, 
sometimes  with  serous  exudates  the  temperature  falls  after  aspiration. 

The  operation  is  extremely  simple  and  is  practically. without  risk.  The  spot 
selected  for  puncture  should  be  either  in  the  seventh  intercostal  space  in 
the  mid-axilla  or  at  the  outer  angle  of  the  scapula  in  the  eighth  space.  The 
arm  of  the  patient  should  be  brought  forward  with  the  hand  on  the  opposite 
shoulder,  so  as  to  widen  the  spaces.  The  needle  should  be  thrust  in  close  to 
the  upper  margin  of  the  rib,  so  as  to  avoid  the  intercostal  artery,  the  wound- 
ing of  which,  however,  is  an  exceedingly  rare  accident.  The  fluid  should  be 
withdrawn  slowly.  The  amount  will  depend  on  the  size  of  the  exudate.  If  the 
fluid  reaches  to  the  clavicle  a  litre  or  more  may  be  withdrawn  with  safety.  In 
chronic  cases  of  serous  pleurisy  after  the  failure  of  rejoeated  tappings  S.  West 
has  shown  the  great  value  of  free  incision  and  drainage.  He  has  reported 
cases  of  recovery  after  effusions  of  fifteen  and  eighteen  months'  standing. 

Symptoms  and  Accidexts  during  Paracentesis. — Pain  is  usually  com- 
plained of  after  a  certain  amount  of  fluid  has  been  withdrawn ;  it  is  sharp  and 
cutting  in  character.  Coughing  occurs  toward  the  close,  and  may  be  severe 
and  paroxysmal.  Pneumothorax  may  follow  an  exploratory  puncture  with  a 
hypodermic  needle;  it  is  rare  during  aspiration.  Subcutaneous  emphysema 
may  develop  from  the  point  of  puncture,  without  the  production  of  pneumo- 
thorax. Ceredral  symptoms. — Paintness  is  not  uncommon.  Epileptic  con- 
Milsions  may  occur  either  during  the  withdrawal  or  while  irrigating  the  pleura. 
These  s3Tnptoms  are  very  difficult  to  explain  and  are  regarded  by  most  authors 
as  of  reflex  origin.  Hemiplegia  may  follow.  And  lastl}'  sudden  death  may 
occur  either  from  sjmcope  or  during  the  convulsions. 

As  A.  E.  Eussell  has  pointed  out,  these  serious  and  even  fatal  events  may 
follow  exploratory  puncture  of  the  lung.  Such  accidents  of  paracentesis  and 
of  washing  out  the  pleura  are  explained  by  the  studies  of  Capp  and  Lewis,  who 
have  shown  that  a  sudden  and  sometimes  fatal  fall  in  blood-pressure  may  fol- 
low the  experimental  irrigation  of  the  pleura  in  dogs.  Expectoration  of  a 
large  quantity  of  alhuminous  fuid  may  occur  suddenly  after  the  tapping,  asso- 
ciated with  dyspnoBa.  Some  cases  have  proved  rapidly  fatal,  with  the  features 
of  an  acute  oedema  of  the  lungs.     It  has  occurred  only  once  in  my  practice. 

Empyema  is  really  a  surgical  affection,  and  I  shall  make  only  a  few  gen- 
eral remarks  upon  its  treatment.  When  it  has  been  determined  by  explora- 
tory puncture  that  the  fluid  is  purulent,  aspiration  should  not  be  performed, 
except  as  preliminary  to  operation  or  as  a  temporary  measure.  Perhaps  it  is 
better  not  to  have  an  exception  to  this  rule,  although  the  empyemas  of  children 
and  the  pneumonic  empyema  occasionally  get  well  rapidly  after  a  single  tap- 
ping. It  is  sad  to  think  of  the  number  of  lives  which  are  sacrificed  annually 
by  the  failure  to  recognize  that  empyema  should  be  treated  as  an  ordinary 
abscess,  by  free  incision.  The  operation  dates  from  the  time  of  Hippocrates 
and  is  b}^  no  means  serious.  A  majority  of  the  cases  get  well,  provided  that 
free  drainage  is  obtained,  and  it  makes  no  difference  practically  what  measures 
are  followed  so  long  as  this  indication  is  met.  The  good  results  in  any  method 
depend  upon  the  thoroughness  with  which  the  cavity  is  drained.  Irrigation  of 
tlie  cavity  is  rarely  necessary  unless  the  contents  are  fetid.  In  the  subsequent 
treatment  a  point  of  great  importance  in  facilitating  the  closure  of  the  cavity 


DISEASES  OF  THE  PLEURA.  655 

is  the  distention  of  the  lung  on  the  affected  side.  This  may  be  acconiplislied 
by  the  method  advised  by  Kalston  James,  whicli  has  been  practised  with  great 
success  in  the  surgical  wards  of  the  Johns  Hopkins  Hospital.  The  patient 
daily,  for  a  certain  length  of  time,  increasing  gradually  with  the  increase  of 
his  strength,  transfers  by  air-pressure  water  from  one  bottle  to  another.  The 
bottles  should  be  large,  holding  at  least  a  gallon  each,  and  by  the  arrangement 
of  tubes,  as  in  the  WolfE's  bottle,  an  expiratory  effort  of  the  patient  forces  the 
water  from  one  bottle  into  the  other.  Equally  efficacious  is  the  plan  advised  by 
Naunyn.  The  patient  sits  in  an  arm  chair  grasping  strongly  one  of  the  rungs 
with  the  hand  and  forcibly  compressing  the  sound  side  against  the  arm  of  the 
chair ;  then  forcible  inspiratory  efforts  are  made  which  act  chiefly  on  the  com- 
pressed lung,  as  the  sound  side  is  fixed.  The  abscess  cavity  is  gradually  closed, 
partly  by  the  falling  in  of  the  chest  wall  and  partly  by  the  expansion  of  the 
lung.  In  some  instances  it  is  necessary  to  resect  portions  of  one  or  more  ribs. 
The  physician  is  often  asked,  in  cases  of  empyema  with  emaciation,  hectic 
and  feeble  rapid  pulse,  whether  the  patient  could  stand  the  operation.  Even 
in  the  most  desperate  cases  the  surgeon  should  never  hesitate  to  make  a  free 
incision. 

II.     CHRONIC    PLEURISY. 

This  affection  occurs  in  two  forms : 

( 1 )  Chronic  pleurisy  with  effusion,  in  which  the  disease  may  set  in  insidi- 
ously or  may  follow  an  acute  sero-fibrinous  pleurisy.  There  are  cases  in  which 
the  liquid  persists  for  months  or  even  years  without  undergoing  any  special 
alteration  and  without  becoming  purulent.  Such  cases  have  the  characters 
which  we  have  described  under  pleurisy  with  effusion. 

(2)  Chronic  dry  pleurisy. — The  cases  are  met  with  (a)  as  a  sequence  of 
ordinary  pleural  effusion.  When  the  exudate  is  absorbed  and  the  layers  of  the 
pleura  come  together  there  is  left  between  them  a  variable  amount  of  fibrinous 
material  which  gradually  undergoes  organization,  and  is  converted  into  a  layer 
of  firm  connective  tissue.  This  process  goes  on  at  the  base,  and  is  represented 
clinically  by  a  slight  grade  of  flattening,  deficient  expansion,  defective  reso- 
nance on  percussion,  and  enfeebled  breathing.  After  recovery  from  empyema 
the  flattening  and  retraction  may  be  still  more  marked.  In  both  cases  it  is  a 
condition  which  can  be  greatly  benefited  by  pulmonary  gymnastics.  In  these 
firm,  fibrous  membranes  calcification  may  occur,  particularly  after  empyema. 
It  is  not  very  uncommon  to  find  between  the  false  membranes  a  small  pocket 
of  fluid  forming  a  sort  of  pleural  cyst.  In  the  great  majority  of  these  cases 
the  condition  is  one  which  need  not  cause  anxiety.  There  may  be  an  occa- 
sional dragging  pain  at  the  base  of  the  lung  or  a  stitch  in  the  side,  but  patients 
may  remain  in  perfectly  good  health  for  years.  The  most  advanced  grade  of 
this  secondary  dry  pleurisy  is  seen  in  those  cases  of  empyema  which  have  been 
left  to  themselves  and  have  perforated  and  ultimately  healed  by  a  gradual 
absorption  or  discharge  of  the  pus,  with  retraction  of  the  side  of  the  chest  and 
permanent  carnification  of  the  lung.  Traumatic  lesions,  such  as  gunshot 
wounds,  may  be  followed  by  an  identical  condition.  Post  mortem,  it  is  quite 
impossible  to  separate  the  layers  of  the  pleura,  which  are  greatly  thickened,- 
particularly  at  the  base,  and  surround  a  compressed,  airless,  fibroid  lung. 
Bronchiectasis  may  gradually  ensue,  and  in  one  remarkable  case  which  I  saw 


656  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

on  several  occasions  with  Blackader,  of  Montreal,  not  only  on  the  affected  side, 
but  also  in  the  lower  lobe  of  the  other  lung. 

(h)  Primitive  dry  pleurisy.  This  condition  may  directly  follow  the  acute 
23lastic  pleurisy  alread}'  described;  but  it  may  set  in  without  any  acute  symp- 
toms whatever,  and  the  patient's  attention  may  be  called  to  it  by  feeling  the 
pleural  friction.  A  constant  effect  of  this  primitive  dry  pleurisy  is  the  adhe- 
sion of  the  layers.  This  is  probably  an  invariable  result,  whether  the  pleurisy 
is  primary  or  secondary.  The  organization  of  the  thin  layer  of  exudation  in 
a  pneumonia  will  unite  the  two  surfaces  by  delicate  bands.  Pleural  adhesions 
are  extremel}^  common,  and  it  is  rare  to  examine  a  hodj  entirely  free  from 
them.  They  may  be  limited  in  extent  or  universal.  Thin  fibrous  adhesions  do 
not  produce  any  alteration  in  the  percussion  characters,  and,  if  limited,  there 
is  no  special  change  heard  on  auscultation.  When,  however,  there  is  general 
s}Tiechia  on  both  sides  the  expansile  movement  of  the  lung  is  considerably  im- 
paired. AYe  should  naturally  think  that  universal  adhesions  would  interfere 
materiall}'  vrith  the  function  of  the  Kmgs,  but  practically  we  see  many  instances 
in  which  there  has  not  been  the  slightest  disturbance.  The  physical  signs  of 
total  adhesion  are  by  no  means  constant.  It  has  been  stated  that  there  is  a 
marked  disproportion  between  the  degree  of  expansion  of  the  chest  walls  and 
the  intensity  of  the  vesicular  murmur,  but  the  latter  is  a  very  variable  factor, 
and  under  perfecth'  normal  conditions  the  breath-sounds,  with  verv  full  chest 
expansion,  may  be  extremely  feeble.  The  diaphragm  phenomenon — Litten's 
sign — is  absent. 

As  already  stated,  it  is  possible,  as  the  late  Sir  Andrew  Clark  held,  that 
a  primitive  dry  pleurisy  may  gradually  lead  to  great  thickening  of  the  mem- 
branes, and  ultimate  invasion  of  the  limg,  causing  a  cirrhosis. 

Lastly,  there  is  a  primitive  dry  pleurisy  of  tuljerculous  origin.  In  it  both 
parietal  and  costal  layers  are  greatly  thickened — perhaps  from  2  to  3  mm.  each 
— and  present  firm  fibroid,  caseous  masses  and  small  tubercles,  while  uniting 
these  two  greatly  thickened  layers  is  a  reddish-gray  fibroid  tissue,  sometimes 
infiltrated  with  serum.  This  may  be  a  local  process  confined  to  one  pleura, 
or  it  may  be  in  both.  These  cases  are  sometimes  associated  with  a  similar  con- 
dition in  the  pericardium  and  peritonseum. 

Occasionally  remarkable  vaso-motor  phenomena  occur  in  chronic  pleurisy, 
whether  simple  or  in  connection  with  tuberculosis  of  an  apex.  Flushing  or 
sweating  of  one  cheek  or  dilatation  of  the  pupil  are  the  common  manifesta- 
tions. They  appear  to  be  due  to  involvement  of  the  first  thoracic  ganglion  at 
the  top  of  the  pleural  cavity. 

III.     HYDROTHORAX. 

Hydrothorax  is  a  transudation  of  simple  non-inflammatory  fluid  into  the 
pleural  cavities,  and  occurs  as  a  secondary  process  in  many  affections.  The 
fluid  is  clear,  without  any  flocculi  of  fibrin,  and  the  membranes  are  smooth. 
It  is  met  with  more  particularly  in  connection  with  general  dropsy,  either 
reDiil^aj;dJ^(^jor_Ji^mic.  It  may,  however,  occur  alone,  or  with  only  slight 
cedema  of  the  feet.  A  child  was  admitted  to  the  ^lontreal  General  Hospital 
with  urgent  dyspncea  and  cyanosis,  and  died  the  night  after  admission.  She 
had  extensive  bilateral  hydrothorax,  which  had  come  on  early  in  the  nephritis 


DISEASES  OF  THE  PLEURA.  657 

of  scarlet  fever.  In  renal  disease  hjclrotliQia-^i^s  almost  always  bilateral,  but 
in  heart  affections  one  pleura  is  more  commonly  involved!  The  physical  signs 
are  those  of  pleural  effusion,  but  the  exudation  is  rarely  excessive.  In  kidney 
and  heart-disease,  even  when  there  is  no  general  dropsy,  the  occurrence  of 
dyspnoea  should  at  once  direct  attention  to  the  pleura,  since  many  patients  are 
carried  off  by  a  rapid  effusion.  In  chronic  valvular  disease  the  effusion  is  usu- 
ally on  the  right  side,  and  may  recur  for  months.  Stengel  attributes'  the 
greater  frequency  of  the  dextral  effusion  to  compression  of  the  azygos  veins. 
Post-mortem  records  show  the  frequency  with  which  this  condition  is  over- 
looked. The  saline  purges  will  in  many  cases  rapidly  reduce  the  effusion,  but, 
if  necessary,  aspiration  should  repeatedly  be  practised. 

IV.    PNEUMOTHORAX. 

(Hydro-Pneumothorax  and  Pyo-Pneumothorax.) 

Air  alone  in  the  pleural  cavity,  to  which  the  term  pneumothorax  is  strictly 
applicable,  is  an  extremely  rare  condition.  It  is  almost  invariably  associated 
with  a  serous  fluid — hydro-pneumothorax,  or  with  pus — pyo-pneumothorax. 

Etiology. — There  exists  normally  within  the  pleural  cavity  of  an  adult 
a  negative  pressure  of  several  (3  to  5 )  millimetres  of  mercury,  due  to  the  recoil 
of  the  distended,  perfectly  elastic  lung.  Hence  through  any  opening  connect- 
ing the  pleural  cavity  with  the  external  air  we  should  expect  air  to  rush  in 
until  this  negative  pressure  is  relieved.  To  explain  the  absence  of  pneumo- 
thorax in  a  few  cases  of  external  injury  laying  the  pleura  bare,  in  which  it 
would  be  expected,  S.  West  has  assumed  the  ^existence  of  a  cohesion  between 
the  pleurae,  but  this  force  has  not  as  yet  been  satisfactorily  demonstrated. 

In  a  case  of  pneumothorax,  if  the  opening  causing  it  remain  patent,  which 
occurs  only  in  some  external  wounds,  or  especially  perforations  through  con- 
solidated areas  of  the  lungs,  the  intrathoracic  pressure  will  be  that  of  the 
atmosphere,  the  lung  will  be  found  to  have  collapsed  as  much  as  possible  by 
virtue  of  its  own  elastic  tension,  the  intercostal  grooves  obliterated,  the  heart 
displaced  to  the  other  side,  and  the  diaphragm  lower  than  normal,  because  the 
negative  pressure  by  reason  of  which  these  organs  are  partly  retained  in  their 
ordinary  position  has  been  relieved.  If  the  opening  becomes  closed  the  intra- 
thoracic pressure  may  rise  above  the  atmospheric  and  the  above-mentioned 
displacements  be  much  increased.  But  most  perforations  through  the  lung 
are  valvular,  a  property  of  lung  tissue,  and  the  intrapleuratl^ressure  is  soon 
about  7  mm.  'of  mercury.  If  there  be  a  fluid  exudate  the  pressure  may  be 
,  higher,  but  the  high  pressures  supposed  are  more  apparent  than  real,  and  that 
measured  at  the  autopsy  table  is  quite  surely  not  that  during  life.  It  is  more 
a  question  of  the  amount  of  distention  than  the  actual  pressure  which  deter- 
mines the  discomfort  of  the  patient. 

Pneumothorax  arises :  ( 1 )  In  perforating  wounds  of  the  chest,  in  which 
case  it  is  sometimes  associated  with  extensive  cutaneous  emphysema.  It  may 
follow  exploratory  puncture  either  with  a  small  needle  or  an  aspirator.  There 
were  ten  cases  in  my  series.  Pneumothorax  rarely  follows  fracture  of  the  rib, 
even  though  the  lung  may  be  torn.  (2)  In  perforation  of  the  pleura  through 
the  diaphragm,  usually  by  malignant  disease  of  the  stomach  or  colon,  or  abscess 
43 


658  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

of  the  liver  perforating  lung  and  pleura.  The  pleura  may  also  he  perforated 
in  cases  of  cancer  of  the  oesophagus.  (3)  When  the  lung  is  perforated.  This 
is  by  far  the  most  common  cause,  and  may  occur:  (a)  In  the  normal  lung 
from  rupture  of  the  air- vesicles  during  straining  or  even  when  at  rest.  Special 
attention  has  been  called  to  this  accident  by  S.  West  and  De  H.  Hall.  The 
air  may  be  absorbed  and  no  ill  effect  follow.  It  does  not  necessarily  excite 
pleurisy,  as  pointed  out  many  years  ago  by  Gairdner,  but  inflammation  and 
effusion  are  the  usual  result.  In  a  recent  case  the  condition  developed  as  the 
patient  was  going  down-stairs ;  no  effusion  followed ;  he  did  not  react  to  tuber- 
culin, (&)  From  perforation  due  to  local  disease  of  the  lung,  either  the  soften- 
ing of  a  caseous  focus  or  the  breaking  of  a  tuberculous  cavity.  According  to 
S.  West,  90  per  cent  of  all  the  cases  are  due  to  this  cause.  Less  common 
are  the  cases  due  to  septic  broncho-pneumonia  and  to  gangrene.  A  rare  cause 
is  the  breaking  of  a  hsemorrhagic  infarct  in  chronic  heart-disease,  of  which  I 
met  an  instance  a  few  years  ago.  (c)  Perforation  of  the  lung  from  the  pleura, 
which  arises  in  certain  cases  of  empyema  and  produces  a  pleuro-bronchial 
fistula.  (4)  Spontaneously,  by  the  development  in  pleural  exudates  of  the 
gas  bacillus  {B.  ah'ogenes  capsulatiis  Welch).  Of  48  cases,  the  basis  of 
Emerson's  exhaustive  monograph  (J.  H.  H.  Eeports,  vol,  xi),  22  were  tuber- 
culous, 6  were  the  result  of  trauma,  10  of  aspiration,  2  were  spontaneous,  2 
followed  bronchiectasis,  2  abscess  of  the  lung,  1  gangrene,  2  an  empyema, 
and  1  abscess  of  the  liver  perforating  through  the  lung. 

Pneumothorax  occurs  chiefly  in  adults,  though  cases  are  met  with  in  very 
young  children.    It  is  more  frequent  in  males  than  in  females. 

A  remarkable  recurrent  variety  has  been  described  by  S.  West,  Goodhart, 
and  Furney.  In  Goodhart's  case  the  pneumothorax  developed  first  in  one 
side  and  then  in  the  other. 

Morbid  Anatomy. — If  the  trocar  or  blow-pipe  is  inserted  between  the  ribs, 
there  may  be  a  jet  of  air  of  sufficient  strength  to  blow  out  a  lighted  match. 
On  opening  the  thorax  the  mediastinum  and  pericardium  are  seen  to  be 
pushed,  or  rather,  as  Douglas  Powell  pointed  out,  "  drawn  over  "  to  the  oppo- 
site side ;  but,  as  before  mentioned,  the  heart  is  not  rotated,  and  the  relation  of 
its  parts  is  maintained  much  as  in  the  normal  condition.  A  serous  or  puru- 
lent fluid  is  usually  present,  and  the  membranes  are  inflamed.  The  cause  of 
the  pneumothorax  can  usually  be  found  without  difficulty.  In  the  great 
majority  of  instances  it  is  the  perforation  of  a  tuberculous  cavity  or  a  break- 
ing of  a  superflcial  caseous  focus.  The  orifice  of  rupture  may  be  extremely 
small.  In  chronic  cases  there  may  be  a  fistula  of  considerable  size  communi- 
cating with  the  bronchi.     The  lung  is  usually  compressed  and  carnified. 

Symptoms. — The  onset  is  usually  sudden  and  characterized  by  severe  pain 
in  the  side,  urgent  dyspnoea,  and  signs  of  general  distress,  as  indicated  by 
slight  lividity  and  a  very  rapid  and  feeble  pulse — the  pneumothorax  accutis- 
simus  of  TJnverricht.  There  may,  however,  be  no  urgent  symptoms,  particu- 
larly in  cases  of  long-standing  phthisis. 

Physical  Signs. — The  physical  signs  are  very  distinctive.  Inspection 
shows  marked  enlargement  of  the  affected  side  with  immobility.  The  heart 
impulse  is  usually  much  displaced.  On  palpation  the  fremitus  is  greatly 
diminished  or  more  commonly  abolished.  On  percussion  the  resonance  may  be 
tympanitic  or  even  have  an  amphoric  quality.     This,  however,  is  not  always 


DISEASES  OF  THE  PLEURA.  659 

the  case.  It  may  be  a  flat  tympany,  resembling  Skoda's  resonance.  In  some 
instances  it  may  be  a  full,  hyperresonant  note,  like  emphysema;  while  in 
others — and  this  is  very  deceptive — there  is  dulness.  These  extreme  variations 
depend  doubtless  upon  the  degree  of  intrapleural  tension.  On  several  occasions 
I  have  known  an  error  in  diagnosis  to  result  from  ignorance  of  the  fact  that, 
in  certain  instances,  the  percussion  note  may  be  "  muffled,  toneless,  almost 
dull"  (Walshe),  There  is  usually  dulness  at  the  base  from  effused' fluid, 
which  can  readily  be  made  to  change  the  level  by  altering  the  position  of  the 
patient.  Movable  dulness  can  be  obtained  much  more  readily  in  pneumothorax 
than  in  a  simple  pleurisy.  On  auscultation  the  breath-sounds  are  suppressed. 
Sometimes  there  is  only  a  distant  feeble  inspiratory  murmur  of  marked  am- 
phoric quality.  The  contrast  between  the  loud  exaggerated  breath-sounds  on 
the  normal  side  and  the  absence  of  the  breath-sounds  on  the  other  is  very 
suggestive.  The  rales  have  a  peculiar  metallic  quality,  and  on  coughing  or 
deep  inspiration  there  may  be  what  Laennec  termed  the  metallic  tinkling. 
The  voice,  too,  has  a  curious  metallic  echo.  What  is  sometimes  called  the 
coin-sound,  termed  by  Trousseau  the  bruit  d'airain,  is  very  characteristic. 
To  obtain  it  the  auscultator  should  place  one  ear  on  the  back  of  the  chest 
wall  while  the  assistant  taps  one  coin  on  another  on  the  front  of  the  chest. 
The  metallic  echoing  sound  which  is  produced  in  this  way  is  one  of  the  most 
constant  and  characteristic  signs  of  pneumothorax.  And,  lastly,  the  Hip- 
pocratic  succussion  splash  may  be  obtained  when  the  auscultator's  head  is 
placed  upon  the  chest  while  the  patient's  body  is  shaken.  A  splashing  sound 
is  produced,  which  may  be  audible  at  a  distance.  A  patient  may  himself 
notice  it  in  making  abrupt  changes  in  posture.  The  signs,  distention,  immo- 
bility, lack  of  vocal  fremitus,  hyperresonance,  absence  of  breath-sounds  and 
coin-sound,  are  those  of  the  pure  pneumothorax  of  Laennec.  The  metallic 
phenomena  may  be  present,  e.  g.,  the  metallic  tinkling  and  amphoric  respira- 
tion, but  these  are  best  heard  in  cases  with  a  consolidated  lung  and  thickened 
pleura,  such  as  occur  in  tuberculosis.  The  movable  dulness  and  splash  on 
succussion  depend  on  fluid.  Of  other  physical  signs  displacement  of  organs 
is  most  constant.  As  already  mentioned,  the  heart  may  be  much  "  drawn 
over  "  to  the  opposite  side,  and  the  liver  greatly  displaced,  so  that  its  upper 
surface  is  below  the  level  of  the  costal  margin,  a  degree  of  dislocation  never 
seen  in  simple  effusion. 

Diagnosis. — The  diagnosis  of  pneumothorax  rarely  offers  any  difficulty,  as 
the  signs  are  very  characteristic.  In  cases  in  which  the  percussion  note  is  dull 
the  condition  may  be  mistaken  for  effusion.  I  made  this  mistake  in  a  case  of 
pulsating  pleurisy,  in  which  the  pneumothorax  followed  heavy  lifting,  and 
it  was  not  until  several  days  later,  after  some  of  the  fluid  had  been  with- 
drawn, that  a  tympanitic  note  developed.  Diaphragmatic  hernia  following 
a  crush  or  other  accident  may  closely  simulate  pneumothorax. 

In  cases  of  very  large  phthisical  cavities  with  tympanitic  percussion  reso- 
nance and  rales  of  an  amphoric,  metallic  quality,  the  question  of  pneumothorax 
is  sometimes  raised.  In  those  rare  instances  of  total  excavation  of  one  lung 
the  amphoric  and  metallic  phenomena  may  be  most  intense,  but  the  absence  of 
dislocation  of  the  organs,  of  the  succussion  splash,  and  of  the  coin-sound 
suffice  to  differentiate  this  condition.  While  this  is  true  in  the  great  majority 
of  cases,  I  have  heard  the  bruit  d'airain  over  a  large  cavity  in  the  right  upper 


660  DISEASES  OF   THE  RESPIRATORY  SYSTEM. 

lobe.  The  condition  of  pyo-pneumothorax  subphrenicus  may  simulate  closely 
true  pnemnothorax. 

Prognosis'. — The  prognosis  in  cases  of  pneumothorax  depends  largely  upon 
the  cause.  S.  West  gives  a  mortality  of  70  per  cent.'  The  tuberculous  cases 
usually  die  within  a  few  weeks.  Of  39  cases,  29  died  within  a  fortnight 
(West)  ;  10  patients  died  on  the  first  day,  2  within  twenty  and  thirty  minutes 
respectively  of  the  attack.  Of  our  22  tuberculous  cases  20  died,  and  5  of  the 
10  cases  following  aspiration.  Pneumothorax  in  a  healthy  individual  often 
ends  in  recovery.  There  are  tuberculous  cases  in  which  the  pneumothorax, 
if  occurring  early,  seems  to  arrest  the  progress  of  the  tuberculosis.  There 
is  a  chronic  pneumothorax  which  may  last  for  between  three  and  four  years. 
It  may  be  a  chronic  condition,  as  in  the  case  just  mentioned,  and  a  fair 
measure  of  health  may  be  enjoyed. 

Treatment. — There  are  three  groups  of  cases:  First,  in  the  pneumothorax 
accutissimus,  with  urgent  dyspnoea,  great  displacement  of  the  heart,  cyanosis, 
and  low  blood  pressure,  an  opening  should  be  made  in  the  pleura  and  kept 
open,  converting  a  valvular  into  an  open  variety.  Immediate  aspiration  with  a 
trocar  has  saved  life.  Second!}^,  the  spontaneous  cases  which  usually  do  well, 
as  the  air  is  quickly  absorbed ;  so  also  with  the  traumatic  variety.  Very  many 
of  the  tuberculous  cases  are  best  let  alone,  if  the  patient  is  doing  well,  or  if 
the  disease  in  the  other  lung  is  advanced.  Thirdly,  when  there  is  pus,  and 
the  patient  is  not  doing  well,  or  in  the  tuberculous  variety  if  the  other  lung 
is  not  involved,  pleurotomy,  or  resection  of  one  or  two  ribs,  may  be  done.  Of 
nine  cases  in  my  series  two  recovered. 

V.     AFFECTIONS    OF    THE    MEDIASTINUM. 

(1)  Simple  Lymphadenitis. — In  all  inflammatory  affections  of  the  bronchi 
and  of  the  lungs  the  groups  of  lymph-glands  in  the  mediastinum  become  swol- 
len. In  the  bronchitis  of  measles,  for  example,  and  in  simple  broncho-pneu- 
monia the  bronchial  glands  are  large  and  infiltrated,  the  tissue  is  engorged  and 
oedematous,  sometimes  intensely  hypergemic.  Much  stress  has  been  laid  by 
some  writers  on  this  enlargement  of  the  glands  in  the  posterior  mediastinum, 
and  De  Mussy  held  that  it  was  an  important  factor  in  inducing  paroxysms  of 
whooping-cough.  They  may  attain  a  size  sufficient  to  induce  dulness  beneath 
the  manubrium  and  in  the  upper  part  of  the  interscapular  regions  behind, 
though  this  is  often  difficult  to  determine.  In  reality  the  glands  lie  chiefly 
upon  the  spine,  and  unless  those  which  are  deep  in  the  root  of  the  lung  are 
large  enough  to  induce  compression  of  the  adjacent  lung  tissue,  I  doubt  if  the 
ordinary  bronchial  adenopathy  ever  can  be  determined  by  percussion  in  the 
upper  interscapular  region.  I  have  never  met  with  an  instance  in  which  the 
compression  of  either  bronchus  seemed  to  have  resulted  from  the  glands,  how- 
ever large.    Tuberculous  affection  of  these  glands  has  already  been  considered. 

(2)  Suppurative  Lymphadenitis. — Occasionally  abscess  in  the  bronchial  or 
tracheal  lymph-glands  is  found.  It  may  follow  the  simple  adenitis,  but  is 
most  frequentl}''  associated  with  the  presence  of  tubercle.  The  liquid  portion 
may  gradually  become  absorbed  and  the  inspissated  contents  undergo  calcifica- 
tion. Serious  accidents  occasionally  occur,  as  perforation  into  the  oesophagus 
or  into  a  bronchus,  or  in  rare  instances,  as  in  the  case  reported  by  Sidney 


DISEASES  OF  THE  PLEURA.  661 

Phillips,  perforation  of  the  aorta,  as  well  as  a  bronchus,  which,  it  is  remarkable 
to  say,  did  not  prove  fatal  rapidly,  but  caused  repeated  attacks  of  haemoptysis 
during  a  period  of  sixteen  months. 

(3)  Tumors;  Cancer  and  Sarcoma. — In  Hare's  elaborate  study  of  520  cases 
of  disease  of  the  mediastinum  there  were  134  cases  of  cancer,  98  cases  of  sar- 
coma, 21  cases  of  lymphoma,  7  cases  of  fibroma,  11  cases  of  dermoid  cysts,  8 
cases  of  hydatid  cysts,  and  instances  of  lipoma,  gumma,  and  enchondroma. 
From  this  we  see  that  cancer  is  the  most  common  form  of  growth.  The  tumor 
occurred  in  the  anterior  mediastinum  alone  in  48  of  the  cases  of  cancer  and  in 
33  of  the  cases  of  sarcoma.  There  are  three  chief  points  of  origin,  the  thymus, 
the  lymph-glands,  and  the  pleura  and  lung.  Sarcoma  is  more  frequently 
primary  than  cancer.  Males  are  more  frequently  affected  than  females.  The 
age  of  onset  is  most  commonly  between  thirty  and  forty. 

Symptoms. — The  signs  of  mediastinal  tumor  are  those  of  intrathoracic 
pressure.  In  some  cases  almost  the  entire  chest  is  filled  with  the  masses. 
The  heart  and  lungs  are  pushed  back  and  it  is  marvelous  how  life  can  be 
maintained  with  such  dislocation  and  compression  of  the  organs.  Dyspncea 
is  one  of  the  earliest  and  most  constant  symptoms,  and  may  be  due  either  to 
pressure  on  the  trachea  or  on  the  recurrent  laryngeal  nerves.  It  may  indeed 
be  cardiac,  due  to  pressure  upon  the  heart  or  its  vessels.  In  a  few  cases  it 
results  from  the  pleural  effusion  which  so  frequently  accompanies  intrathoracic 
growths.  Associated  with  the  dyspncea  is  a  cough,  often  severe  and  parox- 
ysmal in  character,  with  the  brazen  quality  of  the  so-called  aneurismal  cough 
when  a  recurrent  nerve  is  involved.  The  voice  may  also  be  affected  from  a 
similar  cause.  Pressure  on  the  vessels  is  common.  The  superior  vena  cava 
may  be  compressed  and  obliterated,  and  when  the  process  goes  on  slowly 
the  collateral  circulation  may  be  completely  established.  Less  commonly  the 
inferior  vena  cava  or  one  or  other  of  the  subclavian  veins  is  compressed.  The 
arteries  are  much  more  rarely  obstructed.  There  may  be  dysphagia,  due  to 
compression  of  the  oesophagus.  In  rare  instances  there  are  pupillary  changes, 
either  dilatation  or  contraction,  due  to  involvement  of  the  sympathetic.  Ex- 
pectoration of  blood,  pus,  and  hair  is  characteristic  of  the  dermoid  cyst,  of 
which  Christian  has  collected  40  cases. 

Physical  Signs. — On  inspection  there  may  be  orthopnoea  and  marked 
cyanosis  of  the  upper  part  of  the  body.  In  such  instances,  if  of  long  dura- 
tion, there  are  signs  of  collateral  circulation  and  the  superficial  mammary 
and  epigastric  veins  are  enlarged.  In  these  cases  of  chronic  obstruction  the 
finger-tips  may  be  clubbed.  There  may  be  bulging  of  the  sternum  or  the 
tumor  may  erode  the  bone  and  form  a  prominent  subcutaneous  growth.  The 
rapidly  growing  lymphoid  tumors  more  commonly  than  others  perforate  the 
chest  wall.  In  4  of  13  cases  of  Hodgkin's  disease,  there  was  mediastinal 
growth,  and  in  3  instances  the  sternum  was  eroded  and  perforated.  The  per- 
foration may  be  on  one  side  of  the  breast-bone.  The  projecting  tumor  may 
pulsate ;  the  heart  may  be  dislocated  and  its  impulse  much  out  of  place.  Con- 
traction of  one  side  of  the  thorax  has  been  noted  in  a  few  instances.  On  pal- 
pation the  fremitus  is  absent  wherever  the -tumor  reaches  the  chest  wall.  If 
pulsating,  it  rarely  has  the  forcible,  heaving  impulse  of  an  aneurismal  sac.  On 
auscultation  there  is  usually  silence  over  the  dull  region.  The  heart-sounds 
are  not  transmitted  and  the  respiratory  murmur  is  feeble  or  inaudible,  rarely. 


662  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

bronchial.  Vocal  resonance  is,  as  a  rule,  absent.  Signs  of  pleural  effusion 
occur  in  a  great  many  instances  of  mediastinal  growth,  and  in  doubtful  cases 
the  aspirator  needle  should  be  used. 

Tumors  of  the  anterior  mediastinum  originate  usually  in  the  thymus,  or 
its  remnants,  or  in  the  connective  tissue;  the  sternum  is  pushed  forward  and 
often  eroded.  The  growth  may  be  felt  in  the  suprasternal  fossa;  the  cervical 
glands  are  usually  involved.  The  pressure  symptoms  are  chiefly  upon  the 
venous  trunks.    Dyspnoea  is  a  prominent  feature. 

Intrathoracic  tumors  in  the  middle  and  posterior  mediastinum  originate 
most  commonly  in  the  Ijnnpli-glands.  The  sjmiptoms  are  out  of  all  propor- 
tion to  the  physical  signs;  there  is  urgent  dyspnoea  and  cough,  which  is  some- 
times loud  and  ringing.  The  pressure  symptoms  are  chiefly  upon  the  gullet, 
the  recurrent  lar}Tigeal,  and  sometimes  upon  the  az3^gos  vein. 

In  a  third  group,  tumors  originating  in  the  pleura  and  the  lung,  the 
pressure  s}Tnptoms  are  not  so  marked.  Pleural  exudate  is  very  much  more 
common ;  the  patient  becomes  anaemic  and  emaciation  is  rapid.  There  may  be 
secondary  involvement  of  the  lymph-glands  in  the  neck. 

DiAGXosis. — The  diagnosis  of  mediastinal  tumor  from  aneurism  is  some- 
times extremely  difficult.  An  interesting  case  reported  and  figured  by  Soko- 
losski,  in  Bd.  19  of  the  Deutsclies  Archiv  fiir  klinische  Medicin,  "in  which 
Oppolzer  diagnosed  aneurism  and  Skoda  mediastinal  tumor,  illustrates  how  in 
some  instances  the  most  skilful  of  observers  may  be  unable  to  agree.  Scarcely 
a  sign  is  found  in  aneurism  which  may  not  be  duplicated  in  mediastinal 
tumor.  This  is  not  strange,  since  the  symptoms  in  both  are  largely  due  to 
pressure.  The  cyanosis,  the  venous  engorgement,  the  signs  of  collateral  cir- 
culation are  as  a  rule  much  more  marked  in  tumor.  The  time  element  is 
important.  If  a  case  has  persisted  for  more  than  eighteen  months  the  dis- 
ease is  probably  aneurism.  There  are,  however,  exceptions  to  this.  By  far 
the  most  valuable  sign  of  aneurism  is  the  diastolic  shock  so  often  to  be  felt, 
and  in  a  majority  of  cases  to  be  heard,  over  the  sac.  This  is  rarely,  if  ever, 
present  in  mediastinal  growths,  even  when  they  perforate  the  sternum  and 
have  communicated  pulsation.  Tracheal  tugging  is  rarely  present  in  tumor. 
Another  point  of  importance  is  that  a  tumor,  advancing  from  the  medias- 
tinum, eroding  the  sternum  and  appearing  externally,  if  aneurismal,  has 
forcible,  heaving,  and  distinctly  expansile  pulsations.  The  radiating  pain  in 
the  back  and  axms  and  neck  is  rather  in  favor  of  aneurism,  as  is  also  a  bene- 
ficial influence  on  it  of  iodide  of  potassium.  The  remarkable  traumatic  cya- 
nosis of  the  upper  half  of  the  body  which  follows  compression  injuries  of  the 
thorax  could  scarcely  be  mistaken  for  the  effect  of  tumor. 

The  frequency  of  pleural  effusion  in  connection  with  mediastinal  tumor 
is  to  be  constantly  borne  in  mind.  It  may  give  curiously  complex  characters 
to  the  physical  signs — characters  which  are  profoundly  modified  after  aspira- 
tion of  the  liquid.  Occasionally  a  tumor  of  the  mediastinum  is  operable. 
Walker,  of  Detroit,  showed  me  a  large  fibro-sarcoma,  which  he  had  removed 
successfully  from  the  anterior  mediastinum. 

(4)  Abscess  of  the  Mediastinum. — Hare  collected  115  cases  of  mediastinal 
abscess,  in  77  of  which  there  were  details  sufficient  to  permit  the  analysis. 
Of  these  cases  the  great  majority  occurred  in  males.  Forty-four  were  instances 
of  acute  abscess.    The  anterior  mediastinum  is  most  commonly  the  seat  of  the 


DISEASES  OF  THE  PLEURA.  663 

suppuration.  The  cases  are  most  frequently  associated  with  trauma.  Some 
have  followed  erysipelas  or  occurred  in  association  with  eruptive  fevers. 
Many  caseSj  particularly  the  chronic  abscesses,  are  of  tuberculous  origin.  Of 
symptoms,  pain  behind  the  sternum  is  the  most  common.  It  may  be  of  a 
throbbing  character,  and  in  the  acute  cases  is  associated  with  fever,  sometimes 
with  chills  and  sweats.  If  the  abscess  is  large  there  may  be  dyspnoea.  The 
pus  may  burrow  into  the  abdomen,  perforate  through  an  intercostal  space,  or  it 
may  erode  the  sternum.  Instances  are  on  record  in  which  the  abscess  has 
discharged  into  the  trachea  or  oesophagus.  In  many  cases,  particularly  of 
chronic  abscess,  the  pus  becomes  inspissated  and  produces  no  ill  effect.  The 
physical  signs  may  be  very  indefinite.  A  pulsating  and  fluctuating  tumor 
may  appear  at  the  border  of  the  sternum  or  at  the  sternal  notch.  The  absence 
of  bruit,  of  the  diastolic  shock,  and  of  the  expansile  pulsation  usually  enables 
a  correct  diagnosis  to  be  made.  When  in  doubt  a  fine  hypodermic  needle  may 
be  inserted. 

(5)  Indurative  Mediastino-Pericarditis. — Harris  has  reviewed  the  subject. 
In  one  form  there  is  adherent  pericardium  and  great  increase  in  the  fibrous 
tissues  of  the  mediastinum;  in  another  there  is  adherent  pericardium  with 
union  to  surrounding  parts,  but  very  little  mediastinitis ;  in  a  third  the  peri- 
cardium may  be  uninvolved.  The  disease  is  rare ;  of  22  cases  17  were  in  males ; 
only  2  were  above  thirty  years  of  age.  The  symptoms  are  essentially  those  of 
that  form  of  adhesive  pericardium  which  is  associated  with  great  hypertrophy 
and  dilatation  of  the  heart,  and  in  which  the  patients  present  a  picture  of  cya- 
nosis, dyspnoea,  anasarca,  etc.  The  pulsus  paradoxus,  described  by  Kussmaul, 
is  not  distinctive.  Occasionally  there  is  also  a  proliferative  peritonitis.  Medi- 
astinal friction  is  sometimes  heard  in  patients  with  adhesive  mediastino-peri- 
carditis — dry,  coarse,  crackling  rales  heard  along  the  sternum,  particularly 
when  the  arms  are  raised. 

(6)  Miscellaneous  Affections. — In  Hare's  monograph  there  were  7  in- 
stances of  fibroma,  11  cases  of  dermoid  cyst,  8  cases  of  hydatid  cyst,  and 
cases  of  lipoma  and  gumma. 

(7)  Emphysema  of  the  Mediastinum. — Air  in  the  cellular  tissues  of  the 
mediastinum  is  met  with  in  cases  of  trauma,  and  occasionally  in  fatal  cases 
of  diphtheria  and  in  whooping-cough.  It  may  extend  to  the  subcutaneous 
tissues,  Champneys  has  called  attention  to  its  frequency  after  tracheotomy, 
in  which,  he  says,  the  conditions  favoring  the  production  are  division  of  the 
deep  fascia,  obstruction  in  the  air-passages,  and  inspiratory  efforts.  The  deep 
fascia,  he  says,  should  not  be  raised  from  the  trachea.  It  is  often  associated 
with  pneumothorax,  and  more  often  in  rupture  of  the  lung  without  pneumo- 
thorax, the  pleura  remaining  intact  and  the  air  dissecting  its  way  along  the 
bronchi  into  the  mediastinum  and  into  the  neck.  The  condition  seems  by  no 
means  uncommon.  Angel  Money  found  it  in  16  of  28  cases  of  tracheotomy, 
and  in  2  of  these  pneumothorax  also  was  present. 


SECTION    VII. 
DISEASES   OF   THE  KIDISTETS. 

I.    MALFORMATIONS. 

Newman  classifies  the  malformations  of  the  kidney  as  follows :  A.  Displace- 
ments without  mobility — (1)  congenital  displacement  without  deformity; 
(2)  congenital  displacement  with  deformity;  (3)  acquired  displacements. 
B.  Malformations  of  the  kidney.  I.  Variations  in  number — (a)  supernumer- 
ary kidney;  (&)  single  kidney^  congenital  absence  of  one  kidney,  atrophy  of 
one  kidney;  (c)  absence  of  both  kidneys.  II.  Variations  in  form  and  size 
— (a)  general  variations  in  form,  lobulation,  etc.;  (&)  hypertrophy  of  one 
kidney;  (c)  fusion  of  two  kidneys — ^horseshoe  kidney,  sigmoid  kidney,  disk- 
shaped  kidney.     C.  Variations  in  pelvis,  ureters,  and  blood-vessels. 

The  fused  kidneys  may  form  a  large  mass,  which  is  often  displaced,  being 
either  in  an  iliac  fossa  or  in  the  middle  line  of  the  abdomen,  or  even  in  the 
pelvis.  Under  these  circumstances  it  may  be  mistaken  for  a  new  growth.  In 
Polk's  case  the  organ  was  removed  under  the  belief  that  it  was  a  floating  kid- 
ney. The  patient  lived  eleven  days,  had  complete  anuria,  and  it  was  found 
post  mortem  that  a  single  fused  kidney  had  been  removed.  A  second  case  of 
the  same  kind  has  been  reported. 

II.    MOVABLE  KIDNEY. 

(Floating-  Kidney;  Palpable  Kidney;  Ren  mobilis;  Nephroptosis.) 

The  kidney  is  held  in  position  by  its  fatty  capsule,  by  the  peritongeum 
which  passes  in  front  of  it,  and  by  the  blood-vessels.  Normally  the  kidney 
is  firmly  fixed,  but  under  certain  circumstances  one  or  the  other  organ,  more 
rarely  both,  becomes  movable.  In  very  rare  cases  the  kidney  is  surrounded, 
to  a  greater  or  less  extent,  by  the  peritonaeum,  and  is  anchored  at  the  hilus 
by  a  mesonephron.  Some  would  limit  the  term  floating  kidney  to  this  con- 
dition. 

Movable  kidney  is  almost  always  acquired.  It  is  more  common  in  women. 
Of  the  667  cases  collected  in  the  literature  by  Kuttner,  584  were  in  women 
and  only  83  in  men.  It  is  more  common  on  the  right  than  on  the  left  side. 
Of  727  cases  analyzed  by  this  author,  it  occurred  on  the  right  in  553  cases,  on 
the  left  in  81,  and  on  both  sides  in  93.  The  greater  frequency  of  the  con- 
dition in  women  may  be  attributed  to  compression  of  the  lower  thoracic  zone 
by  tight  lacing,  and,  more  important  still,  to  the  relaxation  of  the  abdominal 
walls  which  follows  repeated  pregnancies.  This  does  not  account  for  all  the 
664 


MOVABLE  KIDNEY.  665 

eases,  as  movable  kidney  is  by  no  means  uncommon  in  nulliparae.  Drummond 
believes  that  in  a  majority  of  the  cases  there  is  a  congenitally  relaxed  condition 
of  the  peritoneal  attachments.  The  condition  has  been  met  with  in  infants  and 
in  children.  Wasting  of  the  fat  about  the  kidney  may  be  a  cause  in  some  in- 
stances. Trauma  and  the  lifting  of  heavy  weights  are  occasionally  factors  in 
its  production.  The  kidney  is  sometimes  dragged  down  by  tumors.  The 
greater  frequency  on  the  right  side  is  probably  associated  with  the  position  of 
the  kidney  just  beneath  the  liver,  and  the  depression  to  which  the  organ  is 
subjected  with  each  descent  of  the  diaphragm  in  inspiration. 

And,  lastly,  movable  kidney  is  met  with  in  many  cases  which  present  that 
combination  of  neurasthenia  with  gastro-intestinal  disturbance  which  has  been 
described  by  Glenard  as  enteroptosis  (see  p.  528). 

To  determine  the  presence  of  a  movable  kidney  the  patient  should  be 
placed  in  the  dorsal  position,  with  the  head  moderately  low  and  the  abdominal 
walls  relaxed.  The  left  hand  is  placed  in  the  lumbar  region  behind  the 
eleventh  and  twelfth  ribs;  the  right  hand  in  the  hypochondriac  region,  in 
the  nipple  line,  just  under  the  edge  of  the  liver.  Bimanual  palpation  may 
detect  the  presence  of  a  firm,  rounded  body  just  below  the  edge  of  the  ribs. 
If  nothing  can  be  felt,  the  patient  should  be  asked  to  draw  a  deep  breath,  when, 
if  the  organ  is  palpable,  it  is  touched  by  the  fingers  of  the  right  hand.  Vari- 
ous grades  of  mobility  may  be  recognized.  It  may  be  possible  barely  to  feel 
the  lower  edge  on  deep  palpation — palpable  Tcidney — or  the  organ  may  be  so 
far  displaced  that  on  drawing  the  deepest  breath  the  fingers  of  the  right  hand 
may  be,  in  a  thin  person,  slipped  above  the  upper  end  of  the  organ,  which  can 
be  readily  held  down,  but  can  not  be  pushed  below  the  level  of  the  navel — 
rn'ovahle  Tcidney.  In  a  third  group  of  cases  the  organ  is  freely  movable,  and 
may  even  be  felt  just  above  Poupart's  ligament,  or  may  be  in  the  middle  line 
of  the  abdomen,  or  can  even  be  pushed  over  beyond  this  point.  To  this  the 
term  floating  kidney  is  appropriate. 

The  movable  kidney  is  not  painful  on  pressure,  except  when  it  is  grasped 
very  firmly,  when  there  is  a  dull  pain,  or  sometimes  a  sickening  sensation. 
Examination  of  the  patient  from  behind  may  show  a  distinct  flattening  in  the 
lumbar  region  on  the  side  in  which  the  kidney  is  mobile. 

Symptoms. — In  a  large  majority  of  cases  there  are  no  symptoms,  and  if 
detected  accidentally  it  is  well  not  to  let  the  patient  know  of  its  presence.  Far 
too  much  stress  has  been  laid  upon  the  condition  of  late  years.  In  other  in- 
stances there  is  pain  in  the  lumbar  region  or  a  sense  of  dragging  and  discom- 
fort, or  there  may  be  intercostal  neuralgia.  In  a  large  group  the  symptoms 
are  those  of  neurasthenia  with  dyspeptic  disturbance.  In  women  the  hysterical 
symptoms  may  be  marked,  and  in  men  various  grades  of  hypochondriasis. 
The  gastric  disturbance  is  usually  a  form  of  nervous  dyspepsia.  Dilatation 
of  the  stomach  has  been  observed,  owing,  as  suggested  by  Bartels,  to  pressure  of 
the  dislocated  kidney  upon  the  duodenum.  This  view  has  been  supported  by 
Oser,  Landau,  and  Ewald.  On  the  other  hand,  Litten  holds  that  the  dilata- 
tion of  the  stomach  is  the  cause  of  the  mobility  of  the  kidney,  and  he  found 
in  40  cases  of  depression  and  dilatation  of  the  stomach  22  instances  of  dislo- 
cation of  the  kidney  on  the  right  side.  The  association,  however,  with  a 
depressed  stomach  is  certainly  common  in  women.  Constipation  is  not  infre- 
quent. Some  writers  have  described  pressure  upon  the  gall-duets,  with  jaun- 
44 


666  DISEASES  OF   THE  KIDNEYS. 

dice,  but  tliis  is  ver}"  rare.  Fffical  accumulation  and  even  obstruction  may  be 
associated  ■vritli  the  displaced  organ. 

Dletl's  Ceises. — In  floating  kidney  tbere  are  attacks  characterized  by 
severe  abdominal  pain^  chills,  nausea,  vomiting,  fever,  and  collapse.  The 
symptoms  vrere  first  described  by  Diet!  in  1864,  and  a  more  wide-spread  knowl- 
edge of  their  occurrence  in  connection  with  this  condition  is  desirable.  My 
attention  was  called  to  them  in  1880  by  Palmer  Howard  in  the  case  of  a  stout 
lady,  who  suifered  repeatedly  with  the  most  severe  attacks  of  abdominal  pain 
and  vomiting,  which  constantly  required  morphia.  A  tumor  was  discovered 
a  little  to  the  right  of  the  navel,  and  the  diagnosis  of  probable  neoplasm  was 
concurred  in  by  Flint  (Sr.)  and  Gaillard  Thomas.  The  patient  lost  weight 
rapidly,  became  emaciated,  and  in  the  spring  of  1881  again  went  to  oSTew 
York,  where  she  saw  Van  Buren,  who  diagnosed  a  floating  kidney  and  said 
that  these  paroxysms  were  associated  with  it  in  a  gouty  person.  He  cut  off  all 
stimulants,  reassured  the  lady  that  she  had  no  cancer,  and  from  that  time  she 
rapidly  recovered,  and  the  attacks  have  been  few  and  far  between.  In  this 
patient  any  overindulgence  in  eating  or  in  drinking  is  stdl  liable  to  be  fol- 
lowed by  a  very  severe  attack.  These  attacks  may  also  be  mistaken  for  renal 
colic,  and  the  operation  of  nephrotomy  has  been  performed. 

In  other  instances  the  attacks  of  pain  may  be  thought  to  be  due  to  in- 
testinal disease  or  to  recurring  appendicitis.  The  cause  of  these  paroxj^smal 
attacks  is  not  quite  clear.  Dietl  thought  the}^  were  due  to  strangulation  of  the 
kidney  or  to  twists  or  kinks  in  the  renal  vessels  due  to  the  extreme  mobility. 
During  the  attacks  the  urine  is  sometimes  high-colored  and  contains  an  excess 
of  uric  acid  or  of  the  oxalates.  It  is  stated,  too,  that  blood  or  pus  may  be 
present.  The  kidney  may  be  tender,  swollen,  and  less  freely  movable.  Che3Tie 
describes  intermittent  hsematuria  in  tliis  condition. 

Intermittent  l\y drone plirosis  is  sometimes  associated  with  movable  kidney. 
Three  cases  are  reported  in  my  Lectures  on  Abdominal  Tumors.  In  two  the 
condition  has  been  completely  relieved  by  a  well-adapted  pad  and  belt ;  in  the 
third,  attacks  recur  at  long  intervals. 

The  diagnosis  is  rarely  doubtful,  as  the  shape  of  the  organ  is  usually 
distinctive  and  the  mobility  marked.  Tumors  of  the  gall-bladder,  ovarian 
growths,  and  tumors  of  the  bowels  may  in  rare  instances  be  confounded  with  it. 

Treatment. — The  kidney  has  been  extirpated  in  many  instances,  but  the 
operation  is  not  without  risk,  and  there  have  been  several  fatal  cases.  Stitch- 
ing of  the  kidne}* — ^nephrorrhaphy — as  recommended  by  Hahn,  is  the  most 
suitable  procedure,  and  relief  is  afforded  in  many  cases  by  the  operation, 
though  not  in  all.  Treatment  designed  to  increase  fat-formation  often  helps 
to  hold  the  kidney  in  place.  In  the  neurasthenic  cases  a  prolonged  rest  treat- 
ment is  indicated. 

In  many  instances  the  greatest  relief  is  experienced  from  a  bandage  and 
pad.  It  should  be  applied  in  the  morning,  vrith  the  patient  in  the  dorsal  or 
knee-breast  position,  and  she  should  be  taught  how  to  push  up  the  kidney.  An 
air  pad  may  be  used  if  the  organ  is  sensitive.  In  other  cases  a  broad  bandage 
well  padded  in  the  lower  abdominal  zone  pushes  up  the  intestines  and  makes 
them  act  as  a  support.  In  the  attacks  of  severe  colic  morphia  is  required. 
When  dependent,  as  seems  sometimes  the  case,  upon  an  excess  of  uric  acid  or 
the  oxalates,  the  diet  must  be  carefullv  regulated. 


CIRCULATORY  DISTURBANCES.  mi 


III.     CIRCULATORY   DISTURBANCES. 

Normally  the  secretion  of  urine  is  accomplished  by  the  maintenance  of 
a  certain  blood-pressure  within  the  glomeruli  and  by  the  activity  of  the  renal 
epithelium.  Bowman's  views  on  this  question  have  been  generally  accepted, 
and  the  watery  elements  are  held  to  be  filtered  from  the  glomeruli ;  the  amount 
depending  on  the  rapidity  and  the  pressure  of  the  blood-current ;  the  quality, 
whether  normal  or  abnormal,  depending  upon  the  condition  of  the  capillary 
and  glomerular  epithelium;  while  the  greater  portion  of  the  solid  ingredients 
are  excreted  by  the  epithelium  of  the  convoluted  tubules.  The  integrity  of  the 
epithelium  covering  the  capillary  tufts  within  Bowman's  capsule  is  essential  to 
the  production  of  a  normal  urine.  If  under  any  circumstances  their  nutrition 
fails,  as  when,  for  example,  the  rapidity  of  the  blood-current  is  lowered,  so  that 
they  are  deprived  of  the  necessary  amount  of  oxygen,  the  material  which  filters 
through  is  no  longer  normal  (i.  e.,  water),  but  contains  serum  albumin.  Colm- 
heim  has  shown  that  the  renal  epithelium  is  extremely  sensitive  to  circulatory 
changes,  and  that  compression  of  the  renal  artery  for  only  a  few  minutes 
causes  serious  disturbance. 

The  circulation  of  the  kidney  is  remarkably  influenced  by  reflex  stimuli 
coming  from  the  skin.  Exposure  to  cold  causes  heightened  blood-pressure 
within  the  kidneys  and  increased  secretion  of  urine.  Bradford  has  shown  that 
after  excision  of  portions  of  the  kidney,  to  as  much  as  one-third  of  the  total 
weight,  there  is  a  remarkable  increase  in  the  flow  of  urine. 

Cong^estion  of  the  Kidneys. — (1)  Active  Congestion;  Hyperemia. — 
Acute  congestion  of  the  kidney  is  met  with  in  the  early  stage  of  nephritis, 
whether  due  to  cold  or  to  the  action  of  poisons  and  severe  irritants.  Turpen- 
tine, cubebs,  cantharides,  and  copaiba  are  all  stated  to  cause  extreme  hyper- 
semia  of  the  organ.  The  most  typical  congestion  of  the  kidney  which  we  see 
post  mortem  is  that  in  the  early  stage  of  acute  Bright's  disease,  when  the  organ 
may  be  large,  soft,  of  a  dark  color,  and  on  section  blood  drips  from  it  freely. 

It  has  been  held  that  in  all  the  acute  fevers  the  kidneys  are  congested, 
and  that  this  explained  the  scanty,  high-colored,  and  often  albuminous  urine. 
On  the  other  hand,  by  Eoy's  oncometer,  Walter  Mendelson  has  shown  that 
the  kidney  in  acute  fever  is  in  a  state  of  extreme  anaemia,  small,  pale,  and 
bloodless;  and  that  this  anaemia,  increasing  with  the  pyrexia  and  interfering 
with  the  nutrition  of  the  glomerular  epithelium,  accounts  for  the  scanty,  dark- 
colored  urine  of  fever  and  for  the  presence  of  albumin.  In  the  prolonged 
fevers,  however,  it  is  probable  that  relaxation  of  the  arteries  again  takes  place. 
Certainly  it  is  rare  to  find  post  mortem  such  a  condition  of  the  kidney  as  is 
described  by  Mendelson.  On  the  contrary,  the  kidney  of  fever  is  commonly 
swollen,  the  blood-vessels  are  congested,  and  the  cortex  frequently  shows  traces 
of  cloudy  swelling.  However,  the  circulatory  disturbances  in  acute  fevers  are 
probably  less  important  than  the  irritative  effects. of  either  the  specific  agents 
of  the  disease  or  the  products  produced  in  their  growth  or  in  the  altered  metab- 
olism of  the  tissues.  The  urine  is  diminished  in  amount,  and  may  contain 
albumin  and  tube-casts,  sometimes  much  of  the  former  and  few  of  the  latter. 

(2)  Passive  Congestion;  Mechanical  Hyperemia. — This  is  found  in 
cases  of  chronic  disease  of  the  heart  or  lung,  with  impeded  circulation,  and  as 


668  DISEASES  OF  THE  KIDNEYS. 

a  result  of  pressure  upon  the  renal  veins  by  tumors,  the  pregnant  uterus,  or 
ascitic  fluid.  In  the  cardiac  kidne}',  as  it  is  called,  the  c3ranotic  induration 
associated  with  chronic  heart-disease,  the  organs  are  enlarged  and  firm,  the 
capsule  strips  off,  as  a  rule,  readily,  the  cortex  is  of  a  deep  red  color,  and  the 
pyramids  of  a  purple  red.  The  section  is  coarse-looking,  the  substance  is  very 
firm,  and  resists  cutting  and  tearing.  The  interstitial  tissue  is  increased,  and 
there  is  a  small-celled  infiltration  between  the  tubules.  Here  and  there  the 
]\Ialpighian  tufts  have  become  sclerosed.  The  blood-vessels  are  usually  thick- 
ened, and  there  may  be  more  or  less  granular,  fatty,  or  hyaline  changes  in  the 
epithelium  of  the  tubules.  The  condition  is  indeed  a  diffuse  nephritis.  The 
urine  is  usually  reduced,  is  of  high  specific  gravity,  and  contains  more  or  less 
albumin.  Hyaline  tube-casts  and  blood-corpuscles  are  not  uncommon.  In 
some  cases  (over  half)  with  macroscopically  no  signs  of  chronic  or  acute 
nephritis  the  urinary  features  lead  to  the  diagnosis  of  acute  nephritis 
(Emerson).  In  uncomplicated  cases  of  the  c3'^anotic  induration  uraemia  is 
rare.  On  the  other  hand,  in  the  cardiac  cases  with  extensive  arterio-sclerosis, 
the  kidneys  are  more  involved  and  the  renal  function  is  likely  to  be  disturbed. 


IV.    ANOMALIES    OF    THE  URINARY    SECRETION. 

1.  Anuria. 

Total  suppression  of  urine  occurs  under  the  following  conditions : 

(1)  As  an  event  in  the  intense  congestion  of  acute  nephritis.  For  a  time 
no  urine  may  be  formed ;  more  often  the  amount  is  greatly  reduced. 

(2)  More  commonly  complete  anuria  is  seen  in  subjects  of  renal  stone, 
fragments  of  which  block  both  ureters;  or  as  in  a  case  recently  reported  by 
Monod  the  calculus  blocked  the  only  kidney,  the  other  being  represented  by  a 
shell  of  tissue.  Sir  William  Eoberts  calls  the  condition  "latent  ursmia." 
There  may  be  very  little  discomfort,  and  the  symptoms  are  very  unlike  those 
of  ordinary  urgemia.  Convulsions  occurred  in  only  5  of  41  cases  (Herter) ; 
headache  in  only  6 ;  vomiting  in  only  13.  Consciousness  is  retained ;  the  pupils 
are  usually  contracted ;  the  temperature  may  be  low ;  there  are  twitchings  and 
perhaps  occasional  vomiting.  Of  41  cases  in  the  literature,  35  occurred  in 
males.  Of  36  cases  in  which  there  was  absolute  anuria,  in  11  the  condition 
lasted  more  than  four  days,  in  18  cases  from  seven  to  fourteen  daj'^s,  and  in 
7  cases  longer  than  fourteen  days  (Herter). 

(3)  Cases  occur  occasionally  in  which  the  suppression  is  prerenal.  The 
following  are  among  the  more  important  conditions  with  which  this  form  of 
anuria  may  be  associated  (Hensley)  :  Fevers  and  inflammations;  acute  poison- 
ing by  phosphorus,  lead,  and  turpentine;  in  the  collapse  after  severe  injuries 
or  after  operations,  or,  indeed,  after  the  passing  of  a  catheter;  in  the  collapse 
stage  of  cholera  and  yellow  fever ;  and,  lastly,  there  is  an  hysterical  anuria,  of 
which  Charcot  reports  a  eas^  in  which  the  suppression  lasted  for  eleven  daj^s. 
Bailey  reports  the  ease  of  a  young  girl,  aged  eleven,  inmate  of  an  orphan 
asylum,  who  passed  no  urine  from  Octol^er  10th  to  December  12th  (when  8 
ounces  were  withdrawn),  and  again  from  this  date  to  March  1st!  The  ques- 
tion of  hysterical  deception  was  considered  in  the  case. 

A  patient  may  live  for  from  ten  days  to  two  weeks  vith  complete  sup- 


ANOMALIES  OF  THE   URINARY  SECRETION.  669 

pression.  In  Polk's  ease,  in  which  the  only  kidney  was  removed,  the  patient 
d  eleven  days.  It  is  remarkable  that  in  many  instances  there  are  no  toxic 
features.    Adams  reports  a  case  of  recovery  after  nineteen  days  of  suppression. 

In  the  obstructive  cases  surgical  interference  should  be  resorted  to.  In 
the  non-obstructive  cases,  particularly  when  due  to  extreme  congestion  of 
the  kidney,  cupping  over  the  loins,  hot  applications,  free  purging,  and  sweat- 
ing with  pilocarpine  and  hot  air  are  indicated.  When  the  secretion  is  once 
started  diuretin  often  acts  well.  Large  hot  irrigations,  with  normal  salt  solu- 
tion, with  Kemp's  double-current  rectal  tubes,  should  be  tried,  as  they  are 
stated  to  stimulate  the  activity  of  the  kidneys  in  a  remarkable  way. 

2.    HEMATURIA. 

Etiology. — The  following  division  may  be  made  of  the  causes  of  hsema- 
turia : 

(1)  General  Diseases. — The  malignant  forms  of  the  acute  specific  fevers. 
Occasionally  in  leukaemia  hgematuria  occurs. 

(2)  Renal  Causes. — Acute  congestion  and  inflammation,  as  in  Bright's 
disease,  or  the  effect  of  toxic  agents,  such  as  turpentine,  carbolic  acid,  Sind^^^f\^ 
cantharides.  When  the  carbolic  spray  was  in  use  many  surgeons  suffered  from  .  j 
haematuria  in  consequence  of  this  poison.  Renal  infarction,  as  in  ulcerative  '^'j*'**^ 
endocarditis.  New  growths,  in  which  the  bleeding  is  usually  profuse.  In  tuber-  <'!;«>•.*- 
culosis  at  the  onset,  when  the  papillae  are  involved,  there  may  be  bleeding.  /^„*^ 
Stone  in  the  kidney  is  a  frequent  cause.  Parasites :  The  Filaria  sanguinis  liom-  ^ 
inis  and  the  BilJiarzia  cause  a  form  of  haematuria  met  with  in  the  tropics.  /V**** 
The  echinocoecus  is  rarely  associated  with  haemorrhage.    It  is  sometimes  met 

with  in  floating  kidney.  / 

Unilateral  renal  hcematuria  has  been  described  by  Senator,  Eshner,  and 
others.  The  cases  are  not  uncommon,  as  48  cases  have  been  tabulated  by 
Eshner.  In  nearly  all  the  diagnosis  of  calculus  or  neoplasm  had  been  made. 
In  16  cases  nothing  was  found  at  operation.  Displacement  was  present  in  6 
cases,  alteration  in  the  pelvis  of  the  kidney  in  9,  other  destructive  lesions  of 
the  kidney  in  11.  The  condition  has  been  termed  by  Senator  renal  haemophilia, 
but  renal  "  epistaxis,"  as  suggested  by  Gull,  is  a  more  appropriate  term. 

(3)  Affections  of  the  Urinary  Passages. — Stone  in  the  ureter,  tumor 
or  ulceration  of  the  bladder,  the  presence  of  a  calculus,  parasites,  and,  very 
rarely,  ruptured  veins  in  the  bladder.  Bleeding  from  the  urethra  occasion- 
ally occurs  in  gonorrhoea  and  as  a  result  of  the  lodgment  of  a  calculus.  Recur- 
ring hasmaturia  may  be  an  early  symptom  in  enlarged  prostate.  An  unusual 
cause  is  the  painful,  villous  tumor  of  the  renal  pelvis,  of  which  Savory  and 
ISTash  report  a  remarkable  case  and  have  collected  49  others  from  the  literature. 
It  would  be  difficult  to  recognize  the  condition  from  stone. 

(4)  Traumatism. — Injuries  may  produce  bleeding  from  any  part  of  the 
urinary  passages.  By  a  fall  or  blow  on  the  back  the  kidney  may  be  ruptured, 
and  this  may  be  followed  by  very  free  bleeding ;  less  commonly  the  blood  comes 
from  injury  of  the  bladder  or  of  the  prostate.  Blood  from  the  urethra  is 
frequently  due  to  injury  by  the  passage  of  a  catheter,  or  sometimes  to  falls. 
Transient  haematuria  follows  all  operations  on  the  kidney. 

The  malarial  haematuria  has  already  been  considered  in  the  section  on 
paludism. 


670  DISEASES  OF  THE  KIDNEYS. 

Diagnosis. — The  diagnosis  of  hj^niaturia  is  usually  eas}^  The  color  of  the 
urine  varies  from  a  light  smok}^  to  a  l^right  red^  or  it  may  have  a  dark  porter 
color.  Examined  with  the  microscope^  the  blood-corpuscles  are  readily  recog- 
nized, either  plainly  visible  and  retaining  their  color,  in  which  case  they  are 
usually  crenated,  or  simply  as  shadows.  In  ammoniacal  urine  or  urines  of 
low  specifi-C  gravity  the  haemoglobin  is  rapidly  dissolved  from  the  corpuscles, 
but  in  normal  urine  they  remain  for  many  hours  unchanged. 

It  is  important  to  distinguish  between  blood  coming  from  the  bladder 
and  from  the  kidneys,  though  this  is  not  always  easy.  From  the  bladder  the 
blood  may  be  found  only  with  the  last  portions  of  urine,  or  only  at  the  ter- 
mination of  micturition.  In  haemorrhage  from  the  kidnej's  the  blood  and  urine 
are  intimately  mixed.  Clots  are  more  commonly  found  in.  the  blood  from  the 
kidneys,  and  may  form  moulds  of  the  pelvis  or  of  the  ureter.  When  the  seat 
of  the  bleeding  is  in  the  bladder,  on  washing  out  this  organ,  the  water  is  more 
or  less  blood-tinged;  but  if  the  source  of  the  bleeding  is  higher,  the  water 
comes  away  clear.  In  many  instances  it  is  difficult  to  settle  the  question  by 
the  examination  of  the  urine  alone,  and  the  symptoms  and  the  physical  signs 
must  also  be  taken  into  account.  Cj'stoscopic  examination  of  the  bladder,  pay- 
ing especial  attention  to  the  urine  flowing  from  each  ureteral  orifice,  and 
catheterization  of  the  ureters  are  aids  in  the  diagnosis  of  doubtful  cases. 

3.    HEMOGLOBINURIA. 

This  condition  is  characterized  by  the  presence  of  blood-pigment  in  the 
urine.  The  blood-cells  are  either  absent  or  in  insignificant  nmnbers.  The 
coloring  matter  is  not  hgematin,  as  indicated  by  the  old  name,  hcematinuria, 
nor  in  reality  always  hsemoglobin,  but  it  is  most  frequently  methsemoglobin. 
The  urine  has  a  red  or  bro'^mish-red,  sometimes  quite  black  color,  and  usually 
deposits  a  very  heav}^  brownish  sediment.  "When  the  haemoglobin  occurs  only  in 
small  quantities,  it  ma}^  give  a  lake  or  smoky  color  to  the  urine.  Microscopical 
examination  shows  the  presence  of  granular  pigment,  sometimes  fragments  of 
blood-disks,  epithelium,  and  very  often  darkly  pigmented  urates.  The  urine 
is  also  albuminous.  The  number  of  red  blood-corpuscles  bears  no  proportion 
whatever  to  the  intensity  of  the  color  of  the  urine.  Examined  spectroscop- 
ically,  there  are  either  the  two  absorption  bands  of  oxyhgemoglobin,  which  is 
rare,  or,  more  commonly,  there  are  the  three  absorption  bands  of  methgemo- 
globin,  of  which  the  one  in  the  red  near  C  is  characteristic'  Two  clinical 
groups  may  be  distinguished. 

(1)  Toxic  Hsemoglobinuria. — This  is  caused  by  poisons  which  produce 
rapid  dissolution  of  the  blood-corpuscles,  such  as  potassium  chlorate  in  large 
doses,  pyrogallic  acid,  carbolic  acid,  arseniuretted  hydrogen,  carbon  monoxide, 
naphthol,  and  muscarine ;  also  the  poisons  of  scarlet  fever,  yellow  fever,  typhoid 
fever,  malaria,  and  s}^hilis.  According  to  Bastianelli,  hsemoglobinuria  due 
to  the  administration  of  quinine  never  occurs  excepting  in  patients  who  are 
suffering  or  who  have  recently  suffered  from  malarial  fever.  It  has  also  fol- 
lowed severe  burns.  Exposure  to  excessive  cold  and  violent  muscular  exertion 
are  stated  to  produce  haemoglobinuria.  A  most  remarkable  toxic  form  occurs 
in  horses,  coming  on  with  great  suddenness  and  associated  with  paresis  of  the 
hind  legs.  Death  may  occur  in  a  few  hours  or  a  few  days.  The  animals  are 
attacked  only  after  being  stalled  for  some  days  and  then  taken  out  and  driven, 


ANOMALIES  OF  THE   URINARY  SECRETION.  671 

particularly  in  cold  weather.  The  form  of  hemoglobinuria  from  cold  and 
exertion  is  extremely  rare.  No  instance  of  it,  even  in  association  with  frost- 
bites, came  under  my  observation  in  Canada.  Blood  transfused  from  one 
mammal  into  another  causes  dissolution  of  the  corpuscles  with  the  produc- 
tion of  hgemoglobinuria ;  and,  lastly,  there  is  the  epidemic  hcemoglohinuria  of 
the  new-born,  associated  with  jaundice,  cyanosis,  and  nervous  symptoms. 

(3)  Paroxysmal  Hsemoglobinuria. — This  rare  disease  is  characterized  by 
the  occasional  passage  of  bloody  urine,  in  which  the  coloring  matter  only  is 
present.  It  is  more  frequent  in  males  than  in  females,  and  occurs  chiefly  in 
adults.  It  seems  specially  associated  with  cold  and  exertion,  and  has  often 
been  brought  on,  in  a  susceptible  person,  by  the  use  of  a  cold  foot-bath.  Par- 
oxysmal hemoglobinuria  has  been  found,  too,  in  persons  subject  to  the  vari- 
ous forms  of  Eaynaud's  disease.  Many  regard  the  relation  between  these  two 
affections  as  extremely  close;  some  hold  that  they  are  manifestations  of  one 
and  the  same  disorder.  Druitt,  the  author  of  the  well-knoAvn  Surgical  Vade- 
mecum,  has  given  a  graphic  description  of  his  sufferings,  which  lasted  for  many 
years,  and  were  accompanied  with  local  asphyxia  and  local  syncope.  The 
connection,  however,  is  not  very  common.  In  only  one  of  the  cases  of  Eay- 
naud's disease  which  I  have  seen  was  paroxysmal  hemoglobinuria  present,  and 
in  it  epileptic  attacks  occurred  at  the  same  time.  The  relation  of  the  disease 
to  malaria  has  been  considered. 

The  attacks  may  come  on  suddenly  after  exposure  to  cold  or  as  a  result 
of  mental  or  bodily  exhaustion.  They  may  be  preceded  by  chills  and  pyrexia. 
In  other  instances  the  temperature  is  subnormal.  There  may  be  vomiting  and 
diarrhoea.  Pain  in  the  lumbar  region  is  not  uncommon.  The  hemoglobinuria 
rarely  persists  for  more  than  a  day  or  two — sometimes,  indeed,  not  for  a  day. 
There  are  instances  in  which,  even  in  the  course  of  a  single  day,  there  have 
been  two  or  three  paroxysms,  and  in  the  intervals  clear  urine  has  been  passed. 
Jaundice  has  been  present  in  a  number  of  cases.  The  cases  are  rarely  if  ever 
fatal. 

The  essential  pathology  of  the  disease  is  unknown,  and  it  is  difficult  to 
form  a  theory  which  will  meet  all  the  facts — ^particularly  the  relation  with  Eay- 
naud's disease,  which  is  rightly  regarded  as  a  vaso-motor  disorder.  Increased 
hemolysis  and  solution  of  the  hemoglobin  in  the  blood-serum  (hemoglobi- 
nemia)  precedes,  in  each  instance,  the  appearance  of  the  coloring  matter  in  the 
urine.  A  full  discussion  of  the  subject  is  to  be  found  in  F.  Chvostek's  mono- 
graph.   Blanc  regards  it  as  distinctly  nervous  in  origin. 

Treatment. — In  all  forms  of  hematuria  rest  is  essential.  In  that  produced 
by  renal  calculi  the  recumbent  posture  may  suffice  to  check  the  bleeding.  Full 
doses  of  acetate  of  lead  and  opium  should  be  tried,  then  ergot,  gallic  and 
tannic  acid,  and  the  dilute  sulphuric  acid.  The  oil  of  turpentine,  which  is 
sometimes  recommended,  is  a  risky  remedy  in  hematuria.  Extr.  hamamelis 
virgin,  and  extr.  hydrastis  canad.  are  also  recommended.  Cold  may  be  applied 
to  the  loins  or  dry  cups  in  the  lumbar  region.  Incision  of  the  kidney  has 
cured  the  so-called  renal  epistaxis. 

The  treatment  of  paroxysmal  hemoglobinuria  is  unsatisfactory.  Amyl 
nitrite  will  sometimes  cut  short  or  prevent  an  attack  (Chvostek).  During  the 
paroxysm  the  patient  should  be  kept  warm  and  given  hot  drinks.  Quinine  is 
recommended  in  large  doses,  on  the  supposition — as  yet  unwarranted — that  the 


672  DISEASES  OF   THE  KIDNEYS. 

disease  is  specially  connected  Tvitli  malaria.  If  there  is  a  s}^liilitic  history, 
iodide  of  potassium  in  full  doses  may  be  tried.  In  a  warm  climate  the  attacks 
are  much  less  frequent. 

4.  Albumixukia. 

"  Reasons  drawn  from  the  urine  are  as  brittle  as  the  urinal  "  is  a  dictum  of 
Thomas  Fuller  peculiarly  appropriate  in  connection  with  this  subject. 

The  presence  of  albumin  in  the  urine,  formerly  regarded  as  indicative  of 
Briglifs  disease,  is  now  recognized  as  occurring  under  many  circumstances 
without  the  existence  of  serious  organic  change  in  the  kidney.  Two  groups 
of  cases  may  be  recognized — those  in  which  the  kidneys  show  no  coarse  lesions, 
and  those  in  which  there  are  evident  anatomical  changes. 

Albumimiria  without  Coarse  Renal  Lesions. —  (a)  Functional^  so-called 
Physiological  Albumixueia. — In  a  normal  condition  of  the  kidney  only 
the  water  and  the  salts  are  allowed  to  pass  from  the  blood.  When  albuminous 
substances  transude  there  is  probably  disturbance  in  the  nutrition  of  the  epi- 
thelium of  the  capillaries  of  the  tuft,  or  of  the  ceUs  surrounding  the  glome- 
rulus. This  statement  is  still,  however,  in  dispute,  and  Senator  and  others 
hold  that  there  is  a  plwsiological  albuminuria  which  may  follow  muscular 
work,  the  ingestion  of  food  rich  in  albumin,  violent  emotions,  cold  bathing, 
and  dyspepsia.  But  on  one  point  all  agree,  that  the  cause  must  be  some- 
thing unusual  and  excessive,  as  an  unusually  hard  tramp,  a  football  match, 
a  race,  etc.  The  presence  of  albumin  in  the  urine,  in  any  form  and  under 
any  circumstance,  may  be  regarded  as  indicative  of  change  in  the  renal  or 
glomerular  epithelium,  a  change,  however,  which  may  be  transient,  slight,  and 
unimportant,  depending  upon  variations  in  the  circulation  or  upon  the  irri- 
tating effects  of  substances  taken  with  the  food  or  temporarily  jDresent,  as  in 
febrile  states. 

Albuminuria  of  adolescence  and  cyclic  albuminuria,  in  which  the  albu- 
min is  present  only  at  certaiu  times  during  the  day — orthostatic  albuminuria 
— are  interesting  forms.  A  majority  of  the  cases  occur  in  young  persons — 
boys  more  commonly  than  girls — and  the  condition  is  often  discovered  acci- 
dentally. These  are  often  the  children  of  neurotic  parents,  and  have  well- 
marked  vasomotor  instability.  Some  cases  last  only  during  puberty,  some 
throughout  life.  Erlanger  and  Hooker  have  shown  that  the  albumin  is  ex- 
creted only  during  periods  with  low  pulse  pressure  (difference  between  the 
diastolic  and  systolic  pressures).  The  urine,  as  a  rule,  contains  only  a  very 
small  amount  of  albumin,  but  in  some  instances  large  quantities  are  present. 
The  most  striking  feature  is  the  variability.  It  may  be  absent  in  the  morn- 
ing and  present  only  after  exertion;  or  it  ma}^  be  greatly  increased  after 
taking  food,  particularly  proteids.  Even  the  change  to  the  upright  position 
(orthostatic)  may  suffice  to  cause  it,  and  in  such  cases  there  may  be  tension  on 
the  renal  veins  by  increase  of  the  lumbar  curve,  since  it  has  been  shown  that  a 
spinal  jacket  will  prevent  the  appearance  of  the  albumin.  The  quantity  of 
urine  may  be  but  little,  if  at  all,  increased,  the  specific  gravity  is  usually  nor- 
mal, and  the  color  may  be  high.  Occasionally  hyaline  casts  may  be  found, 
and  in  some  instances  there  has  been  transient  glycosuria.  As  a  rule,  the  pulse 
is  not  of  high  tension  and  the  second  aortic  sound  is  not  accentuated. 

Various  forms  of  this  affection  have  been  recognized  by  writers,  such 


ANOMALIES  OF  THE   URINARY  SECRETION.  673 

as  neurotic,  dietetic,  cyclic,  intermittent,  and  paroxysmal — names  which  indi- 
cate the  characters  of  the  different  varieties.  A  large  proportion  of  the  cases 
get  well  after  the  condition  has  persisted  for  a  variable  period.  This  in  itself 
is  an  evidence  that  the  changes,  whatever  their  nature,  are  transient  and  slight. 
In  these  instances  the  albumin  exists  in  small  quantity,  tube-casts  are  rarely 
present,  and  the  arterial  tension  is  not  increased.  In  a  second  group  the  albu- 
min is  more  persistent,  the  amount  is  larger,  though  it  may  vary  from  day 
to  day,  and  the  pulse  tension  is  increased.  In  such  instances  the  per- 
sistent albuminuria  probably  indicates  actual  organic  change  in  the  kidney. 

(&)  Febrile  Albuminuria. — Pyrexia,  by  whatever  cause  produced,  may 
cause  slight  albuminuria.  The  presence  of  the  albumin  is  due  to  slight 
changes  in  the  glomeruli  induced  by  the  fever,  such  as  cloudy  swelling,  which 
can  not  be  regarded  as  an  organic  lesion.  It  is  extremely  common,  occurring 
in  pneumonia  (in  about  70  per  cent  of  our  cases),  diphtheria,  typhoid  fever 
(about  60  per  cent  of  our  cases),  malaria,  especially  the  sestivo-autumnal  type, 
and  even  in  the  fever  of  acute  tonsillitis.  The  amount  of  albumin  is  slight, 
and  it  usually  disappears  from  the  urine  with  the  cessation  of  the  fever. 
Hyaline  and  even  epithelial  casts  accompany  the  condition. 

(c)  H^Mic  Changes. — Purpura,  scurvy,  chronic  poisoning  by  lead  or 
mercury,  syphilis,  leukeemia,  and  profound  anaemia  may  be  associated  with 
slight  albuminuria.  Abnormal  ingredients  in  the  blood,  such  as  bile-pigment 
and  sugar,  may  cause  the  passage  of  small  amounts  of  albumin. 

The  transient  albuminuria  of  pregnancy  may  belong  to  this  h^mic  group, 
although  in  a  majority  of  such  cases  there  are  'changes  in  the  renal  tissue. 
Albumin  may  be  found  sometimes  after  the  inhalation  of  ether  or  chloroform. 

(d)  Nervous  System. — Albuminuria  occurs  in  certain  affections  of  the 
nervous  system.  This  so-called  neurotic  albuminuria  is  seen  after  an  epileptic 
seizure  and  in  apoplexy,  tetanus,  exophthalmic  goitre,  and  injuries  of  the  head. 

Albuminuria  with  Definite  Lesions  of  the  Urinary  Organs. — (a)  Conges- 
tion of  the  kidney,  either  active,  such  as  follows  exposure  to  cold  and  is  asso- 
ciated with  the  early  stages  of  nephritis,  or  passive,  due  to  obstructed  outflow 
in  disease  of  the  heart  or  lungs,  or  to  pressure  on  the  renal  veins  by  the  preg- 
nant uterus  or  tumors. 

(&)  Organic  disease  of  the  kidneys — acute  and  chronic  Bright's  disease, 
amyloid  and  fatty  degeneration,  suppurative  nephritis,  and  tumors. 

(c)  Affections  of  the  pelvis,  ureters,  and  bladder,  when  associated  with 
the  formation  of  pus. 

Tests  for  Albumin. — ^Both  morning  and  evening  urine  should  be  examined, 
and  in  doubtful  cases  at  least  three  specimens.  If  turbid,  the  urine  should  be 
filtered,  though  turbidity  from  the  urates  is  of  no  moment,  since  it  disappears 
at  once  on  the  application  of  heat. 

Heat  and  Nitric-acid  Test. — The  urine  is  boiled  in  a  test-tube  over  a  spirit- 
lamp,  and  a  drop  of  nitric  acid  is  then  added.  If  a  cloudiness  occurs  on  boil- 
ing, it  may  be  due  to  phosphates,  which  are  dissolved  on  the  addition  of  an 
acid.    Persistence  of  the  cloudiness  indicates  albumin. 

Heller's  Test. — A  small  quantity  of  fuming  nitric  acid  is  poured  into  the 
test-tube,  and  with  a  pipette  the  urine  is  allowed  to  flow  gently  down  the  side 
upon  the  acid.  At  the  line  of  junction  of  the  two  fluids,  if  albumin  is  present, 
a  white  ring  is  formed.     This  contact  method  is  trustworthy,  and,  for  the 


674:  DISEASES  OF  THE  KIDNEYS. 

routine  clinical  ^vork.  is  prolmbly  the  most  satisfactory.  A  diffused  liaze.  due 
to  mucin  (nucleo-albumin),  is  sometimes  seen  just  above  the  white  ring  of 
albumin:  and  in  very  concentrated  urines,  or  after  the  taking  of  balsamic 
remedies,  a  slight  cloudiness  may  be  due  to  urates  or  uric  acid,  which  clears 
on  heating  or  warming.  A  colored  ring  at  the  junction  of  the  acid  and  the 
urine  is  due  to  the  oxidation  of  tlie  coloring  matters  in  the  urine. 

Ferrocyanide-of -potassium  and  Acetic-acid  Test. — Fill  an  ordinary  test- 
tube  half  full  of  urine,  and  add  5  or  6  cc.  of  potassium-ferrocyanide  solution 
(1  in  20).  Thoroughly  mix  the  urine  and  reagent  and  add  10  to  15  drops  of 
acetic  acid.  If  albumin  be  present,  a  cloudiness  varying  in  degree  accord- 
ing to  the  amount  of  albumin  will  be  produced.  This  is  a  very  reliable 
test,  as  it  precipitates  all  forms  of  albumin,  acid  and  alkaline,  but  does  not 
precipitate  mucin,  peptones,  phosphates,  urates,  vegetable  alkaloids,  or  the 
pine  acids. 

Sir  William  Eoberts  strongly  recommends  the  magnesium-nitric  test.  One 
volume  of  strong  nitric  acid  is  mixed  with  five  volumes  of  the  saturated  solu- 
tion of  sulphate  of  magnesium.  This  is  used  in  the  same  way  as  the  nitric 
acid  in  Hellers  test. 

Picric  acid,  introduced  Ijy  George  Johnson,  is  a  delicate  and  useful  test 
for  albumin.  A  saturated  solution  is  used  and  employed  as  in  the  contact 
method.  It  has  been  urged  against  this  test  that  it  throws  down  the  mucin, 
peptones,  and  certain  vegetable  alkaloids,  but  these  are  dissolved  by  heat. 

For  minute  traces  of  albumin  the  trichloracetic  acid  may  be  used,  or  Mil- 
lard's fluid,  which  is  extremely  delicate  and  consists  of  glacial  carbolic  acid 
(95  per  cent),  2  drachms;  pure  acetic  acid,  T  drachms;  liquor  potassge,  2  ounces 
6  drachms. 

A  quantitative  estimate  of  the  albumin  can  be  made  by  means  of  Esbach's 
tube,  but  the  rough  method  of  heating  and  boiling  a  certain  quantity  of 
acidulated  urine  in  a  test-tube  and  allowing  it  to  stand,  is  often  employed. 
The  depth  of  deposit  can  then  be  compared  with  the  whole  amount  of  urine, 
and  the  proportion  is  expressed  as  a  mere  trace,  almost  solid — one-fourth,  one- 
half,  and  so  on.  This,  of  course,  does  not  give  an  accurate  indication  of  the 
proportion  of  albumin  in  the  total  quantity  of  urine.  For  the  more  elabo- 
rate methods  the  reader  is  referred  to  the  works  on  urinalysis. 

The  above  tests  refer  entirely  to  serum-albumin.  Other  albuminous  sub- 
stances occur,  such  as  albumose,  serum-globulin,  peptones,  and  hemi-albumose 
or  propeton.     They  are  not  of  much  clinical  importance. 

Albumosuria. — Traces  of  albumoses  are  found  in  the  urine  in  many  febrile 
diseases,  as  pneumonia,  and  in  chronic  suppuration,  and  have  little  clinical 
significance. 

Myelopathic  Albumosuria,  ''  KaliJer's  disease,''  is  characterized  by  multi- 
ple myelomata  with  persistent  excretion  of  what  is  known  as  the  Bence-Jones 
body,  a  proteid  discovered  by  him  in  1848.  There  are  between  thirty-five  and 
forty  cases  on  record  (Anders  and  Boston.  Lancet,  1903;  Parkes  Weber,  Med.- 
Chir.  Trans.,  vol.  Ixxxvi).  Males  above  forty  years  of  age  are  usually  affected. 
The  Bence-Jones  body  does  not  appear  ^vith  other  tumors  of  the  bones.  As 
in  a  case  which  I  saw  with  Hamburger,  the  persistent  albumosuria  may  lead 
to  the  diagnosis  of  multiple  myelomata  before  any  bone  tumors  can  be  felt. 
The  disease  rims  a  fatal  course.     The  simplest  reaction  is  the  white  precipi- 


ANOMALIES  OF  THE   URINARY  SECRETION.  675 

tate  formed  on  adding  nitric  acid  to  the  urine;  when  boiled  it  disappears,  to 
reappear  on  cooling.  As  in  one  of  Bradshaw's  cases,  the  urine  may  be  of  a 
milky  white  color  when  passed. 

Globulin  rarely  occurs  in  the  urine  alone,  but  generally  in  association  with 
serum-albumin.  The  latter  is  usually  present  in  greater  quantity,  but  in  severe 
organic  renal  disease  and  in  diabetes  Maguire  has  found  that  the  proportion 
of  globulin  to  albumin  is  often  2.5  to  1.  Senator  states  that  more  globulin  is 
present  with  the  lardaceous  kidney  than  in  other  forms  of  nephritis.  The 
clinical  significance  of  globulin  is  the  same  as  that  of  serum-albumin. 

Prognosis. — This  depends,  of  course,  entirely  upon  the  caiise.  Febrile 
albuminuria  is  transient,  and  in  a  majority  of  the  cases  depending  upon 
heemic  causes  the  condition  disappears  and  leaves  the  kidneys  intact.  A  trace 
of  albumin  in  a  man  over  forty,  with  or  without  a  few  hyaline  casts,  is  not 
of  much  significance,  except  as  an  indication  that  his  kidneys,  like  his  hair, 
are  beginning  to  turn  "  gray  "  with  age.  In  many  instances  the  discovery  is  a 
positive  advantage,  as  the  man  is  made  to  realize,  perhaps,  for  the  first  time 
that  he  has  been  living  carelessly.  I  have  discussed  the  question  from  this 
standpoint  in  a  paper  with  the  paradoxical  title  "  On  the  Advantages  of  a 
Trace  of  Albumin  and  a  few  Tube-casts  in  the  Urine  of  Men  over  Fifty  Years 
of  Age"  CN.  Y.  Med.  Jour.,  vol.  Ixxiv). 

The  persistence  of  a  slight  amount  of  albumin  in  young  men  without  in- 
creased arterial  tension  is  less  serious,  as  even  after  continuing  for  years  it 
may  disappear.  I  have  already  spoken  of  the  outlook  in  the  so-called  cyclic 
albuminuria. 

Practically  in  all  cases  the  presence  of  albumin  indicates  a  change  of 
some  sort  in  the  glomeruli,  the  nature,  extent,  and  gravity  of  which  it  is 
difficult  to  estimate ;  so  that  other  considerations,  such  as  the  presence  of  tube- 
casts,  the  existence  of  increased  tension,  the  general  condition  of  the  patient, 
and  the  infiuence  of  digestion  upon  the  albumin,  must  be  carefully  considered. 

The  physician  is  daily  consulted  as  to  the  relation  of  albuminuria  and 
life  assurance.  As  his  function  is  to  protect  the  interests  of  the  company, 
he  should  reject  all  cases  in  which  albumin  occurs  in  the  urine.  It  is  even 
doubtful  if  an  exception  should  be  made  in  young  persons  with  transient 
albuminuria.  ]S[aturally,  companies  lay  great  stress  upon  the  presence  or 
absence  of  albumin,  but  in  the  most  serious  and  fatal  malady  with  which  they 
have  to  deal — chronic  interstitial  nephritis — the  albumin  is  often  absent  or 
transient,  even  when  the  disease  is  well  developed.  After  the  fortieth  year, 
from  a  standpoint  of  life  insurance,  the  state  of  the  arteries  and  the  blood 
pressure  is  far  more  important  than  the  condition  of  the  urine. 

With  reference  to  the  significance  of  albuminuria  in  adults,  I  quite  agree 
with  the  following  conclusions  of  F.  C.  Shattuck : 

(1)  Eenal  albuminuria,  as  proved  by  the  presence  of  both  albumin  and 
casts,  is  ^auch  more  common  in  adults,  quite  apart  from  Bright's  disease  or 
any  obvious  source  of  renal  irritation,  than  is  generally  supposed. 

(2)  The  frequency  increases  steadily  and  progressively  with  advancing  age. 

(3)  This  increase  with  age  suggests  the  explanation  that  the  albuminuria 
is  often  an  indication  of  senile  degeneration. 

(4)  Though  it  can  not  be  regarded  as  yet  as  absolutely  proved,  it  is  highly 
probable  that  faint  traces  of  albumin  and  hyaline  and  finely  granular  easts 


676  DISEASES  OF  THE  KIDNEYS. 

of  small  diameter  are  often,  especially  in  those  past  fifty  years  of  age,  of  little 
or  no  practical  importance. 

E.  C.  Cabot's  studies  also  show  that  we  have  been  laying  altogether  too 
much  stress  on  albumin  and  tube-casts  as  indicative  of  serious  disease  of  the 
kidneys. 

5.  Pyuria  {Pus  in  the  Urine). 

Causes. — (1)  Pyelitis  and  Pyelonephritis. — In  large  abscesses  of  the 
kidney,  pyonephrosis,  the  pus  may  be  intermittent,  while  in  calculous  and 
tuberculous  pyelitis  the  p5airia  is  usually  continuous,  though  varying  in  in- 
tensity. In  cases  due  to  the  colon  or  tubercle  bacillus  the  urine  is  acid,  in 
those  due  to  the  proteus  bacillus  alkaline,  while  in  the  staphylococcus  cases 
the  urine  is  either  less  acid  than  normal,  or  alkaline.  In  the  pyelitis  and 
pyelonephritis  following  cystitis  the  urine  is  alkaline  or  acid,  depending  upon 
the  infecting  micro-organism;  more  mucus,  frequent  micturition,  and  a  pre- 
vious bladder  history  are  aids  in  diagnosis. 

(2)  Cystitis. — The  urine  is  usually  acid,  especially  in  women,  since  the 
colon  bacillus  is  a  very  common  cause  of  these  infections.  The  pus  and  mucus 
are  more  ropy,  and  triple  phosphate  crystals  are  found  in  the  freshly  passed 
urine  in  the  alkaline  infections. 

(3)  Urethritis,  particularly  gonorrhoea.  The  pus  appears  first,  is  in 
small  quantities,  and  there  are  signs  of  local  inflammation. 

(4)  In  LEUCORRHCEA  the  quantity  of  pus  is  usually  small,  and  large  flakes 
of  vaginal  epithelium  are  numerous.  In  doubtful  cases,  when  leucorrhoea 
is  present,  the  urine  should  be  withdrawn  through  a  catheter. 

(5)  Eupture  of  Abscesses  into  the  Urinary  Passages. — In  such  cases 
as  pelvic  or  perityplitic  abscess  there  have  been  previous  symptoms  of  pus 
formation.  A  large  amount  is  passed  within  a  short  time,  then  the  discharge 
stops  abruptly  or  rapidly  diminishes  within  a  few  days. 

Pus  gives  to  the  urine  a  white  or  yellowish-white  appearance.  On  settling, 
the  sediment  is  sometimes  ropy,  the  supernatant  fluid  usually  turbid.  In  cases 
due  to  urea-decomposing  microbes  (proteus  bacillus,  various  staphylococci)  the 
odor  may  be  ammoniacal  even  in  fresh  urine.  Examination  with  the  micro- 
scope reveals  the  presence  of  a  large  number  of  pus-corpuscles,  which  are 
usually,  when  the  pus  comes  from  the  bladder,  well  formed;  the  protoplasm 
is  granular,  and  often  shows  many  translucent  processes. 

The  only  sediment  likely  to  be  confounded  with  pus  is  that  of  the  phos- 
phates; but  it  is  whiter  and  less  dense,  and  is  distinguished  immediately  by 
microscopical  examination  or  by  the  addition  of  acid. 

With  the  pus  there  is  always  more  or  less  epithelium  from  the  bladder 
and  pelves  of  the  kidneys,  but  since  in  these  situations  the  forms  of  cells  are 
practically  identical,  they  afford  no  information  as  to  the  locality  from  which 
the  pus  has  come. 

The  treatment  of  pus  in  the  urine  is  considered  under  the  conditions  in 
which  it  occurs. 

6.  ChYLURIA ISTON-PARASITIC. 

This  is  a  rare  affection,  occurring  in  temperate  regions  and  unassoeiated 

with  the  Filaria  hancrofti.    The  urine  is  of  an  opaque  white  color;  it  resem- 


ANOMALIES  OF  THE   URINARY  SECRETION.  677 

bles  milk  closely,  is  occasionally  mixed  with  blood  (haematochyluria),  and 
sometimes  coagulates  into  a  firm,  jelly-like  mass.  In  other  instances  there 
is  at  the  bottom  of  the  vessel  a  loose  clot  which  may  be  distinctly  blood-tinged. 
Under  the  microscope  the  turbidity  seems  to  be  caused  by  numerous  minute 
granules — more  rarely  oil  droplets  similar  to  those  of  milk.  In  Montreal  I 
made  the  dissection  in  a  case  of  thirteen  years'  duration  and  could  find  no 
trace  of  parasites  (see  Hertz,  Med.-Chir.  Soc.  Trans.,  1907). 

7.  LiTHUEiA  (Lithcemia;  Lithic-acid  Diathesis). 

The  general  relations  of  uric  acid  have  already  been  considered  in  speak- 
ing of  gout. 

Occurrence  in  the  TTrine. — The  uric  acid  occurs  in  combination  chiefly 
with  ammonium  and  sodium,  forming  the  acid  urates.  In  smaller  quan- 
tities are  the  potassium,  calcium,  and  lithium  salts.  The  uric  acid  may  be 
separated  from  its  bases  and  crystallizes  in  rhombs  or  prisms,  which  are  usu- 
ally of  a  deep  red  color,  owing  to  the  staining  of  the  urinary  pigments.  The 
sediment  formed  is  granular  and  the  groups  of  crystals  look  like  grains  of 
Cayenne  pepper.  It  is  very  important  not  to  mistake  a  deposit  of  uric  acid 
for  an  excess.  The  deposition  of  numerous  grains  in  the  urine  within  a  few 
hours  after  passing  is  more  likely  to  be  due  to  conditions  which  diminish  the 
solvent  power  than  to  increase  in  the  quantity.  Of  the  conditions  which 
cause  precipitation  of  the  uric  acid  Eoberts  gives  the  following:  ^^  (1)  High 
acidity;  (2)  poverty  in  mineral  salts;  (3)  low  pigmentation;  and  (4)  high 
percentage  of  uric  acid."  The  grade  of  acidity  is  probably  the  most  impor- 
tant element. 

In  health  the  weight  of  uric  acid  excreted  bears  a  fairly  constant  ratio  to 
the  weight  of  urea  eliminated.  According  to  von  Noorden,  the  average  ratio 
is  1  to  50,  while  the  average  ratio  of  the  nitrogen  of  uric  acid  to  the  total 
nitrogen  eliminated  in  the  urine  is  1  to  70.  In  several  of  the  cases  of  gout  in 
my  wards  Futcher  found  that  in  the  intervals  between  the  acute  arthritic 
attacks  the  uric  acid  was  reduced  to  a  much  greater  extent  than  the  urea, 
so  that  the  ratio  of  the  former  to  the  latter  often  varied  between  1  to  300  up 
to  (in  one  case)  1  to  1,500,  a  return  to  about  the  normal  proportions  occurring 
during  the  acute  attacks. 

More  common  is  the  precipitation  of  amorphous  urates,  forming  the  so- 
called  brick-dust  or  lateritious  deposit,  which  has  a  pinkish  color,  due  to 
the  presence  of  urinary  pigment.  It  is  composed  chiefly  of  the  acid  sodium 
urates.  It  occurs  particularly  in  very  acid  urine  of  a  high  specific  gravity. 
As  the  urates  are  more  soluble  in  warm  solutions,  they  frequently  deposit  as 
the  urine  cools.  Here,  too,  the  deposition  does  not  necessarily,  indeed  usually 
does  not,  mean  an  excessive  excretion,  but  the  existence  of  conditions  favoring 
the  deposit. 

Lithaemia. — In  addition  to  what  has  already  been  said  under  gout,  we  may 
consider  here  the  hypothetical  condition  known  as  lithtemia,  or  the  uric-acid 
diathesis.  Murchison  introduced  the  term  to  designate  certain  symptoms  due, 
as  he  supposed,  to  functional  disturbance  of  the  liver.  Not  only  have  his 
views  been  widely  adopted,  but,  as  is  so  often  the  case  when  we  give  the  rein 
to  theoretical  conceptions  of  disease,  the  so-called  manifestations  of  this  state 
have  so  multiplied  that  some  authors  attribute  to  this  cause  a  considerable  pro- 


678  DISEASES  OF  THE  KIDNEYS. 

portion  of  the  ailments  affecting  the  various  systems  of  the  body.  Thus  one 
writer  enumerates  not  fewer  than  forty-one  separate  morbid  conditions  asso- 
ciated with  lithaemia,  and  one  of  them  astigmatism  against  the  rule !  From 
our  lack  of  knowledge  of  the  mode  of  formation  and  elimination  of  uric  acid 
it  is  very  evident  that  the  physiology  of  the  subject  must  be  widely  extended 
before  we  are  in  a  position  to  draw  safe  conclusions.  Thus  it  is  by  no  means 
sure  that,  as  Murchison  supposed,  the  essential  defect  is  a  functional  dis- 
order of  the  liver,  disturbing  the  metabolism  of  the  albuminous  ingredients,  nor 
is  it  at  all  certain  that  the  only  offending  substance  is  uric  acid.  In  the 
present  imperfect  state  of  knowledge  it  is  impossible  with  any  clearness  to 
define  the  pathology  of  the  so-called  uric-acid  diathesis.  We  may  say  that 
certain  s}Tnptoms  arise  in  connection  with  defective  food  or  tissue  metabolism, 
more  particularly  of  the  nitrogenous  elements.  Deficient  oxidation  is  prob- 
ably the  most  essential  factor  in  the  process,  with  the  result  of  the  formation 
of  less  readily  soluble  and  less  readily  eliminated  products  of  retrograde  meta- 
morphosis. This  faulty  metabolism  if  long  continued  may  lead  to  gout,  with 
uratic  deposits  in  the  joints,  acute  inflammations,  and  arterial  and  renal  dis- 
ease. In  a  large  group  of  cases  the  disturbed  metabolism  produces  high  ten- 
sion in  the  arteries  (probabh'  as  a  direct  sequence  of  interference  with  the 
capillary  circulation)  and  ultimately  degenerations  in  various  tissues,  par- 
ticularly the  scleroses. 

Overeating  and  overdrinking,  when  combined  with  deficient  muscular  ex- 
ercise, lie  at  the  basis  of  this  nutritional  disturbance.  The  symptoms  which 
are  believed  to  characterize  the  uric-acid  diathesis  have  already  been  briefly 
treated  of  under  the  section  on  irregular  gout,  and  the  question  of  diet  and 
exercise  has  also  been  there  considered. 

8.    OXALURIA. 

The  discovery  of  calcium-oxalate  crystals  in  the  urine  by  Donne  in  1838 
led  to  the  description  of  the  so-called  oxalic-acid  diathesis.  It  is  claimed  that 
all  the  oxalic  acid  found  in  the  urine  is  taken  into  the  body  with  the  food 
(Dunlop).  In  health  none,  or  only  a  trace,  is  formed  in  the  body.  The 
amount  fluctuates  with  the  quantity  of  food  taken,  and  is  usually  below  10 
milligrammes  daily  (H.  Baldwin).  It  seems  to  be  formed  in  the  body  when 
there  is  an  absence  of  free  hydrochloric  acid  in  the  gastric  juice,  and  in 
connection  with  excessive  fermentation  in  the  intestines.  It  never  forms  a 
heavy  deposit,  but  the  crystals — ^usually  octahedral,  rarely  dumb-bell-shaped 
— collect  in  the  mucus-cloud  and  on  the  sides  of  the  vessel. 

When  in  excess  and  present  for  any  considerable  time,  the  condition  is 
known  as  oxaluria,  the  chief  interest  of  which  is  in  the  fact  that  the  crystals 
may  be  deposited  before  the  urine  is  voided,  and  form  a  calculus.  It  is  held 
by  many  that  there  is  a  special  diathesis  associated  with  its  presence  in  excess 
and  manifested  clinically  by  dyspepsia,  particularly  the  nervous  form,  irrita- 
bility, depression  of  spirits,  lassitude,  and  sometimes  marked  hypochondriasis. 
There  may  be  in  addition  neuralgic  pains  and  the  general  symptoms  of  neuras- 
thenia. The  local  and  general  symptoms  are  probably  dependent  upon  some 
disturbance  of  metabolism  of  which  the  oxaluria  is  one  of  the  manifesta- 
tions. It  is  a  feature  also  in  many  gouty  persons,  and  in  the  condition  called 
lithgemia. 


ANOMALIES  OF  THE   URINARY  SECRETION.  679 


9.  Cystinukia. 

Stadthagen  claims  that  normal  urine  does  not  contain  cystin,  though  Bau- 
mann  and  Goldmann  succeeded  in  separating  it  in  very  small  quantities  from 
healthy  urine  as  a  benzoyl  compound.  It  is  associated  with  elimination  of 
diamines  both  in  the  fasces  and  urine.  It  is  very  rarely  met  with,  and,. its 
chief  interest  is  owing  to  the  fact  that  it  may  form  calculi,  sometimes  in  large 
numbers.  It  is  a  sort  of  chemical  malformation  (Garrod),  and  its  presence 
has  been  determined  in  many  members  of  the  same  family.  The  condition 
appears  sometimes  to  be  hereditary.  As  it  contains  sulphur,  it  is  thought  to 
be  formed  from  the  taurin  of  the  bile.  The  colorless  hexagonal  crystals  are 
very  characteristic  in  appearance,  and  yet  uric  acid  may  assume  the  same 
form.    Cystin  is  soluble  in  ammonia  and  reprecipitated  by  acetic  acid. 

10.  Phosphaturia. 

The  phosphoric  acid  is  excreted  from  the  body  in  combination  with  potas- 
sium, sodium,  calcium,  and  magnesium,  forming  two  classes,  the  alkaline 
phosphates  of  sodium  and  potassium  and  the  earthy  phosphates  of  lime  and 
magnesia.  The  amount  of  phosphoric  acid  (P2O5)  excreted  in  the  twenty- 
four  hours  varies,  according  to  Hammarsten,  between  1  and  5  grammes,  with 
an  average  of  2.5  grammes.  It  is  derived  mainly  from  the  phosphoric  acid 
taken  in  the  food,  but  also  in  part  as  a  decomposition  product  from  nuclein, 
protagon,  and  lecithin.  Of  the  alkaline  phosphates,  those  in  combination  with 
sodium  are  the  most  abundant.  The  alkaline  phosphates  of  the  urine  are 
more  abundant  than  the  earthy  phosphates. 

Of  the  earthy  pJiosphates,  those  of  lime  are  abundant,  of  magnesium  scanty. 
In  urine  which  has  undergone  the  ammoniacal  fermentation,  either  inside 
or  outside  the  body,  there  is  in  addition  the  ammonio-magnesium  or  triple 
phosphate,  which  occurs  in  triangular  prisms  or  in  feathery  or  stellate  crys- 
tals; hence  the  term  given  to  this  form  of  stellar  phosphates.  The  earthy 
phosphates  occur  as  a  sediment  in  the  urine  when  the  alkalinity  is  due  to  a 
fixed  alkali,  or  under  certain  circumstances  the  deposit  may  take  place  within 
the  bladder,  and  then  the  phosphates  are  passed  at  the  end  of  micturition  as 
a  whitish  fluid,  which  is  popularly  confounded  with  spermatorrhoea.  Eecent 
study  of  these  cases  with  symptoms  of  neurasthenia  and  a  phosphate  sediment 
in  the  fresh  urine  would  indicate  an  abnormality  in  the  calcium  metabolism, 
an  absolute  increase  of  this  with  a  decrease  of  the  phosphoric  acid.  The  cal- 
cium phosphate  may  be  precipitated  by  heat  and  produce  a  cloudiness  which 
may  be  mistaken  for  albumin,  but  is  at  once  dissolved  upon  making  the  urine 
acid.  This  condition  is  very  frequent  in  persons  suffering  from  dyspepsia  or 
from  debility  of  any  kind.  The  phosphates  may  be  in  great  excess,  rising  in 
the  twenty- four  hours  to  from  7  to  9  grammes  (Tessier),  whereas  the  normal 
amount  is  not  more  than  2.5  grammes.  And,  lastly,  the  phosphates  may  be 
deposited  in  urine  which  has  undergone  decomposition,  in  which  the  carbonate 
of  ammonia  from  the  urea  combines  with  the  magnesium  phosphates,  forming 
the  triple  salt.    This  is  seen  in  cystitis,  due  to  a  urea-decomposing  microbe. 

The  clinical  significance  of  an  excess  of  phosphates,  to  which  the  term 
phosphaturia  is  applied,  has  been  much  discussed.     It  must  be  remembered 


680  DISEASES  OF  THE  KIDNEYS. 

that  a  deposit  does  not  necessarily  mean  an  excess^  to .  determine  which  a 
careful  anah'sis  of  the  twenty-four  hours'  secretion  should  be  made.  It  has 
long  been  thought  that  there  is  a  relation  between  the  activity  of  the  nerve- 
tissues  and  the  output,  of  phosphoric  acid ;  but  the  question  can  not  3'et  be  con- 
sidered settled.  The  amount  is  increased  in  wasting  diseases,  such  as  phthi- 
sis, acute  yellow  atrophy  of  the  liver,  leukaemia,  and  severe  anaemia,  whereas 
it  is  diminished  in  acute  diseases  and  during  pregnancy. 

In  a  condition  termed  by  Tessier,  Ealfe,  and  others,  phosphatic  diabetes 
there  are  polyuria,  thirst,  emaciation,  and  a  great  increase  in  the  excretion 
of  phosphates,  which  may  be  as  much  as  from  T  to  9  grammes  in  the  day. 
The  urine  is  usually  acid  and  free  from  sugar:  the  patients  are  nervous;  in 
some  instances  sugar  has  been  present  in  the  urine,  and  in  others  it  subse- 
quently makes  its  appearance. 

11.    IXDICAXUEIA. 

The  substance  in  the  urine  which  has  received  this  name  is  the  indoxyl- 
sulphate  of  potassium,  in  which  form  it  appears  in  the  urine  and  is  color- 
less. When  concentrated  acids  or  strong  oxidizing  agents  are  added  to  the 
urine,  this  substance  is  decomposed  and  the  indigo  set  free.  It  is  present  only 
in  small  quantities  in  healthy  urine.  It  is  derived  from  the  indol,  a  product 
formed  in  the  intestine  by  the  decomposition  of  the  albumin  under  the  influ- 
ence of  bacteria.  When  absorbed,  this  is  oxidized  in  the  tissues  to  indoxyl, 
which  combines  with  the  potassium  sulphate,  forming  the  above-named  sub- 
stance. 

The  quantity  of  indican  is  diminished  on  a  milk  (and  a  Kefir)  diet.  It 
is  increased  in  all  wasting  diseases,  as  carcinoma,  and  whenever  any  large 
quantities  of  albuminous  substances  are  undergoing  rapid  decomposition,  as 
in  the  severer  forms  of  peritonitis  and  empyema.  It  is  not  usually  increased  in 
constipation,  although  it  may  be  present  in  large  amounts  with  no  other  dis- 
coverable cause,  but  is  met  with  in  ileus,  particularly  in  obstruction  of  the 
small  intestine.  Indican  has  occasionally  been  found  in  calculi.  Though,  as 
a  rule,  the  urine  is  colorless  when  passed,  there  are  instances  in  which  the 
decomposition  has  taken  place  within  the  body,  and  a  blue  color  has  been 
noticed  immediately  after  the  urine  was  voided.  Sometimes,  too,  in  alka- 
line urine  on  exposure  there  is  a  bluish  film  on  the  surface.  Methylene  blue, 
a  coloring  matter  for  candy,  etc.,  must  be  excluded. 

To  test  for  indican,  place  4  or  5  ce.  of  nitric  or  hydrochloric  acid  in  a 
test-tube;  boil,  and  add  an  equal  quantity  of  urine.  A  bluish  ring  develops 
at  the  point  of  contact.  Add  1  or  2  cc.  of  chloroform  and  shake  the  test- 
tube;  on  separation  the  chloroform  has  a  violet  or  bluish  color  due  to  the 
presence  of  indican.    Obermayer's  reagent  is  also  good. 

12.  Melanueia. 

Black  urine  may  be  dark  when  passed  or  may  become  so  later.  In  the 
following  conditions  melanuria  may  occur:  (1)  Jaundice.  Only  in  very 
chronic  cases  of  deeply  bronzed  icterus  do  we  see  the  urine  quite  dark,  due  to 
the  presence  of  large  quantities  of  biliverdin.  (2)  Haematuria  and  haemo- 
globinuria.    Here  it  is  a  matter  of  the  exaggeration  of  the  smoky  tint  du-e  to 


ANOMALIES  OF  THE   URINARY  SECRETION.  681 

the  presence  of  blood  in  various  quantities.  (3)  Haematoporphyrinuria,  in 
which  the  color  ranges  from  a  dark  pink  to  blackness.  The  presence  of  the 
haematoporphyrin  is  due  to  the  toxic  action  of  sulphonal  or  its  allies,  and 
occurs  when  the  drug  has  been  taken  for  long  periods.  (4)  Melanuria,  in 
which  the  urine  has,  as  a  rule,  the  normal  color  when  passed,  and  on 
standing  becomes  black  as  ink.  In  some  instances  it  is  black  when  passed. 
Melanuria  of  this  type  only  occurs  with  the  presence  of  melanotic  tumors. 
(5)  Alkaptonuria  and  ochronosis.  (See  section  on  Alkaptonuria.)  (6)  In- 
dicanuria.  When  rich  in  indoxyl  sulphate  the  urine  is  brown  in  color,  or 
becomes  so  after  standing,  due  to  the  oxidation  products  of  indol.  This  is  by 
far  the  most  common  cause  of  black  urine,  and  in  any  disease  leading  to  an 
abundant  secretion  of  indican,  as  in  intestinal  obstruction,  etc.,  black  urine 
may  be  passed.  As  Garrod  suggests,  it  is  probable  that  the  black  urine  in 
cases  of  tuberculosis  is  of  an  allied  nature.  (7)  After  certain  articles  of 
diet  and  drugs.  Some  dark-colored  vegetable  pigments,  as  black  cherries 
and  plums  and  bilberries,  cause  darkening  qf  the  urine.  Eesorcin  may  do  the 
same.  Carboluria  is  by  no  means  uncommon,  and  was  frequently  seen  in  the 
days  of  the  antiseptic  spray.  It  has  been  ascribed  to  hydrochinone  formed 
from  phenol.  Napthalene,  creasote,  and  the  salicylates  may  cause  darken- 
ing of  the  urine,  or  even  blackness.  For  a  full  consideration  of  the  subject 
of  black  urine,  see  A.  E.  Garrod,  The  Practitioner,  March,  1904. 

13.  Alkaptonuria  and  Ochronosis. 

"  Alkaptonuria  is  not  the  manifestation  of  a  disease,  but  is  rather  of  the 
nature  of  an  alternative  course  of  metabolism,  harmless  and  usually  congen- 
ital and  lifelong"  (Garrod).  Of  40  known  examples,  19  occurred  in  seven 
families,  and  several  were  the  offspring  of  first  cousins  (Garrod).  There  are 
two  points  of  clinical  interest.  The  alkapton  urine  reduces  Fehling's  solution, 
and  diabetes  may  be  suggested,  but  it  does  not  ferment,  and  it  is  optically 
inactive.  The  linen  may  be  stained  by  the  urine,  which  in  some  cases  is  dark 
when  passed.  In  1866  Virchow  recorded  a  case  of  blackening  of  the  carti- 
lages and  ligaments — ochronosis.  Cases  have  since  been  described  post  mor- 
tem. In  my  cases  the  cartilages  of  the  ear  were  blackened,  the  sclerotics  were 
stained  a  brownish-black  color,  and  in  one  there  was  a  butterfly-shaped  patch 
of  ebony  black  pigmentation  of  the  skin  of  the  nose  and  cheeks.  A  chronic 
arthritis  usually  accompanies  the  condition,  and  in  my  cases  (brothers)  there 
was  a  curious  "  goose-gait,"  due  to  a  bend  in  the  lumbar  region.  Langstein 
and  Meyer  conclude  that  alkaptonuria  is  an  anomaly  of  metabolism  with  the 
excretion  in  the  urine  of  intermediate  products.  These  are  aromatic  bodies, 
homogentisic  and  uroleucic  acid,  and  originate  from  the  destruction  of  the 
albuminous  elements  of  the  food  and  of  the  organs. 

14.  Pneumaturia. 

Gas  may  be  passed  with  the  urine — 

1.  After  mechanical  introduction  of  air  in  vesical  irrigation  or  cysto- 
scopic  examination  in  the  knee-elbow  position. 

3.  As  a  result  of  the  introduction  of  gas-forming  organisms  in  catheteri- 
zation or  other  operation.     Glycosuria  has  been  present  in  a  majority  of  the 


682  DISEASES  OF  THE  KIDNEYS. 

cases.  The  yeast  fungus,  the  colon  bacillus,  and  the  bacillus  aerogenes  cap- 
sulatus  have  been  found. 

3.  In  cases  of  vesico-enteric  fistula. 

In  gas  production  -n-ithin  the  bladder  the  s}Taptoms  are  those  of  a  mild 
cystitis,  with  the  passage  of  gas  at  the  end  of  micturition,  sometimes  with 
a  loud  sound.  The  diagnosis  is  readily  made  by  causing  the  patient  to  urinate 
in  a  bath  or  by  plunging  the  end  of  the  catheter  under  water. 

15.  Other  Suestances. 

LiPURiA. — Fat  in  the  urine,  or  lipuria,  occurs,  according  to  Halliburton, 
first,  without  disease  of  the  kidneys,  as  in  excess  of  fat  in  the  food,  after  the 
administration  of  cod-liver  oil,  in  fat  embolism  occurring  after  fractures,  in 
the  fatty  degeneration  in  phosphorus  poisoning,  in  prolonged  suppuration,  as 
in  phthisis  and  pygemia,  in  the  lipgemia  of  diabetes  mellitus ;  secondly,  with  dis- 
ease of  the  kidneys,  as  in  the  fatty  stage  of  chronic  Bright's  disease,  in  whicli 
fat  casts  are  sometimes  present,  and,  according  to  Ebstein,  in  pyonephrosis; 
and,  thirdly,  in  the  affection  known  as  chyluria.  The  urine  is  usually  turbid, 
but  there  may  be  fat  drops  as  well,  and  fatty  crystals  have  been  found. 

LiPACiDUEiA  is  a  term  applied  by  von  Jaksch  to  the  condition  in  which 
there  are  volatile  fatty  acids  in  the  urine,  such  as  acetic,  but}Tic,  formic,  and 
propionic  acid. 

AcETOxuEiA. — Yon  Jaksch  distinguishes  the  following  forms  of  patholog- 
ical acetonuria:  The  febrile,  the  diabetic,  the  acetonuria  with  certain  forms 
of  cancer,  the  form  associated  with  inanition,  acetonuria  in  psychoses,  and 
the  acetonuria  which  results  from  auto-intoxication.  It  is  doubtful,  however, 
whether  the  s}Tnptoms  in  these  are  really  due  to  the  acetone.  It  may  be  the 
substances  from  which  this  is  formed,  particularly  the  diacetic  acid  or  the 
^ -oxy-butyric  acid.  The  odor  of  the  acetone  may  be  marked  in  the  breath 
and  evident  in  the  urine.    The  tests  have  been  given  in  the  section  on  diabetes. 

Diacetic  acid  is  probably  never  present  in  the  urine  in  health.  With 
a  solution  of  ferric  chloride  it  gives  a  Burgundy-red  color.  A  similar  reac- 
tion is  given  by  acetic,  formic,  and  oxy-but}Tic  acids;  it  may  be  present  in 
the  urine  of  patients  who  are  taking  antipyrin,  thallin,  and  the  salicylates. 
Hammarsten  states  that  if  the  reaction  be  due  to  the  presence  of  diacetic  acid, 
it  will  not  be  obtaiued  in  carrying  out  the  test  with  a  second  specimen  of  urine 
which  has  been  boiled  and  allowed  to  cool.  The  ethereal  extract  of  the  acidu- 
lated urine  gives  the  reaction  if  diacetic  acid  be  present,  whereas  the  other 
substances  which  may  be  mistaken  for  diacetic  acid  are  insoluble  in  ether. 

^-oxT-BUTTEic  ACID  is  believed  by  Stadelmann,  Kiilz,  and  Minkowski  to 
be  the  cause  of  diabetic  coma.  It  is  a  product  of  the  decomposition  of  the 
tissue  albumins,  and  from  it  diacetic  acid  is  readily  formed  by  oxidation.  Its 
tests  have  already  been  given. 

Choluria  and  glycosuria  have  already  been  considered  under  jaundice  and 
diabetes. 

H^MATOPOEPHYRiN  Occasionally  occurs  in  the  iiririe.  It  was  first  recog- 
nized by  Hoppe-Seyler.  ]S3"encki  and  Sieler  determined  its  exact  formula,  and 
the  former  demonstrated  that  the  only  chemical  difference  between  hjematia 
and  hffimatoporph3'rin  is  that  the  latter  is  simply  haematin  free  from  iron.  It 
has  been  found  iu  the  urine  in  pulmonary  tuberculosis,  pleurisy  with  effusion, 


UREMIA.  683 

acute  rlieumatisni,  lead  poisoning,  and  intestinal  haemorrhages.  This  pig- 
ment has  been  found  very  frequently  after  the  administration  of  sulphonal, 
and  sometimes  imparts  a  very  dark  color  to  the  urine. 

V.    UREMIA. 

Definition. — A  toxemia  developing  in  the  course  of  nephritis  or  in  con- 
ditions associated  with  anuria.  The  nature  of  the  poison  or  poisons  is  as  yet 
unknown,  whether  they  are  the  retained  normal  products  or  the  products  of 
an  abnormal  metabolism. 

Theories  of  TJrsemia. — The  view  most  widely  held  is  that  uraemia  is  due  to 
the  accumulation  in  the  blood  of  excrementitious  material — body  poisons — 
which  should  be  thrown  off  by  the  kidneys.  "  If,  however,  from  any  cause, 
these  organs  make  default,  or  if  there  be  any  prolonged  obstruction  to  the 
outflow  of  urine,  accumulation  of  some  or  of  all  the  poisons  takes  place,  and 
the  characteristic  s3anptoms  are  manifested,  but  the  accumulation  may  be  very 
slow  and  the  earlier  symptoms,  corresponding  to  the  comparatively  small 
dose  of  poison,  may  be  very  slight ;  yet  they  are  in  kind,  though  not  in  degree, 
as  indicative  of  uraemia  as  are  the  more  alarming,  which  appear  toward  the 
end,  and  to  which  alone  the  name  ursemia  is  often  given"  (Carter).  Herter 
and  others  have  shown  that  the  toxicity  of  the  blood-serum  in  uraemic  states  is 
increased.  The  part  played  by  urea  itself,  by  the  salts,  and  by  the  nitrogenous 
extractives  has  not  been  determined. 

Another  view  is  that  uraemia  depends  on  the  products  of  an  abnormal 
metabolism.  Brown-Sequard  suggested  that  the  kidney  has  an  internal  secre- 
tion, and  it  is  urged  that  the  symptoms  of  uraemia  are  due  to  its  disturbance. 
Bradford's  experiments  show  that  the  kidneys  do  influence  profoundly  the 
metabolism  of  the  tissues  of  the  body,  particularly  of  the  muscles.  If  more  than 
two-thirds  of  the  total  kidney  weight  be  removed,  there  is  an  extraordinary 
increase  in  the  production  of  urea  and  of  the  nitrogenous  bodies  of  the  creatin 
class.  He  favors  this  view,  but  acknowledges  that  we  are  still  ignorant  of  the 
nature  of  the  poison.  From  a  careful  study  of  the  question,  Hughes  and 
Carter  concluded  that  the  poison  was  an  albuminous  product  quite  different 
from  anything  in  normal  urine.  In  Bradford's  Goulstonian  Lectures  (1898) 
will  be  found  a  full  discussion  of  the  question. 

Traube  believed  that  the  symptoms  of  uraemia,  particularly  the  coma  and 
convulsions,  were  due  to  localized  oedema  of  the  brain. 

Symptoms. — Clinically,  we  may  recognize  latent,  acute,  and  chronic  forms 
of  uraemia.  The  latent  form  has  been  considered  under  the  section  on  anuria. 
Acute  uraemia  may  arise  in  any  form  of  nephritis.  It  is  more  common  in 
the  post-febrile  varieties.  Bradford  thinks  that  it 'is  specially  associated  with 
a  form  of  contracted  white  kidney  in  young  subjects.  Chronic  forms  of 
uraemia  are  more  frequent  in  the  arterio-sclerotic  and  granular  kidney.  For 
convenience  the  symptoms  of  uraemia  may  be  described  under  cerebral,  dysp- 
nceic,  and  gastro-intestinal  manifestations. 

Among  the  Cerebeal  s}Tnptoms  of  ursemia  may  be  described : 

(a)  Mania. — This  may  come  on  abruptly  in  an  individual  who  has  shown 
no  previous  indications  of  mental  trouble,  and  who  may  not  be  known  to 
have  Bright's  disease.     In  a  remarkable  case  of  this  kind  which  came  under 


684  DISEASES  OF  THE  KIDNEYS. 

my  observation  the  patient  l^ecame  suddenly  maniacal  and  died  in  six  days. 
More  commonly  the  delirium  is  less  violent,  but  the  patient  is  noisy,  talka- 
tive, restless,  and  sleepless. 

(h)  Delusional  Insanity  (FoUe  Briglitique). — Cases  are  by  no  means  un- 
common, and  excellent  clinical  reports  have  been  issued  on  the  subject  from 
several  of  the  asylums,  particularly  by  Bremer,  Christian,  and  Alice  Bennett. 
Delusions  of  persecution  are  common.  One  of  my  cases  committed  suicide  by 
jumping  out  of  a  window.  The  condition  is  of  interest  medico-legally  because 
of  its  bearing  on  testamentary  capacity.  Profound  melancholia  may  also 
supervene. 

(c)  Convulsions. — These  may  come  on  unexpectedly  or  be  preceded  by 
pain  in  the  head  and  restlessness.  The  attacks  may  be  general  and  identical 
with  those  of  ordinary  epilepsy,  though  the  initial  cry  may  not  be  present. 
The  fits  may  recur  rapidly,  and  in  the  interval  the  patient  is  usually  uncon- 
scious. Sometimes  the  temperature  is  elevated,  but  more  frequently  it  is  de- 
pressed, and  may  sink  rapidly  after  the  attack.  Local  or  Jacksonian  epilepsy 
may  occur  in  most  characteristic  form  in  uremia.  A  remarkable  sequence  of 
the  convulsions  is  blindness — urcemic  amaurosis — which  may  persist  for  sev- 
eral days.  This,  however,  may  occur  apart  from  the  convulsions.  It  usually 
passes  off  in  a  day  or  two.  There  are,  as  a  rule,  no  ophthalmoscopic  changes. 
Sometimes  ura3mic  deafness  supervenes,  and  is  probably  also  a  cerebral  mani- 
festation. It  may  also  occur  in  connection  with  persistent  headache,  nausea, 
and  other  gastric  symptoms. 

{d)  Coma. — ^Unconsciousness  invariably  accompanies  the  general  convul- 
sions, but  a  coma  may  develop  gradually  -without  any  convulsive  seizures.  Fre- 
quently it  is  preceded  by  headache,  and  the  patient  gradually  becomes  dull 
and  apathetic.  In  these  cases  there  may  have  been  no  previous  indications  of 
renal  disease,  and  unless  the  urine  is  examined  the  nature  of  the  case  may  be 
overlooked.  Twitchings  of  the  muscles  occur,  particularly  in  the  face  and 
hands,  but  there  are  many  cases  of  coma  in  which  the  muscles  are  not  involved. 
In  some  of  these  cases  a  condition  of  torpor  persists  for  weeks  or  even  months. 
The  tongue  is  usually  furred  and  the  breath  very  foul  and  heavy. 

(e)  Local  Palsies. — In  the  course  of  chronic  Bright's  disease  hemiplegia 
or  monoplegia  may  come  on  spontaneously  or  follow  a  convulsion,  and  post 
mortem  no  gross  lesions  of  the  brain  be  found,  but  only  a  localized  or  diffused 
oedema.  These  cases,  which  are  not  very  uncommon,  may  simulate  almost  every 
form  of  organic  paralysis  of  cerebral  origin. 

(/)  Of  other  cerebral  symptoms,  headache  is  important.  It  is  most 
often  occipital  and  extends  to  the  neck.  It  may  be  an  early  feature  and  asso- 
ciated with  giddiness.  Other  nervous  symptoms  of  uremia  are  intense  itching 
of  the  skin,  numbness  and  tingling  in  the  fingers,  and  cramps  in  the  muscles 
of  the  calves,  particularly  at  night.    An  erythema  may  be  present. 

IjEiEiiic  DTSPNCEA  is  classified  by  Palmer  Howard  as  follows:  (1)  Con- 
tinuous dj^spncea;  (2)  paroxysmal  dyspncea;  (3)  both  types  alternating;  and 
(4)  Cheyne- Stokes  breathing.  The  attacks  of  dyspnoea  are  most  commonly 
nocturnal;  the  patient  may  sit  up,  gasp  for  breath,  and  evince  as  much  dis- 
tress as  in  true  asthma.  Occasionally  the  breathing  is  noisy  and  stridulous. 
The  Chejme-Stokes  type  may  persist  for  weeks,  and  is  not  necessarily  associated 
with  coma.     I  have  seen  it  in  a  man  who  travelled  over  a  hundred  miles  to 


UREMIA.  685 

consult  a  physician.  In  another  instance  a  patient,  up  and  about,  could  when 
at  meals  feed  himself  only  in  the  apnoea  period.  Though  usually  of  serious 
omen  and  occurring  with  coma  and  other  symptoms,  recovery  may  follow 
even  after  persistence  for  weeks  or  even  months. 

The  GASTEO-iNTESTiNAL  manifestations  of  uremia  often  set  in  with  abrupt- 
ness. Uncontrollable  vomiting  may  come  on  and  its  cause  be  quite  unrecog- 
nizable. A  young  married  woman  was  admitted  to  my  wards  in  the  Montreal 
General  Hospital  with  persistent  vomiting  of  four  or  five  days'  duration. 
The  urine  was  slightly  albuminous,  but  she  had  none  of  the  usual  signs  of 
ursmia,  and  the  case  was  not  regarded  as  one  of  Bright's  disease.  The  vom- 
iting persisted  and  caused  death.  The  post  mortem  showed  extensive  sclero- 
sis of  both  kidneys.  The  attacks  may  be  preceded  by  nausea  and  may  be  asso- 
ciated with  diarrhoea.  In  some  instances  the  diarrhoea  may  come  on  without 
the  vomiting ;  sometimes  it  is  profuse  and  associated  with  an  intense  catarrhal 
or  even  diphtheritic  inflammation  of  the  colon. 

A  special  uremic  stomatitis  has  been  described  (Barie)  in  which  the 
mucosa  of  the  lips,  gums,  and  tongue  is  swollen  and  erythematous.  The  saliva 
may  be  increased,  and  there  is  difficulty  in  swallowing  and  in  mastication. 
The  tongue  is  usually  very  foul  and  the  breath  heavy  and  fetid.  A  cutaneous 
erythema  may  occur  and  a  remarkable  urea  "  frost "  on  the  skin. 

Fever  is  not  uncommon  in  urgemic  states,  and  may  occur  with  the  acute 
nephritis,  with  the  complications,  and  as  a  manifestation  of  the  uremia  itself 
(Stengel). 

Very  many  patients  with  chronic  uraemia  succumb  to  what  I  have  called 
terminal  infections — acute  peritonitis,  pericarditis,  pleurisy,  meningitis,  or 
endocarditis. 

Diagnosis. — Herter  calls  attention  to  the  value  of  the  clinical  determina- 
tion of  the  urea  in  the  blood  (for  which  purpose  only  a  few  cubic  centimetres 
are  required)  as  an  index  of  the  degree  of  renal  inadequacy.  Cryoscopy,  the 
electrical  conductivity  of  blood  and  urine,  also  the  methylene  blue,  potassium 
iodide,  salicylic-acid  tests  have  been  employed  in  the  hope  of  testing  the  func- 
tional ability  of  the  kidneys.  The  result  has  been  that  while  in  some  cases 
of  urgemia  one  finds  the  expected  accumulation  of  urea  and  ions  in  the 
blood,  in  others  the  kidneys  are,  judged  by  these  tests,  normal.  In  some 
cases  of  nephritis  without  any  signs  of  ursemia  the  kidneys  are  apparently 
as  insufficient  as  the  worst  uremia  cases.  In  but  2  of  96  cases  could  the  urea 
determination  have  been  of  any  value  in  predicting  ursemia,  and  equal  drops 
in  the  urea  occurred  without  this  symptom  (Emerson). 

It  is  still  common  to  depend  on  the  urea  estimation  as  of  service  in  fore- 
telling an  ursemia,  but  in  the  96  cases  of  nephritis  with  ursemia  in  my  wards 
in  but  2  cases  was  it  of  any  real  value. 

Ursemia  may  be  confounded  with : 

(a)  Cerebral  lesions,  such  as  hsemorrhage,  meningitis,  or  even  tumor.  In 
apoplexy,  which  is  so  commonly  associated  with  kidney  disease  and  stiff  arte- 
ries, the  sudden  loss  of  consciousness,  particularly  if  with  convulsions,  may 
simulate  a  ursemic  attack;  but  the  mode  of  onset,  the  existence  of  complete 
hemiplegia,  with  conjugate  deviation  of  the  eyes,  suggest  haemorrhage.  As 
already  noted,  there  are  cases  of  uremic  hemiplegia  or  monoplegia  which  can 
not  be  separated  from  those  of  organic  lesion  and  which  post  mortem  show 


686  DISEASES  OF   THE  KIDNEYS. 

no  trace  of  coarse  disease  of  the  brain.  I  know  of  an  instance  in  wMcli  a  con- 
sultation was  held  upon  the  propriet}^  of  operation  in  a  case  of  hemiplegia 
believed  to  be  due  to  subdural  haemorrhage  which  post  mortem  was  shown  to 
be  urtemic.  Indeed,  in  some  of  these  cases  it  is  quite  impossible  to  distinguish 
between  the  two  conditions.  So,  too,  cases  of  meningitis,  in  a  condition  of 
deep  coma,  with  perhaps  slight  fever,  furred  tongue,  but  without  localizing 
s}Tnptoms,  may  readily  be  confounded  with  urtemia. 

(&)  With  certain  infectious  diseases.  ITrEemia  may  persist  for  weeks  or 
months  and  the  patient  lies  in  a  condition  of  torpor  or  even  unconsciousness, 
with  a  heavily  coated,  perhaps  dry,  tongue,  muscular  twitchings,  a  rapid  feeble 
pulse,  with  slight  fever.  This  state  not  unnaturally  suggests  the  existence  of 
one  of  the  infectious  diseases.  Cases  of  the  kind  are  not  uncommon,  and  I 
have  known  them  to  be  mistaken  for  t}iDhoid  fever  and  for  miliary  tuberculosis. 

(c)  IJraemic  coma  may  be  confounded  with  poisoning  by  alcohol  or  opium. 
In  opium  poisoning  the  pupils  are  contracted;  in  alcoholism  they  are  more 
commonly  dilated.  In  uremia  they  are  not  constant;  they  may  be  either 
vridelv  dilated  or  of  medium  size.  The  examination  of  the  eye-ground  should 
be  made  to  determine  the  presence  or  absence  of  albuminuric  retinitis.  The 
urine  should  be  dra^m  off  and  examined.  The  odor  of  the  breath  sometimes 
gives  an  important  hint. 

The  condition  of  the  heart  and  arteries  should  also  be  taken  into  account. 
Sudden  uraemic  coma  is  more  common  in  the  chronic  interstitial  nephritis. 
The  character  of  the  delirium  in  alcoholism  is  sometimes  important,'  and  the 
coma  is  not  so  deep  as  in  uraemia  or  opium  poisoning.  It  may  for  a  time  be 
impossible  to  determine  whether  the  condition  is  due  to  ursemia,  profound 
alcoholism,  or  haemorrhage  into  the  pons  Varolii. 

And  lastly,  in  connection  with  sudden  coma,  it  is  to  be  remembered  that 
insensilDility  may  occur  after  prolonged  muscular  exertion,  as  after  running 
a  ten-mile  race.  In  some  instances  unconsciousness  Has  come  on  rapidly  with 
stertorous  breathing  and  dilated  pupils.  Cases  have  occurred  under  conditions 
in  which  sun-stroke  could  be  excluded;  and  Poore,  who  reports  a  case  in  the 
Lancet  (1894),  considers  that  the  condition  is  due  to  the  too  rapid  accumu- 
lation of  waste  products  in  the  blood,  and  to  hyperpjTCxia  from  suspension  of 
sweating. 

The  treatment  will  be  considered  under  Chronic  Bright's  Disease. 

VI.    ACUTE    BRIGHT 'S    DISEASE. 

Definition. — Acute  diffuse  nephritis,  due  to  the  action  of  cold  or  of  toxic 
agents  upon  the  kidneys. 

In  all  instances  changes  exist  in  the  epithelial,  vascular,  and  intertubular 
tissues,  which  vary  in  intensity  in  different  forms;  hence  writers  have  de- 
scribed a  tubular,  a  glomerular,  and  an  acute  interstitial  nephritis.  Delafield 
recognizes  acute  exudative  and  acute  productive  forms,  the  latter  characterized 
by  proliferation  of  the  connective-tissue  stroma  and  of  the  cells  of  the  Mal- 
pighian  tufts. 

Etiology. — The  following  are  the  principal  causes  of  acute  nephritis: 

(1)  Cold.  Exposure  to  cold  and  wet  is  one  of  the  most  common  causes. 
It  is  particularly  prone  to  follow  exposure  after  a  drinking-bout. 


ACUTE  BRIGHT'S  DISEASE.  687 

(2)  The  poisons  of  the  specific  fevers,  particularly  scarlet  fever,  less  com- 
monly typhoid  fever,  measles,  diphtheria,  small-pox,  chicken-pox,  malaria, 
cholera,  yellow  fever,  meningitis,  and,  very  rarely,  dysentery.  Acute  nephritis 
may  be  associated  with  syphilis  and  with  acute  tuberculosis,  particularly  the 
former,  to  which  Bradford  has  recently  called  attention  as  an  important  cause. 
He  suggests  that  many  of  the  idiopathic  cases  and  those  ascribed  to  cold  may 
be  of  syphilitic  origin.  It  may  also  occur  in  septicaemia  and  in  acute  ton- 
sillitis. In  exudative  erythema  and  the  allied  purpuric  affections  acute 
nephritis  is  not  uncommon.  Among  1,833  cases  of  malaria  at  the  Jolins 
Hopkins  Hospital  there  were  26  of  nephritis  (Thayer), 

(3)  Toxic  agents,  such  as  turpentine,  cantharides,  potassium  chlorate, 
and  carbolic  acid  may  cause  an  acute  congestion  which  sometimes  terminates 
in  nephritis.    Alcohol  probably  never  excites  an  acute  nephritis. 

(4)  Pregnancy,  in  which  the  condition  is  thought  by  some  to  result  from 
compression  of  the  renal  veins,  although  this  is  not  yet  finally  settled.  The 
condition  may  in  reality  be  due  to  toxic  products  as  yet  undetermined. 

(5)  Acute  nephritis  occurs  occasionally  in  connection  with  extensive  lesions 
of  the  skin,  as  in  burns  or  in  chronic  skin-diseases,  and  also  after  trauma.  It 
may  follow  operations  on  the  kidney. 

Morbid  Anatomy. — The  kidneys  may  present  to  the  naked  eye  in  mild 
eases  no  evident  alterations.  When  seen  early  in  more  severe  forms  the  organs 
are  congested,  swollen,  dark,  and  on  section  may  drip  blood.  Bright's  original 
description  is  as  follows : 

"  The  kidneys  .  .  .  stripped  easily  out  of  their  investing  membrane, 
were  large  and  less  firm  than  they  often  are,  of  the  darkest  chocolate  color, 
interspersed  with  a  few  white  points,  and  a  great  number  nearly  black;  and 
this,  with  a  little  tinge  of  red  in  parts,  gave  the  appearance  of  a  polished  fine- 
grained porphyry  or  greenstone.  .  .  .  On  (section)  these  colors  were  found 
to  pervade  the  whole  cortical  part;  but  the  natural  striated  appearance  was 
not  lost,  and  the  external  part  of  each  mass  of  tubuli  was  particularly  dark 
.  .  .  a  very  considerable  quantity  of  blood  oozed  from  the  kidney,  showing 
a  most  unusual  accumulation  in  the  organ." 

In  other  instances  the  surface  is  pale  and  mottled,  the  capsule  strips  off 
readily,  and  the  cortex  is  swollen,  turbid,  and  of  a  grayish-red  color,  while 
the  pyramids  have  an  intense  beefy-red  tint.  The  glomeruli  in  some  instances 
stand  out  plainly,  being  deeply  swollen  and  congested ;  in  other  instances  they 
are  pale. 

Histology. — The  histology  may  be  thus  summarized:  (a)  Glomerular 
changes.  In  a  majority  of  thei  cases  of  nephritis  due  to  toxic  agents,  which 
reach  the  kidney  through  the  blood-vessels,  the  tufts  suffer  first,  and  there  is 
either  an  acute  intracapillary  glomerulitis,  in  which  the  capillaries  become 
filled  with  cells  and  thrombi,  or  involvement  of  the  epithelium  of  the  tuft  and 
of  Bo-wman's  capsule,  the  cavity  of  which  contains  leucocytes  and  red  blood- 
corpuscles.  Hyaline  degeneration  of  the  contents  and  of  the  walls  of  the 
capillaries  of  the  tuft  is  an  extremely  common  event.  These  processes  are 
perhaps  best  marked  in  scarlatinal  nephritis.  There  may  be  proliferation 
about  Bowman's  capsule.  These  changes  interfere  with  the  circulation  in  the 
tufts  and  seriously  influence  the  nutrition  of  the  tubular  structures  beyond 
them. 


688  DISEASES  OF  THE  KIDNEYS. 

(h)  The  alterations  in  the  tubular  epithelium  consist  in  cloudy  swelling, 
fatty  change,  and  hyaline  degeneration.  In  the  convoluted  tubules,  the 
accumulation  of  altered  cells  with  leucocytes  and  blood-corpuscles  causes  the 
enlargement  and  swelling  of  the  organ.  The  epithelial  cells  lose  their 
striation,  the  nuclei  are  obscured,  and  hyaline  droplets  often  accumulate  in 
them. 

(c)  Interstitial  changes.  In  the  milder  fotms  a  simple  inflammatory 
exudate — serum  mixed  with  leucocytes  and  red  blood-corpuscles — exists  be- 
tween the  tubules.  In  severer  cases  areas  of  small-celled  infiltration  occur 
about  the  capsules  and  between  the  convoluted  tubes.  These  changes  may 
be  wide-spread  and  uniform  throughout  the  organs  or  more  intense  in  certain 
regions. 

Councilman  has  described  an  acute  interstitial  nephritis  occurring  chiefly 
in  children  after  fevers,  characterized  by  the  presence  of  cells  similar  to  those 
described  by  Unna  as  plasma  cells.  He  thinks  that  these  cells  are  formed  in 
other  organs,  chiefly  the  spleen  and  bone  marrow,  and  are  carried  to  the 
kidneys  in  the  blood-current. 

Symptoms. — The  onset  is  usually  sudden,  and  when  the  nephritis  follows 
cold,  dropsy  may  be  noticed  within  twenty-four  hours.  After  fevers  the  onset 
is  less  abrupt,  but  the  patient  gradually  becomes  pale  and  a  puffiness  of  the 
face  or  swelling  of  the  ankles  is  first  noticed.  In  children  there  may  at  the 
outset  be  convulsions.  Chilliness  or  rigors  initiate  the  attack  in  a  limited 
number  of  cases.  Pain  in  the  back,  nausea,  and  vomiting  may  be  present. 
The  fever  is  variable.  Many  cases  in  adults  have  no  rise  in  temperature.  In 
young  children  with  nephritis  from  cold  or  scarlet  fever  the  temperature  may, 
for  a  few  days,  range  from  101°  to  103°. 

The  most  characteristic  symptoms  are  the  urinary  changes.  There  may 
at  first  be  suppression;  more  commonly  the  urine  is  scanty,  highly  colored, 
and  contains  blood,  albumin,  and  tube-casts.  The  quantity  is  reduced  and 
only  4  or  5  ounces  may  be  passed  in  the  twenty-four  hours ;  the  specific  grav- 
ity is  high — 1.025,  or  even  more;  the  color  varies  from  a  smoky  to  a  deep 
porter  color,  but  is  seldom  bright  red.  On  standing  there  is  a  heavy  deposit ; 
microscopically  there  are  blood-corpuscles,  epithelium  from  the  urinary  pas- 
sages, and  hyaline,  blood,  and  epithelial  tube-casts.  The  albumin  is  abundant, 
forming  a  curdy,  thick  precipitate.  The  largest  amounts  of  albumin  are  seen 
in  the  early  acute  nephritis  of  syphilis.  In  Hoffmann's  case  this  reached  8.5 
per  cent.  The  total  excretion  of  urea  is  reduced,  though  the  percentage  is 
high. 

Ancemia  is  an  early  and  marked  symptom.  In  cases  of  extensive  dropsy, 
effusion  may  take  place  into  the  pleura  and  peritonaeum.  There  are  cases 
of  scarlatinal  nephritis  in  which  the  dropsy  of  the  extremities  is  trivial  and 
effusion  into  the  pleurae  extensive.  The  lungs  may  become  oedematous.  In 
rare  cases  there  is  oedema  of  the  glottis.  Epistaxis  may  occur  or  cutaneous 
ecchymoses  may  develop  in  the  course  of  the  disease. 

The  pulse  may  be  hard,  the  tension  increased,  and  the  second  sound  in 
the  aortic  area  accentuated.  Occasionally  dilatation  of  the  heart  comes  on 
rapidly  and  may  cause  sudden  death  (Goodhart).  The  skin  is  dry  and  it  may 
be  difficult  to  induce  sweating. 

Urcemic  sjrmptoms  occur  in  a  limited  number  of  cases,  either  at  the  onset 


ACUTE  BRIGHT' S  DISEASE.  689 

with  suppression,  more  commonly  later  in  the  disease.  Ocular  changes  are 
not  so  common  in  acute  as  in  chronic  Bright's  disease,  but  hsemorrhagic 
retinitis  may  occur  and  occasionally  papillitis. 

The  course  of  acute  Bright's  disease  varies  considerably.  The  description 
just  given  is  of  the  form  which  most  commonly  follows  cold  or  scarlet  fever. 
In  many  of  the  febrile  cases  dropsy  is  not  a  prominent  symptom,  and  the 
diagnosis  rests  rather  with  the  examination  of  the  urine.  Moreover,  the  con- 
dition may  be  transient  and  less  serious.  In  other  cases,  as  in  the  acute 
nephritis  of  typhoid  fever,  there  may  be  hsematuria  and  pronounced  signs  of 
interference  with  the  renal  function.  The  most  intense  acute  nephritis  may 
exist  without  anasarca. 

In  scarlatinal  nephritis,  in  which  the  glomeruli  are  most  seriously  affected, 
suppression  of  the  urine  may  be  an  early  symptom,  the  dropsy  is  apt  to  be 
extreme,  and  ursemic  manifestations  are  common.  Acute  Bright's  disease  in 
children,  however,  may  set  in  very  insidiously  and  be  associated  with  transient 
or  slight  oedema,  and  the  symptoms  may  point  rather  to  affection  of  the 
digestive  system  or  to  brain-disease. 

Diagnosis. — It  is  very  important  to  bear  in  mind  that  the  most  serious 
involvement  of  the  kidneys  may  be  manifested  only  by  slight  cedema  of  the 
feet  or  puffiness  of  the  eyelids,  without  impairment  of  the  general  health.  On 
the  other  hand  from  the  urine  alone  a  diagnosis  can  not  be  made  with  cer- 
tainty since  simple  cloudy,  swelling,  and  circulatory  changes  may  cause  a  simi- 
lar condition  of  urine.  The  first  indication  of  trouble  may  be  a  ursemic  con- 
vulsion. This  is  particularly  the  case  in  the  acute  nephritis  of  pregnancy,  and 
it  is  a  good  rule  for  the  practitioner,  when  engaged  to  attend  a  case,  invariably 
to  ask  that  during  the  seventh  and  eighth  months  the  urine  should  occasionally 
be  sent  for  examination. 

In  nephritis  from  cold  and  in  scarlet  fever  the  symptoms  are  usually 
marked  and  the  diagnosis  is  rarely  in  doubt.  As  already  mentioned,  every 
case  in  which  albumin  is  present  must  not  be  called  acute  Bright's  disease, 
not  even  if  tube-casts  be  present.  Thus  the  common  febrile  albuminuria, 
although  it  represents  the  first  link  in  the  chain  of  events  leading  to  acute 
Bright's  disease,  should  not  be  placed  in  the  same  category. 

There  are  occasional  cases  of  acute  Bright's  disease  with  anasarca,  in 
which  albumin  is  either  absent  or  present  only  as  a  trace.  This  is  a  rare 
condition.  Tube-casts  are  usually  found,  and  the  absence  of  albumin  is  rarely 
permanent.    The  urine  may  be  reduced  in  amount. 

The  character  of  the  casts  is  of  use  in  the  diagnosis  of  the  form  of 
Bright's  disease,  but  scarcely  of  such  extreme  value  as  has  been  stated.  Thus, 
the  hyaline  and  granular  casts  are  common  to  all  varieties.  The  blood  and 
epithelial  casts,  particularly  those  made  up  of  leucocytes,  are  most  common 
in  the  acute  cases. 

Prognosis. — The  outlook  varies  somewhat  with  the  cause  of  the  disease. 
Eecoveries  in  the  form  following  exposure  to  cold  are  much  more  frequent 
than  after  scarlatinal  nephritis.  In  younger  children  the  mortality  is  high, 
amounting  to  at  least  one-third  of  the  cases.  Serious  symptoms  are  low 
arterial  tension,  the  occurrence  of  uraemia,  and  effusion  into  the  serous  sacs. 
The  persistence  of  the  dropsy  after  the  first  month,  intense  pallor,  and  a  large 
amount  of  albumin  indicate  the  possibility  of  the  disease  becoming  chronic. 
45 


690  DISEASES  OF  THE  KIDNEYS. 

For  some  months  after  the  disappearance  of  the  dropsy  there  may  be  traces 
of  albumin  and  a  few  tube-casts. 

In  a  case  of  scarlatinal  nephritis,  if  the  progress  is  favorable,  the  dropsy 
diminishes  in  a  week  or  ten  days,  the  urine  increases,  the  albumin  lessens, 
and  by  the  end  of  a  month  the  dropsy  has  disappeared  and  the  urine  is  nearly 
free.  In  very  young  children  the  course  may  be  rapid,  and  I  have  known  the 
urine  to  be  free  from  albumin  in  the  fourth  week.  Other  cases  are  more 
insidious,  and  though  the  dropsy  may  disappear,  the  albumin  persists  in  the 
urine,  the  angemia  is  marked,  and  the  cojidition  becomes  chronic,  or,  after 
several  recurrences  of  the  dropsy,  improves  and  complete  recovery  takes  place. 

Treatment. — The  patient  should  be  in  bed  and  there  remain  until  all 
traces  of  the  disease  have  disappeared.  As  sweating  plays  such  an  important 
part  in  the  treatment,  it  is  well,  if  possible,  to  accustom  the  patient  to 
blankets.    He  should  also  be  clad  in  thin  Canton  flannel. 

The  diet  should  consist  of  milk  or  butter-milk,  gruels  made  of  arrow-root 
or  oat-meal,  barley  water,  and,  if  necessary,  beef  tea  and  chicken  broth.  It  is 
better,  if  possible,  to  confine  the  patient  to  a  strictly  milk  diet.  As  conva- 
lescence is  established,  bread  and  butter,  lettuce,  water-cress,  grapes,  oranges, 
and  other  fruits  may  be  given.  Meats  should  be  used  very  sparingly.  As 
there  is  marked  retention  of  the  chlorides,  which  seem  to  bear  a  relation  to  the 
dropsy,  salt  should  be  withheld. 

The  patient  should  drink  freely  of  alkaline  mineral  waters,  ordinary  water, 
or  lemonade.  The  fluids  keep  the  kidneys  flushed  and  wash  out  the  dehris 
from  the  tubes.  A  useful  drink  is  a  drachm  of  cream  of  tartar  in  a  pint  of 
boiling  water,  to  which  may  be  added  the  juice  of  half  a  lemon  and  a  little 
sugar.     Taken  when  cold,  this  is  a  pleasant  and  satisfactory  diluent  drink. 

ISTo  remedies,  so  far  as  known,  control  directly  the  changes  which  are  going 
on  in  the  kidneys.  The  indications  are :  (1)  To  give  the  excretory  function  of 
the  kidney  rest  by  utilizing  the  skin  and  the  bowels,  in  the  hope  that  the 
natural  processes  may  be  sufficient  to  effect  a  cure;  (2)  to  meet  the  symptoms 
as  they  arise. 

In  a  case  of  scarlet  fever  it  may  occasionally  be  possible  to  avert  an  attack, 
the  premonitory  symptoms  of  which  are  marked  increase  in  the  arterial  tension 
and  the  presence  of  blood  coloring  matter  in  the  urine  (Mahomed),  An 
active  saline  cathartic  may  completely  relieve  this  condition. 

At  the  onset,  when  there  is  pain  in  the  back  or  hsematuria,  the  Paquelin 
cautery  or  the  dry  or  wet  cups  give  relief.  The  last  should  not  be  used  in 
children.  Warm  poultices  are  often  grateful.  In  cases  which  set  in  with 
suppression  of  urine,  these  measures  should  be  adopted,  and  in  addition  the 
hot  bath  with  subsequent  pack,  copious  diluents,  and  a  free  purge.  The  dropsy 
is  best  treated  by  hydrotherapy — either  the  hot  bath,  the  wet  pack,  or  the 
hot-air  bath.  In  children  the  wet  pack  is  usually  satisfactory.  It  is  applied 
by  wi'inging  a  blanket  out  of  hot  water,  wrapping  the  child  in  it,  covering  this 
with  a  dry  blanket,  and  then  with  a  rubber  cloth.  In  this  the  child  may 
remain  for  an  hour.  It  may  be  repeated  daily.  In  the  case  of  adults,  the 
hot-air  bath  or  the  vapor  bath  may  be  conveniently  given  by  allowing  the 
vapor  or  air  to  pass  from  a  funnel  beneath  the  bed-clothes,  which  are  raised 
on  a  low  cradle.  More  efficient,  as  a  rule,  is  a  hot  bath  of  from  fifteen  or 
twenty  minutes,  after  which  the  patient  is  wrapped  in  blankets.    The  sweating 


ACUTE  BRIGHT'S  DISEASE.  691 

produced  by  these  measures  is  usually  profuse,  rarely  exhausting,  and  in  a 
majority  of  cases  the  dropsy  can  in  this  way  be  relieved.  There  are  some 
cases,  however,  in  which  the  skin  does  not  respond  to  the  baths,  and  if  the 
symptoms  are  serious,  particularly  if  uraemia  supervenes,  jaborandi  or  its 
active  principle,  pilocarpine,  may  be  used.  The  latter  may  be  given  hypoder- 
micall}^,  in  doses  of  from  a  sixth  to  an  eighth  of  a  grain  in  adults,  and  from  a 
twentieth  to  a  twelfth  of  a  grain  in  children  of  from  two  to  ten  years. 

The  bowels  should  be  kept  open  by  a  morning  saline  purge ;  in  children  the 
fluid  magnesia  is  readily  taken;  in  adults  the  sulphate  of  magnesia  may  be 
given  by  Hay's  method,  in  concentrated  form,  in  the  morning,  before  anything 
is  taken  into  the  stomach.  In  Bright's  disease  it  not  infrequently  causes 
vomiting.  The  compound  powder  of  jalap,  in  half -drachm  doses,  or,  if  neces- 
sary, elaterium  may  be  used.  If  the  dropsy  is  not  extreme,  the  urine  not  very 
concentrated,  and  urgemic  symptoms  are  not  present,  the  bowels  should  be  kept 
loose  without  active  purgation.  If  these  measures  fail  to  reduce  the  dropsy  and 
it  has  become  extreme,  the  skin  may  be  punctured  with  a  lancet  or  drained 
by  a  small  silver  canula  (Southey's  tube),  which  is  inserted  beneath  it.  A 
fine  aspirator  needle  may  be  used,  and  the  fluid  allowed  to  drain  through  a 
piece  of  long,  narrow  rubber  tubing  into  a  vessel  beneath  the  bed.  If  the 
dyspnoea  is  marked,  owing  to  pressure  of  fluid  in  the  pleurae,  aspiration  should 
be  performed.  In  rare  instances  the  ascites  is  extreme  and  may  require  para- 
centesis, or  a  Southey's  tube  may  be  inserted  and  the  fluid  gradually  withdrawn. 
If  ursemic  convulsions  occur,  the  intensity  of  the  paroxysms  may  be  limited 
by  the  use  of  chloroform;  to  an  adult  a  pilocarpine  injection  should  be  at 
once  given,  and  from  a  robust,  strong  man  20  ounces  of  blood  may  be  with- 
drawn. In  children  the  loins  may  be  dry  cupped,  the  wet  pack  used,  and  a 
brisk  purgative  given.  Bromide  of  potassium  and  chloral  sometimes  prove 
useful. 

Vomiting  may  be  relieved  by  ice  and  by  restricting  the  amount  of  food. 
Drop  doses  of  creasote,  iodine,  and  carbolic  acid  may  be  given.  The  dilute 
hydrocyanic  acid  with  bismuth  is  often  effectual. 

The  question  of  the  use  of  diuretics  in  acute  Bright's  disease  is  not  yet 
settled.  The  best  diuretic,  after  all,  is  water,  which  may  be  taken  freely 
with  the  citrate  of  potash  or  the  benzoate  of  soda,  salts  which  are  held  to  favor 
the  conversion  of  the  urates  into  less  irritating  and  more  easily  excreted  com- 
pounds. Digitalis  and  strophanthus  are  useful  diuretics,  and  may  be  employed 
without  risk  when  the  arterial  tension  is  low  and  the  cardiac  impulse  is  not 
forcible.  *  I  have  never  seen  any  injurious  effects  from  their  employment  after 
the  early  symptoms  had  lessened  in  intensity. 

For  the  persistent  albuminuria,  I  agree  with  Eoberts  and  Eosenstein  that 
we  have  no  remedy  of  the  slightest  value.  Kothing  indicates  more  clearly  our 
helplessness  in  controlling  kidney  metabolism  than  inability  to  meet  this  com- 
mon symptom.  Astringents,  alkalies,  nitroglycerin,  and  mercury  have  been 
recommended. 

For  the  anaemia  always  associated  with  acute  Bright's  disease  iron  should 
be  employed.  It  should  not  be  given  until  the  acute  symptoms  have  subsided. 
In  the  adult  it  may  be  used  in  the  form  of  the  perchloride  in  increasing  doses, 
as  convalescence  proceeds.  In  children,  the  syrup  of  the  iodide  of  iron  or  the 
syrup  of  the  phosphate  of  iron  are  better  preparations.     Tyson  has  recently 


692  DISEASES  OF   THE  KIDNEYS. 

urged  caution  in  the  too  free  use  of  iron  in  kidney  disease.    The  dilatation  of 
the  heart  is  best  treated  with  digitalis,  strophanthus,  and  strychnia. 

In  the  convalescence  from  acute  Bright's  disease,  cart  should  be  taken  to 
guard  the  patient  against  cold.  The  diet  should  still  consist  chiefly  of  milk 
and  a  return  to  mixed  food  should  be  gradual.  A  change  of  air  is  often  bene- 
ficial, particularly  a  residence  in  a  warm,  equable  climate. 


Vn.     CHRONIC    BRIGHT'S    DISEASE. 

Here,  too,  in  all  forms  we  deal  with  a  diffuse  process,  involving  epithelial, 
interstitial,  and  glomerular  tissues.  Clinically  two  groups  are  recognized — 
(a)  the  chronic  parenchymatous  nephritis,  which  follows  the  acute  attack  or 
comes  on  insidiously,  is  characterized  by  marked  dropsy,  and  post  mortem  by 
the  large  white  Tiidney.  In  the  later  stages  of  this  process  the  kidney  may  be 
smaller — a  condition  known  as  the  small  white  Jcidney;  (h)  chronic  inter- 
stitial nephritis,  in  which  dropsy  is  not  common  and  the  cardio-vascular 
changes  are  pronounced.  Delafield  recognizes  a  chronic  diffuse  nephritis  with 
exudation  and  a  chronic  jDroductive  diffuse  nephritis  without  exudation,  the 
latter  corresponding  to  the  contracted  kidney  of  authors. 

The  amyloid  kidney  is  usually  spoken  of  as  a  variety  of  Bright's  disease, 
but  in  reality  it  is  a  degeneration  wliich  may  accompany  any  form  of  nephritis. 

1.  Cheoxic  Paeexchtmatous  Nepheitis 

(Chrotiic    Desquamative    and    Chronic    Tubal    NepTiritis;    Chronic    Diffuse 
Nephritis  with  Exudation) . 

Etiology. — In  many  cases  the  disease  follows  the  acute  nephritis  of  cold, 
scarlet  fever,  or  pregnancy.  More  frequently  than  is  usually  stated  the  disease 
has  an  insidious  onset  and  occurs  independently  of  any  acute  attack.  The 
fevers  may  play  an  important  I'ole  in  certain  of  these  cases.  Eosenstein,  Bar- 
tels,  and,  in  this  country,  I.  E.  Atkinson  and  Thayer  have  laid  special  stress 
upon  malaria  as  a  cause.  The  use  of  alcohol  is  believed  to  lead  to  this  form  of 
nephritis.  In  chronic  suppuration,  syphilis,  and  tuberculosis  the  diffuse  paren- 
ch}Tnatous  nephritis  is  not  uncommon,  and  is  usualty  associated  with  amyloid 
disease.  Males  are  rather  more  subject  to  the  affection  than  females.  It  is 
met  with  most  commonly  in  young  adults,  and  is  by  no  means  infrequent  in 
children  as  a  sequence  of  scarlatinal  nephritis. 

Morbid  Anatomy. — Several  varieties  of  this  form  have  been  recognized. 
The  large  white  ]cid?iey  of  Wilks,  in  which  the  organ  is  enlarged,  the  capsule 
is  thin,  and  the  surface  white  with  the  stellate  veins  injected  is  not  very  com- 
mon in  America.  On  section  the  cortex  is  swollen  and  yellowish- white  in  color, 
and  often  presents  opaque  areas.  The  p}Tamids  may  be  deeply  congested.  On 
microscopical  examination  it  is  seen  that  the  epithelium  is  granular  and  fatty, 
and  the  tubules  of  the  cortex  are  distended,  and  contain  tube-casts.  Hyaline 
changes  are  also  present  in  the  epithelial  cells.  The  glomeruli  are  large,  the 
capsules  thickened,  the  capillaries  show  hyaline  changes,  and  the  epithelium 
of  the  tuft  and  of  the  capsule  is  extensively  altered.  The  interstitial  tissue  is 
everywhere  increased^  though  not  to  an  extreme  degree.     I  have  had  in  my 


CHRONIC  BRIGHT'S  DISEASE.  693 

wards  but  30  such  cases  with  autopsy.  The  average  weight  of  both  kidneys  was 
430  grammes,  the  heaviest  580  grammes. 

The  second  variety  of  this  form  results  from  the  gradual  increase  in  the 
connective  tissue  and  the  subsequent  shrinkage,  forming  what  is  called  the 
small  white  kidney  or  the  pale  granular  kidney.  It  is  doubtful  whether  this 
is  always  preceded  by  the  large  white  kidney.  Some  observers  hold  that  it  may 
be  a  primary  independent  form.  The  capsule  is  thickened  and  the  surface  is 
rough  and  granular.  On  section  the  resistance  is  greatly  increased,  the  cortex 
is  reduced  and  presents  numerous  opaque  white  or  whitish-yellow  foci,  con- 
sisting of  accumulations  of  fatty  epithelium  in  the  convoluted  tubules.  This 
combination  of  contracted  kidney  with  the  areas  of  marked  fatty  degeneration 
has  given  the  name  of  small  granular  fatty  kidney  to  this  form.  The  inter- 
stitial changes  are  marked,  many  of  the  glomeruli  are  destroyed,  the  degenera- 
tion of  epithelium  in  the  convoluted  tubules  is  wide-spread,  and  the  arteries 
are  greatly  thickened. 

Belonging  to  this  chronic  tubal  nephritis  is  a  variety  known  as  the  chronic 
hcemorrhagic  nephritis^  in  which  the  organs  are  enlarged,  yellowish-white  in 
color,  and  in  the  cortex  are  many  brownish-red  areas,  due  to  haemorrhage  into 
and  about  the  tubes.  In  other  respects  the  changes  are  identical  with  those  in 
the  large  white  kidney. 

Of  changes  in  the  other  organs  the  most  marked  are  thickening  of  the 
blood-vessels  and  hypertrophy  of  the  left  heart. 

Symptoms. — Following  an  acute  nephritis,  the  disease  may  present,  in  a 
modified  way,  the  symptoms  of  that  affection.  In  many  cases  it  sets  in 
insidiously,  and  after  an  attack  of  dyspepsia  or  a  period  of  failing  health  and 
loss  of  strength  the  patient  becomes  pale,  and  pufifiness  of  the  eyelids  or  swollen 
feet  are  noticed  in  the  morning. 

The  symptoms  are  as  follows :  The  urine  is,  as  a  rule,  diminished  in  quan- 
tity, averaging  500  cc,  often  scanty.  It  has  a  dirty-yellow,  sometimes  smoky, 
color,  and  is  turbid  from  the  presence  of  urates.  On  standing,  a  heavy  sedi- 
ment falls,  in  which  are  found  numerous  tube-casts  of  various  forms  and  sizes, 
hyaline,  both  large  and  small,  epithelial,  granular,  and  fatty  casts.  Leuco- 
cytes are  abundant;  red  blood-corpuscles  are  frequently  met  with,  and  epi- 
thelium from  the  kidneys  and  pelves.  The  albumin  is  abundant  and  may  be 
from  4  to  6  per  cent.  It  is  more  abundant  in  the  urine  passed  during  the  day. 
The  specific  gravity  may  be  high  in  the  early  stages — from  1.020  to  1.025,  even 
1.040 — though  in  the  later  stages  it  is  lower.  The  urea  is  always  reduced  in 
quantity.    As  the  case  improves  from  5  to  6  litres  a  day  may  be  voided. 

Dropsy  is  a  marked  and  obstinate  symptom  of  this  form  of  Bright's  dis- 
ease. The  face  is  pale  and  puffy,  and  in  the  morning  the  eyelids  are  oede- 
matous.  The  anasarca  is  general,  and  there  may  be  involvement  of  the  serous 
sacs.  In  these  chronic  cases  associated  with  large  white  kidney  there  is  often  a 
distinctive  appearance  in  the  face ;  the  complexion  is  pasty,  the  pallor  marked, 
and  the  eyelids  are  oedematous.  The  dropsy  is  peculiarly  obstinate.  Urgemic 
symptoms  are  common,  though  convulsions  are  perhaps  less  frequent  than  in 
the  interstitial  nephritis. 

The  tension  of  the  pulse  is  usually  increased ;  the  vessels  ultimately  become 
stiff  and  the  heart  hypertrophied,  though  there  are  instances  of  this  form  of 
nephritis  in  which  the  heart  is  not  enlarged.     The  aortic  second  sound  is 


694  DISEASES  OF  THE  KIDNEYS. 

accentuated.  Eetinal  changes,  though  less  frequent  than  in  the  chronic  inter- 
stitial neiDliritis,  occur  in  a  considerable  number  of  cases. 

Gastro-intestinal  symptoras  are  common.  Vomiting  is  frequently*  a  dis- 
tressing and  serious  sj-mptom,  and  diarrhcea  may  be  profuse.  Ulceration  of 
the  colon  may  occur  and  prove  fatal. 

It  is  sometimes  impossible  to  determine,  even  by  the  most  careful  exami- 
nation of  the  urine  or  by  analysis  of  the  s}Tnptoms,  whether  the  condition  of 
the  kidney  is  that  of  the  large  white  or  of  the  small  white  form.  In  cases, 
however,  which  have  lasted  for  several  years,  with  the  progressive  increase  in 
the  renal  connective  tissue  and  the  cardio-vascular  changes,  the  clinical  picture 
may  approach,  in  certain  respects,  that  of  the  contracted  kidney.  The  urine 
is  increased,  with  low  specific  gravity.  It  is  often  turbid,  may  contain  traces 
of  blood,  the  tube-casts  are  numerous  and  of  every  variety  of  form  and  size, 
and  the  albumin  is  abundant.  Dropsy  is  usually  present,  though  not  so 
extensive  as  in  the  early  stages. 

Prognosis. — The  prognosis  is  e-slre^ely  grave.  In  a  case  which  has  per- 
sisted for  more  than  a  year  recovery  rarely  takes  place.  Death  is  caused  either 
by  great  effusion  with  oedema  of  the  lungs,  by  uraemia,  or  by  secondary  inflam- 
mation of  the  serous  membranes.  Occasionally  in  children,  even  when  the 
disease  has  persisted  for  two  years,  the  symptoms  disappear  and  recovery  takes 
place. 

Treatment. — Essentially  the  same  treatment  should  be  carried  out  as  in 
acute  Bright's  disease.  Milk  or  butter-milk  should  constitute  for  a  time  the 
chief  article  of  food.  Later  more  food  may  be  allowed,  oysters,  fresh  vege- 
tables, and  fruit.  The  dropsy  should  be  treated  by  the  hot  baths,  and  a  salt- 
free  diet.  Iron  preparations  should  be  given  when  there  is  marked  anaemia. 
It  is  to  be  remembered  that  the  pallor  of  the  face  may  not  be  a  good  index  of 
the  blood  condition.  The  acetate  of  potash,  digitalis,  and  diuretin  are  useful 
in  increasing  the  flow  of  urine.  Basham's  mixture  given  in  plenty  of  water 
will  be  found  beneficial. 

2.  Chronic  Interstitial  ^vTephritis 

(Contracted  Kidney;  Granular  Kidney;  Cirrliosis  of  tlie  Kidney;  Gouty  Kid- 
ney; Renal  Sclerosis). 

Sclerosis  of  the  kidney  is  met  with  (a)  as  a  sequence  of  the  large  white 
kidney,  forming  the  so-called  pale  granular  or  secondary  contracted  kidney; 
(h)  as  an  independent  primary  affection;  (c)  as  a  sequence  of  arterio-sclerosis. 

Etiology. — The  primary  form  is  chronic  from  the  outset,  and  is  a  slow, 
creeping  degeneration  of  the  kidney  substance — in  many  respects  only  an 
anticipation  of  the  gradual  changes  which  take  place  in  the  organ  in  extreme 
old  age.  In  man}'  cases  no  satisfactory  cause  can  be  assigned.  In  others  there 
are  hereditary  influences,  as  in  the  remarkable  family  studied  by  Dickinson, 
in  which  a  pronounced  tendency  to  chronic  Bright's  disease  occurred  in  four 
generations.  Families  in  which  the  arteries  tend  to  degenerate  early  are  more 
prone  to  interstitial  nephritis.  Syphilis  is  held  by  some  to  be  a  cause,  and 
possibly  in  some  cases  the  mercurial  treatment.  Alcohol  probably  plays  an 
important  part,  particularly  in  conjunction  with  other  factors.  Among  the 
better  classes  in  America  chronic  Bright's  disease  is  very  common,  and  is,  I 


CHRONIC  BPdGlirS  DISEASE.  695 

believe,  caused  luorc  ficqucnlly  by  o\e:catiiig  than  by  excesses  in  alcoliol. 
Some  believe  excesoive  u^e  of  meat  is  injurious,  since  it  increases  the  mate- 
rials out  of  which  uric  acid  is  formed.  By  many  a  functional  disorder  of  the 
liver,  leading  to  lithsmia,  is  regarded  as  the  most  efficient  factor.  It  is  quite 
possible  that  in  persons  who  habitually  eat  and  drink  too  much  the  work 
thrown  upon  this  organ  is  excessive,  and  the  elaboration  of  certain  materials 
is  so  defective  that  in  their  excretion  from  the  general  circulation  they  irritate 
the  kidneys.  Actual  gout,  which  in  England  is  a  common  cause  of  inter- 
stitial nephritis,  is  not  an  important  factor  here.  Lead,  as  is  well  known,  may 
produce  renal  sclerosis.  For  a  full  discussion  on  the  etiology  and  varieties  of 
renal  cirrhosis  the  student  is  referred  to  the  work  of  S.  West. 

Arteriosclerotic  Form. — By  far  the  most  common  form  in  America  is 
secondary  to  arterio-sclerosis.  The  kidneys  are  not  much,  if  at  all,  contracted, 
very  hard,  red,  and  show  patches  of  cortical  atrophy.  It  is  seen  in  men  over 
forty  who  have  worked  hard,  eaten  freely,  and  taken  alcohol  to  excess.  They 
are  conspicuous  victims  of  the  "  strenuous  life,"  the  incessant  tension  of  which 
is  felt  first  in  the  arteries.  After  forty  in  men  of  this  class  nothing  is  more 
salutary  than  to  experience  the  shock  lirought  by  the  knowledge  of  the  pres- 
ence of  albumin  and  tube-casts  in  the  urine.  The  associated  cardio-vascular 
changes  are  of  varying  degrees  of  intensity,  and  upon  them,  not  upon  the  renal 
condition,  does  the  outlook  depend. 

Morbid  Anatomy. — The  contracted  kidneys  are  small,  and  together  may 
weigh  no  more  than  an  ounce  and  a  half.  Of  174  cases  of  chronic  interstitial 
nephritis  (white  kidney)  from  my  wards,  with  autopsy,  in  79  cases  the  com- 
bined weight  of  kidneys  was  over  300  grammes;  in  57  cases,  200-300 
grammes;  30  cases,  150-200  grammes;  and  below  150  grammes,  8  cases.  Of 
the  arterio-sclerotic  form  61  per  cent  weighed  over  300  grammes  and  but  6 
per  cent  below  200  grammes.  Unilateral  nephritis  is  excessively  rare,  not 
occurring  once  in  the  series,  a  striking  contrast  to  Edebohl's  figures,  9  of  72 
cases  in  which  the  operation  of  stripping  the  capsule  was  performed.  The 
capsule  is  thick  and  adherent;  the  surface  of  the  organ  irregular  and  cov- 
ered with  small  nodules,  which  have  given  to  it  the  name  of  granular  kidney. 
In  stripping  off  the  capsule,  portions  of  the  kidney  substance  are  removed. 
Small  cysts  are  frequently  seen  on  the  surface.  The  color  is  usually  reddish, 
often  a  very  dark  red.  On  section  the  substance  is  tough  and  resists  cutting; 
the  cortex  is  thin  and  may  measure  no  more  than  a  couple  of  millimetres. 
The  pyramids  are  less  wasted.  The  small  arteries  are  greatly  thickened  and 
stand  out  prominently.  The  fat  about  the  pelvis  is  greatly  increased.  Bright's 
original  description  is  as  follows : 

"...  The  kidney  is  quite  rough  and  scabrous  to  the  touch  externally, 
and  is  seen  to  rise  in  numerous  projections  not  much  exceeding  a  large  pin's 
head,  yellow,  red,  and  purplish.  The  form  of  the  kidney  is  often  inclined  to 
be  lobulated,  the  feel  is  hard,  and  on  making  an  incision  the  texture  is  found 
approaching  to  semi-cartilaginous  firmness,  giving  great  resistance  to  the 
knife.  The  tubular  portions  are  observed  to  be  drawn  near  to  the  surface  of 
the  organ,  with  less  interstitial  deposit  than  in  the  last  variety  .  .  .  the 
kidney     .     .     .      (is  usually)      ...     of  a  purplish  gray  tinge." 

Microscopically  there  is  seen  a  marked  increase  in  the  connective  tissue  and 
degeneration  and  atrophy  of  the  secreting  structures,  glomerular  and  tubal, 


696  DISEASES  OF  THE  KIDNEYS. 

the  former  predominating  and  giving  the  main  characters  to  the  lesion.  The 
following  are  the  most  important  changes : 

(a)  An  increase  in  the  fibrous  elements,  widely  distributed  throughout  the 
organ,  but  more  advanced  in  the  cortex,  particularly  in  the  tissue  between  the 
medullary  rays.  In  the  pjTamids  the  distribution  of  new  growth  is  less  patchy 
and  more  diffuse.  In  the  early  stages  of  the  process  there  is  a  small-celled  infil- 
tration between  the  tubes  and  around  the  glomeruli,  and  finally  this  becomes 
fibrillated  and  is  seen  encircling  the  tubules  and  Bowman's  capsules,  around 
the  latter  often  forming  concentric  layers. 

(&)  The  changes  in  the  glomeruli  are  striking,  and  in  advanced  cases  a 
very  considerable  number  of  them  have  undergone  complete  atrophy  and  are 
represented  as  densely  encapsulated  hyaline  structures.  The  atrophy  is  partly 
due  to  changes  in  the  capillary  walls  and  multiplication  of  cells  between  the 
loops,  partly  to  extensive  hyaline  degeneration,  and  in  part,  no  doubt,  to  the 
alterations  in  the  afferent  vessels.  The  normal  glomeruli  usually  show  some 
thickeiung  of  the  capsule  and  increase  in  the  cells  of  the  tufts. 

(c)  The  tubules  show  changes  in  the  epithelium,  which  vary  a  good  deal 
in  different  localities.  Where  the  connective-tissue  growth  is  most  advanced 
they  are  greatly  atrophied  and  the  epithelium  may  be  represented  by  small 
cubical  cells.  In  other  instances  the  epithelium  has  entirely  disappeared. 
On  the  other  hand,  in  the  regions  represented  by  the  projecting  granules  the 
tubules  are  usually  dilated,  and  the  epithelium  shows  hyaline,  fatty,  and  granu- 
lar changes.  Very  many  of  them  contain  dark  masses  of  epithelial  debris  and 
tube-casts.  In  the  interstitial  tissue  and  in  the  tubules  there  may  be  pigment- 
ary changes  due  to  hsemorrhage.  The  dilatation  of  the  tubules  may  reach  an 
extreme  grade,  forming  definite  cysts. 

(d)  The  arteries  show  an  advanced  sclerosis.  The  intima  is  greatly  thick- 
ened and  there  are  changes  in  the  adventitia  and  in  the  media,  consisting  in 
increase  in  the  thickness  due  to  proliferation  of  the  connective  tissue,  in  the 
latter  coat  at  the  expense  of  the  muscular  elements. 

The  view  most  generally  entertained  at  present  is  that  the  essential  lesion 
is  in  the  secreting  tissues  of  the  tubules  and  the  glomeruli,  and  that  the 
connective-tissue  overgTowth  is  secondary  to  this.  Greenfield  holds  that  the 
primary  change  is  in  most  instances  in  the  glomeruli,  to  which  both  the  degen- 
eration in  the  epithelium  of  the  convoluted  tubules  and  the  increase  in  the 
intertubular  connective  tissue  are  secondary. 

Associated  with  contracted  kidney  are  general  arterio-sclerosis  and  hyper- 
trophy of  the  heart.  The  changes  in  the  arteries  have  already  been  described 
in  the  section  on  arterio-sclerosis.  The  hypertrophy  of  the  heart  is  constant, 
and  the  enlargement  may  reach  an  extreme  grade.  Variations  depend,  no 
doubt,  in  part  upon  the  extent  of  the  diffuse  arterial  degeneration,  but  there 
are  instances  in  which  the  term  cor  iovinum  may  be  applied  to  the  enlarged 
organ.  In  such  cases  the  h}'pertrophy  is  not  confined  to  the  left  ventricle,  but 
involves  the  entire  heart.  The  explanation  of  this  has  been  much  discussed. 
It  was  at  first  held  to  be  due  to  the  increased  work  thrown  upon  the  organ 
in  driving  the  impure  blood  through  the  capillary  system.  Basing  his  opinion 
upon  the  supposed  muscular  increase  in  the  smaller  arteries,  Johnson  regarded 
it  as  an  effort  to  overcome  a  sort  of  stop-cock  action  of  these  vessels,  which, 
under  the  influence  of  the  irritating  ingredient  in  the  blood,  contracted  and 


CHRONIC  bright;^  disease.  697 

increased  greatly  the  peripheral  resistance.  Traube  believed  that  the  oblitera- 
tion of  a  large  number  of  capillary  territories  in  the  kidney  materially  raised 
the  arterial  pressure,  and  in  this  way  led  to  the  hypertrophy  of  the  heart;  an 
additional  factor,  he  thought,  was  the  diminished  excretion  of  water,  which 
also  heightened  the  pressure  within  the  blood-vessels. 

With  our  present  knowledge  the  most  satisfactory  explanation  is  that  given 
by  Cohnheim,  which  is  thus  clearly  and  succinctly  put  by  Fagge :  "  He  gives 
reasons  for  thinking  that  the  activity  of  the  circulation  through  the  kidneys 
at  any  moment — in  other  words,  the  state  of  the  smaller  renal  arteries  as 
regards  contraction  or  dilatation — depends  not  (as  in  the  case  of  the  tissues 
generally)  upon  the  need  of  those  organs  for  blood,  but  solely  upon  the  amount 
of  material  for  the  urinary  secretion  that  the  circulatory  fluid  happens  then 
to  contain.  This  suggestion  has  bearings  .  .  .  upon  the  development  of 
hypertrophy  in  one  kidney  when  the  other  has  been  entirely  destroyed.  But 
another  consequence  deducible  from  it  is  that  when  parts  of  both  kidneys  have 
undergone  atrophy,  the  blood-ilow  to  the  parts  that  remain  must,  cceteris  pari- 
bus, be  as  great  as  it  would  have  been  to  the  whole  of  the  organs  if  they  had 
been  intact.  But  in  order  that  such  a  quantity  of  blood  should  pass  through  the 
restricted  capillary  area  now  open  to  it,  an  excessive  pressure  must  obviously 
be  necessary.  This  can  be  brought  to  bear  only  by  the  exertion  of  more  than 
the  normal  degree  of  force  on  the  part  of  the  left  ventricle,  combined  with 
the  maintenance  of  a  corresponding  resistance  in  all  other  districts  of  the 
arterial  system.  And  so  one  can  account  at  once  for  the  high  arterial  pressure 
and  for  the  cardio-vascular  changes  that  are  secondary  to  it."  W.  P.  Herring- 
ham  in  a  recent  study  of  the  subject  concludes  that  the  cardiac  hypertrophy 
depends  upon  degeneration  and  rigidity  of  the  aorta  and  large  arteries,  changes 
which  incapacitate  them  from  acting  as  an  elastic  reservoir  and  transfer  their 
functions  to  the  smaller  vessels,  which  naturally  offer  much  more  resistance 
and  give  the  heart  more  work  to  do. 

Symptoms. — Perhaps  a  majority  of  the  cases  are  latent,  and  are  not  recog- 
nized until  the  occurrence  of  one  of  the  serious  or  fatal  complications.  Even 
an  advanced  grade  of  contracted  kidney  may  be  compatible  with  great  mental 
and  bodily  activity.  There  may  have  been  no  symptoms  whatever  to  suggest 
to  the  patient  the  existence  of  a  serious  malady.  In  other  cases  the  general 
health  is  disturbed.  The  patient  complains  of  lassitude,  is  sleepless,  has 
to  get  up  at  night  to  micturate;  the  digestion  is  disordered,  the  tongue  is 
furred;  there  are  complaints  of  headache,  failing  vision,  and  breathlessness 
on  exertion. 

So  complex  and  varied  is  the  clinical  picture  of  chronic  Bright's  disease 
that  it  will  be  best  to  consider  the  symptoms  under  the  various  systems. 

Urinary  System. — In  the  small  contracted  kidney  polyuria  is  common. 
Frequently  the  patient  has  to  get  up  two  or  three  times  during  the  night  to 
empty  the  bladder,  and  there  is  increased  thirst.  It  is  for  these  symptoms 
occasionally  that  relief  is  sought.  And  yet  in  many  cases  with  very  small 
kidneys  this  feature  has  not  been  present.  A  careful  study  of  the  cases  from 
my  wards,  of  the  urine  and  the  anatomical  condition,  showed  that  almost 
no  parallelism  could  be  made  between  the  weight  of  the  kidney,  its  appear- 
ance, and  the  urine  it  secreted  before  death.  Of  the  174  cases  with  autopsy,  in 
almost  a  third  the  renal  changes  were  so  slight  that  the  nephritis  was  not  men- 


698  DISEASES  OF   THE  KIDNEYS. 

tioned  as  a  part  of  the  clinical  diagnosis  (Emerson).  The  color  is  a  light 
3'ellow,  and  the  specific  gravity  ranges  from  1.005  to  1.012.  Persistent  low 
specific  gravity  is  one  of  the  most  constant  and  important  features  of  the 
disease.  Traces  of  albumin  are  found,  but  may  be  absent  at  times,  particularly 
in  the  early  morning  urine.  It  is  often  simply  a  slight  cloudiness,  and  may  be 
apparent  only  with  the  more  delicate  tests.  The  sediment  is  scanty,  and  in  it 
a  few  hyaline  or  granular  casts  are  found.  The  quantity  of  the  solid  con- 
stituents of  the  urine  is,  as  a  rule,  diminished,  though  in  some  instances  the 
urea  may  be  excreted  in  full  amount.  In  attacks  of  dyspepsia  or  bronchitis,  or 
in  the  later  stages  when  the  heart  fails,  the  quantity  of  albumin  may  be  greatly 
increased  and  the  urine  diminished.  Occasionally  blood  occurs  in  the  urine, 
and  there  ma}'  even  be  htematuria  (S.  West).  Slight  leakage,  represented 
by  the  constant  presence  of  a  few  red  cells,  may  be  present  early  in  the  disease 
and  persist  for  years.  In  the  arteriosclerotic  form  the  quantity  of  urine  is 
normal,  or  reduced  rather  than  increased;  the  specific  gravit}'^  is  normal  or 
high,  the  color  of  the  urine  is  good,  and  there  are  hyaline  and  finely  granular 
casts.  The  amount  of  albumin  varies  greatly  with  the  food  and  exercise,  and 
is  usually  much  in  excess  of  that  seen  with  the  contracted  kidneys,  and  does 
not  show  so  often  the  albumin-free  intervals  of  that  form,  also  it  is  more 
common  to  find  albumin,  no  casts,  while  in  the  contracted  kidney  casts,  no 
albumin,  should  one  be  absent. 

Circulatory  System. — The  pulse  is  hard,  the  tension  increased,  and  the 
vessel  wall,  as  a  rule,  thickened.  As  already  mentioned,  a  distinction  must 
be  made  between  increased  tension  and  thickening  of  the  arterial  wall.  The 
tension  may  be  plus  in  a  normal  vessel,  but  in  chronic  Bright's  disease  it  is 
more  common  to  have  increased  tension  in  a  stifi:  artery. 

A  pulse  of  increased  tension  has  the  following  characters :  It  is  hard  and 
incompressible,  requiring  a  good  deal  of  force  to  overcome  it;  it  is  persistent, 
and  in  the  intervals  between  the  beats  the  vessel  feels  full  and  can  be  rolled 
beneath  the  finger.  These  characters  may  be  present  in  a  vessel  the  walls  of 
which  are  little,  if  at  all,  increased  in  thickness.  To  estimate  the  latter  the 
pulse  wave  should  be  obliterated  in  the  radial,  and  the  vessel  wall  felt  beyond 
it.  In  a  perfecth^  normal  vessel  the  arterial  coats,  under  these  circumstances, 
can  not  be  differentiated  from  the  surrounding  tissue;  whereas,  if  thickened, 
the  vessel  can  be  rolled  beneath  the  finger.  Persistent  high  blood  pressure 
is  one  of  the  earliest  and  most  important  s}Tnptoms  of  iaterstitial  nephritis. 
During  the  disease  the  pressure  may  rise  to  250  mm.  or  even  300  mm.,  but  this 
is  very  rare.  With  dropsy  and  cardiac  dilatation  the  pressure  may  fall,  but 
not  necessarily.  The  cardiac  features  are  equally  important,  though  often 
less  obvious.  H^^pertrophy  of  the  left  ventricle  occurs  to  overcome  the  resist- 
ance offered  in  the  arteries.  The  enlargement  of  the  heart  ultimately  becomes 
more  general.  The  apex  is  displaced  downward  and  to  the  left;  the  impulse 
is  forcible  and  may  be  heaving.  In  elderly  persons  with  emphysema,  the  dis- 
placement of  the  apex  may  not  be  evident.  The  first  sound  at  the  apex  may  be 
duplicated;  more  commonly  the  second  sound  at  the  aortic  cartilage  is  accen- 
tuated, a  ver}'-  characteristic  sign  of  increased  tension.  The  sound  in  extreme 
cases  may  have  a  bell-like  quality.  In  many  cases  a  systolic  murmur  develops 
at  the  apex,  probably  as  a  result  of  relative  insutficiency.  It  may  be  loud  and 
transmitted  to  the  axilla.     Finally  the  hypertrophy  fails,  the  heart  becomes 


CHRONIC  BRIGHT'S  DISEASE.  699 

dilated^  gallop  rhythm  is  present,  and  the  general  condition  is  that  of  a  chronic 
heart-lesion. 

Respiratory  System. — Sudden  oedema  of  the  glottis  may  occur.  Effu- 
sion into  the  pleurae  or  sudden  oedema  of  the  lungs  may  prove  fatal.  Acute 
pleuris}^  and  pneumonia  are  not  uncommon.  Bronchitis  is  a  frequent  accom- 
paniment, particularly  in  the  winter.  Sudden  attacks  of  oppressed  breathing, 
particularly  at  night,  are  not  infrequent.  This  is  often  a  ursemic  symptom, 
but  is  sometimes  cardiac.  The  patient  may  sit  up  in  bed  and  gasp  for  breath, 
as  in  true'  asthma.  Cheyne- Stokes  breathing  may  be  present,  most  commonly 
toward  the  close,  but  th^^patient  may  be  walking  about  and  even  attending  to 
his  occupation. 

Digestive  System. — Dyspepsia  and  loss  of  appetitie  are  common.  Severe 
and  uncontrollable  vomiting  may  be  the  first  symptom.  This  is  usually  re- 
garded as  a  manifestation  of  ursemia,  but  it  may  occur  without  any  other 
indications,  and  I  have  known  it  to  prove  fatal  without  any  suspicion  that 
chronic  Bright's  disease  was  present.  Severe  and  even  fatal  diarrhoea  may 
develop.    The  tongue  may  be  coated  and  the  breath  heavy  and  urinous. 

Nervous  System. — ^Various  cerebral  manifestations  have  already  been 
mentioned  under  uraemia.  Headache,  sometimes  of  the  migraine  type,  may 
be  an  early  and  persistent  feature  of  chronic  Bright's  disease.  Cerebral 
apoplexy  is  closely  related  to  interstitial  nephritis.  The  haemorrhage  may 
take  place  into  the  meninges  or  the  cerebrum.  It  is  usually  associated  with 
marked  changes  in  the  vessels.  Neuralgias,  in  various  regions,  are  not  un- 
common. 

Special  Senses. — Troubles  in  vision  may  be  the  first  symptom  of  the 
disease.  It  is  remarkable  in  how  many  cases  of  interstitial  nephritis  the  con- 
dition is  diagnosed  first  by  the  ophthalmic  surgeon.  The  flame-shaped  retinal 
haemorrhages  are  the  most  common.  Less  frequent  is  diffuse  retinitis  or 
papillitis.  Sudden  blindness  may  supervene  without  retinal  changes — 
uraemic  amaurosis.  Diplopia  is  a  rare  event.  Recurring  conjunctival  and 
palpebral  haemorrhages  are  fairly  common.  Auditory  troubles  are  by  no 
means  infrequent  in  chronic  Bright's  disease.  Ringing  in  the  ears,  with 
dizziness,  is  not  uncommon.  Various  forms  of  deafness  may  occur.  Epis- 
taxis  is  not  infrequent,  either  alone,  or  of  a  severe  tjrpe  in  association  with 
purpura. 

Skin. — CEdema  is  not  common  in  interstitial  nephritis.  Slight  puffiness 
of  the  ankles  may  be  present,  but  in  a  majority  of  the  cases  dropsy  does  not 
supervene.  When  extensive,  it  is  almost  always  the  result  of  gradual  failure 
of  the  hypertrophied  heart.  The  skin  is  often  dry  and  pale,  and  sweats  are  not 
common.  In  some  instances  the  sweat  may  deposit  a  white  frost  of  urea  on 
the  surface  of  the  skin.  Eczema  is  a  common  accompaniment  of  chronic  inter- 
stitial nephritis.  Tingling  of  the  fingers  or  numbness  and  pallor — the  dead 
fingers — are  not,  as  some  suppose,  in  any  way  peculiar  to  Bright's  disease. 
Intolerable  itching  of  the  skin  may  be  present,  and  cramps  in  the  muscles  are 
by  no  means  rare. 

Haemorrhages  are  not  infrequent;  epistaxis  may  prove  serious  and  exten- 
sive ;  purpura  may  occur.  Broncho-pulmonary  hemorrhages  are  said,  by  some 
French  writers,  to  be  common,  but  no  instance  of  it  has  come  under  my  obser- 
vation.   Ascites  is  rare  except  in  association  with  cirrhosis  of  the  liver. 


700  DISEASES  OF   THE  KIDNEYS. 

Diagnosis. — The  autopsy  often  discloses  the  true  nature  of  the  disease, 
one  of  the  many  intercurrent  affections  of  which  may  have  proved  fatal.  The 
early  stages  of  interstitial  nephritis  are  not  recognizable.  In  a  patient  with 
increased  pulse  tension  (particularly  if  the  vessel  wall  is  sclerotic),  with  the 
apex  beat  of  the  heart  dislocated  to  the  left,  the  second  aortic  sound  ringing 
and  accentuated,  the  urine  abundant  and  of  low  specific  gravity,  with  a  trace 
of  albumin  and  an  occasional  hyaline  or  granular  cast,  the  diagnosis  of  inter- 
stitial nephritis  may  be  safely  made.  Of  all  the  indications,  that  offered  by  the 
pulse  is  the  most  important.  Persistent  high  tension  with  thickening  of  the 
arterial  wall  in  a  man  under  fifty  means  that  serious  mischief  has  already 
taken  place,  that  cardio-vascular  changes  are  certainly,  and  renal  most  prob- 
ably, present.  It  is  important  in  the  diagnosis  of  this  condition  not  to  rest 
content  with  a  single  examination  of  the  urine.  Both  the  evening  and  the 
morning  secretion  should  be  studied.  The  sediment  should  be  collected  in 
a  conical  glass,  and  in  looking  for  tube-casts  a  large  surface  should  be  examined 
with  a  tolerably  low  power  and  little  light.  The  arterio-sclerotic  kidney  may 
exist  for  a  long  time  without  the  occurrence  of  albumin,  or  the  albumin  may 
be  in  very  small  quantities.  Toward  the  end  it  is  impossible  to  differentiate 
the  primary  interstitial  nephritis  from  an  arterio-sclerotic  kidne}^,  nor  clini- 
cally is  it  of  any  special  value  so  to  do.  In  middle-aged  men,  with  very  high 
tension,  great  thickening  of  the  superficial  arteries,  and  marked  hypertrophy 
of  the  heart,  the  renal  are  more  likely  to  be  secondary  to  the  arterial  changes. 

Prognosis. — Chronic  Bright's  disease  is  an  incurable  affection,  and  the 
anatomical  conditions  on  which  it  depends  are  quite  as  much  beyond  the  reach 
of  medicines  as  wrinkled  skin  or  gray  hair.  Interstitial  nephritis,  however, 
is  compatible  with  the  enjoyment  of  life  for  many  jeavs,  and  it  is  now  uni- 
versally recognized  that  increased  tension,  thickening  of  the  arterial  walls,  and 
polyuria  with  a  small  quantity  of  albumin,  neither  doom  a  man  to  death 
within  a  short  time  nor  necessarily  interfere  with  the  pursuits  of  an  active 
life  so  long  as  proper  care  be  taken.  I  Imow  patients  who  have  had  high 
tension  and  a  little  albumin  in  the  urine  with  hyaline  casts  for  ten,  twelve, 
and,  in  one  instance,  fifteen  years.  Serious  indications  are  the  occurrence 
of  ursemic  symptoms,  dilatation  of  the  heart,  the  onset  of  serous  effusions,  the 
onset  of  Cheyne- Stokes  breathing,  persistent  vomiting,  and  diarrhoea. 

Treatment. — Patients  without  local  indications  or  in  whom  the  con- 
dition has  been  accidentally  discovered  should  so  regulate  their  lives  as  to 
throw  the  least  possible  strain  upon  heart,  arteries,  and  kidneys.  A  quiet  life 
without  mental  worry,  with  gentle  but  not  excessive  exercise,  and  residence  in 
an  equable  climate,  should  be  recommended.  In  addition  they  should  be  told 
to  keep  the  bowels  regular,  the  skin  active  by  a  daily  tepid  bath  with  friction, 
and  the  urinary  secretion  free  by  drinking  daily  a  definite  amount  of  either 
distilled  water  or  some  pleasant  mineral  water.  Alcohol  should  be  strictly 
prohibited.    Tea  and  coffee  are  allowable. 

The  diet  should  be  light  and  nourishing,  and  the  patient  should  be  warned 
not  to  eat  excessively,  and  not  to  take  meat  more  than  once  a  day.  Care  in 
food  and  drink  is  probably  the  most  important  element  in  the  treatment  of 
these  early  cases. 

A  patient  in  good  circumstances  may  be  urged  to  go  away  during  the 
winter  months,  or,  if  necessary,  to  move  altogether  to  a  warm  equable  climate, 


CHRONIC  BRIGHT'S  DISEASE.  701 

like  that  of  Southern  California.  There  is  no  doubt  of  the  value  in  these 
cases  of  removal  from  the  changeable,  irregular  weather  which  prevails  in  the 
temperate  regions  from  November  until  April. 

At  this  period  medicines  are  not  required  unless  for  certain  special  symp- 
toms. Patients  derive  much  benefit  from  an  annual  visit  to  certain  mineral 
springs,  such  as  Poland,  Bedford,  Saratoga,  in  this  country,  and  Vichy  and 
others  in  Europe.  Mineral  waters  have  no  curative  influence  upon  chronic 
Bright's  disease;  they  simply  help  the  interstitial  circulation  and  keep  the 
drains  flushed.  In  this  early  stage,  when  the  patient's  condition  is  good,  the 
tension  not  high,  and  the  quantity  of  albumin  small,  medicines  are  not  indi- 
cated, since  no  remedies  are  known  to  have  the  slightest  influence  upon  the 
progress  of  the  disease.  Sooner  or  later  symptoms  arise  which  demand  treat- 
ment.    Of  these  the  following  are  the  most  important: 

(a)  Greatly  Increased  Arterial  Tension. — It  is  to  be  remembered  that  a 
certain  increase  of  tension  is  not  only  necessary  but  unavoidable  in  chronic 
Bright's  disease,  and  probably  the  most  serious  danger  is  too  great  lowering 
of  the  blood  tension.  The  happy  medium  must  be  sought  between  such  height- 
ened tension  as  throws  a  serious  strain  upon  the  heart  and  risks  rupture  of 
the  vessels  and  the  low  tension  which,  under  these  circumstances,  is  specially 
liable  to  be  associated  with  serous  efl^usions.  In  cases  with  persistent  high 
tension  the  diet  should  be  light,  an  occasional  saline  purge  should  be  given, 
and  sweating  promoted  by  means  of  hot  air  or  the  hot  bath.  If  these  meas- 
ures do  not  suffice,  nitroglycerin  may  be  tried,  beginning  with  1  minim  of  the 
1-per-cent  solution  three  times  a  day,  and  gradually  increasing  the  dose  if 
necessary.  Patients  vary  so  much  in  susceptibilty  to  this  drug  that  in  each 
case  it  must  be  tested,  the  limit  of  dosage  being  that  at  which  the  patient 
experiences  the  physiological  effect.  As  much  as  10  minims  of  the  1 -per- 
cent solution  may  be  given  three  times  a  day.  In  many  cases  I  have  given  it 
in  much  larger  doses  for  weeks  at  a  time.  I  have  never  seen  any  ill  effects 
from  it.  If  the  dose  is  excessive  the  patients  complain  at  once  of  flushing  or 
headache.  Its  use  may  be  kept  up  for  six  or  seven  weeks,  then  stopped  for  a 
week  and  resumed.  Its  value  is  seen  not  only  in  the  reduction  of  the  tension, 
but  also  in  the  striking  manner  in  Avhich  it  relieves  the  headache,  dizziness, 
and  dyspnoea.  The  sodium  nitrite  may  be  given  in  doses  of  grs.  iii-v  three 
times  a  day. 

(&)  More  or  less  ancemia  is  present  in  advanced  cases,  and  is  best  met 
by  the  use  of  iron.  Weir  Mitchell,  who  has  had  a  unique  experience  in  certain 
forms  of  chronic  Bright's  disease,  gives  the  tincture  of  the  perchloride  of  iron 
in  large  doses — from  half  a  drachm  to  a  drachm  three  times  a  day.  He 
thinks  that  it  not  only  benefits  the  angemia,  but  that  it  also  is  an  important 
means  of  reducing  the  arterial  tension. 

(c)  Many  patients  with  Bright's  disease  present  themselves  for  treat- 
ment with  signs  of  cardiac  dilatation;  there  is  a  gallop  rhythm  or  the  heart- 
sounds  have  a  fcetal  character,  the  breath  is  short,  the  urine  scanty  and  highly 
albuminous,  and  there  are  signs  of  local  dropsy.  In  these  cases  the  treatment 
must  be  directed  to  the  heart.  A  morning  dose  of  salts  or  calomel  may  be 
given,  and  digitalis  in  10-minim  doses,  three  or  four  times  a  day.  Strychnia 
may  be  used  with  benefit  in  this  condition.  In  some  instances  other  cardiac 
tonics  may  be  necessary,  but  as  a  rule  the  digitalis  acts  promptly  and  well. 


702  DISEASES  OF  THE  KIDNEYS. 

(d)  Urcemic  Symptoms. — Even  before  marked  manifestations  are  present 
there  may  he  extreme  restlessness,  mental  wandering,  a  heavy,  foul  breath, 
and  a  coated  tongue.  Headache  is  not  often  complained  of,  though  intense 
frontal  headache  may  be  an  early  s}Taptom  of  uremia.  In  this  condition, 
too,  the  patient  may  complain  of  palpitation,  feelings  of  numbness,  and 
sometimes  nocturnal  cramps.  For  these  symptoms  the  saline  purgatives  should 
be  ordered,  and  hot  baths,  so  as  to  induce  copious  sweating.  Grandin  states 
that  irrigation  of  the  bowel  with  water  at  a  temperature  from  120°  to  150° 
is  most  useful.  Xitroglycerin  also  may  be  freely  used  to  reduce  the  tension. 
For  the  ursmic  convulsions,  if  severe,  inhalations  of  cliloroform  may  be 
used.  If  the  patient  is  robust  and  full-blooded,  from  12  to  20  oimces  of  blood 
should  be  removed.  The  patient  should  be  freely  sweated,  and  if  the  convul- 
sions tend  to  recur  chloral  may  be  given,  either  by  the  mouth  or  per  rectum, 
or,  better  still,  morphia.  Ursemic  coma  must  be  treated  by  active  purgation, 
and  sweating  should  be  promoted  by  the  use  of  pilocarpine  or  the  hot  bath. 
For  the  restlessness  and  delirium  morphia  is  indispensable.  Since  its  recom- 
mendation in  urgemic  states  some  years  ago,  by  Stephen  MacKenzie,  I  have 
used  this  remedy  extensively- and  can  speak  of  its  great  value  in  these  cases. 
I  have  never  seen  ill  effects  or  any  tendency  to  coma  follow.  It  is  of  special 
value  in  the  dyspnoea  and  Che}Tie-Stokes  breathing  of  advanced  arterio-scle- 
rosis  with  chronic  urgemia. 

SuKGiCAL  Teeat:mext. — Edebohls  has  introduced  the  operation  of  decap- 
sulization  of  the  kidneys  in  Brighfs  disease  in  order  to  establish  new  vascular 
connections,  and  so  influence  the  nutrition  and  work  of  the  organs.  In  his 
work  (Surgical  Treatment  of  Bright's  Disease,  1904)  records  are  given  of  72 
cases;  7  died  within  two  weeks,  22  died  at  periods  more  or  less  remote,  3  disap- 
peared from  observation,  and  -40  were  known  to  be  living — one  eleven  years  and 
eight  months  after  the  operation.  As  Edebohls  says,  the  difficult  thing  fo 
determine  is  the  existence  of  chronic  Bright's  disease  before  operation.  Xo 
case  should  be  regarded  as  such  on  the  urine  examination  alone.  The  cardio- 
vascular condition  should  be  studied  and  the  retinae.  There  is  probably  a 
small  group  of  suitable  cases — the  subacute  and  chronic  forms  which  fol- 
low the  acute  infections — in  which  the  outlook  is  hopeless  from  medical  treat- 
ment. 

VIII.     AMYLOID  DISEASE. 

Amyloid  (lardaceous  or  wax}-)  degeneration  of  the  kidneys  is  simply  an 
event  in  the  process  of  chronic  Bright's  disease,  most  commonly  in  the  chronic 
parenchymatous  nephritis  following  fevers,  or  of  cachectic  states.  It  has  no 
claim  to  be  regarded  as  one  of  the  varieties  of  Bright's  disease.  The  affection 
of  the  kidneys  is  generally  a  part  of  a  wide-spread  amyloid  degeneration  occur- 
ring in  prolonged  suppuration,  as  in  disease  of  the  bone,  in  s}^hilis,  tubercu- 
losis, and  occasionally  leukaemia,  lead  poisoning,  and  gout.  It  varies  curiously 
in  frequency  in  different  localities. 

Anatomically  the  amyloid  kidne}'  is  large  and  pale,  the  surface  smooth, 
and  the  vense  stellatae  well  marked.  On  section  the  cortex  is  large  and  may 
show  a  peculiar  glistening,  infiltrated  appearance,  and  the  glomeruli  are  very 
distinct.  The  p}Tamids,  in  striking  contrast  to  the  cortex,  are  of  a  deep  red 
color.    A  section  soaked  in  dilute  tincture  of  iodine  shows  spots  of  a  walnut 


PYELITIS.  703 

or  mahogany  brown  color.  The  Malpighian  tufts  and  the  straight  vessels  may- 
be most  affected.  In  lardaceous  disease  of  the  kidneys  the  organs  are  not 
always  enlarged.  They  may  be  normal  in  size  or  small,  pale,  and  granular. 
The  amyloid  change  is  first  seen  in  the  Malpighian  tufts,  and  then  involves 
the  afferent  and  efferent  vessels  and  the  straight  vessels.  It  may  be  confined 
entirely  to  them.  In  later  stages  of  the  disease  the  tubules  are  affected,  chiefly 
the  membrane,  rarely,  if  ever,  the  cells  themselves.  In  addition,  the  kidneys 
always  show  signs  of  diffuse  nephritis.  The  Bowman's  capsules  are  thick- 
ened, there  may  be  glomerulitis,  and  the  tubal  epithelium  is  swollen,  granular, 
and  fatty. 

Symptoms. — The  renal  features  alone  may  not  indicate  the  presence  of 
this  degeneration.  Usually  the  associated  condition  gives  a  hint  of  the  nature 
of  the  process.  The  urine,  as  a  rule,  shows  important  changes;  the  quantity 
is  increased,  and  it  is  pale,  clear,  and  of  low  specific  gravity.  The  albumin  is 
usually  abundant,  but  it  may  be  scanty,  and  in  rare  instances  absent.  Pos- 
sibly the  variations  in  the  situation  of  the  amyloid  changes  may  account  for 
this,  since  albumin  is  less  likely  to  be  present  when  the  change  is  confined  to 
the  vasa  recta.  In  addition  to  ordinary  albumin  globulin  may  be  present. 
The  tube-casts  are  variable,  usually  hyaline,  often  fatty  or  finely  granular. 
Occasionally  the  amyloid  reaction  can  be  detected  in  the  hyaline  casts.  Dropsy 
is  present  in  many  instances,  particularly  when  there  is  much  anaemia 
or  profound  cachexia.  It  is  not,  however,  an  invariable  symptom,  and 
there  are  cases  in  which  it  does  not  develop.  Diarrhoea  is  a  common  accom- 
paniment. 

Increased  arterial  tension  and  cardiac  hypertrophy  are  not  usually  pres- 
ent, except  in  those  cases  in  which  amyloid  degeneration  occurs  in  the  sec- 
ondary contracted  kidney;  under  which  circumstances  there  may  be  ursemia 
and  retinal  changes,  which,  as  a  rule,  are  not  met  with  in  other  forms. 

Diagnosis. — By  the  condition  of  the  urine  alone  it  is  not  possible  to  rec- 
ognize amyloid  changes  in  the  kidney.  Usually,  however,  there  is  no  diffi- 
culty, since  the  Bright's  disease  comes  on  in  association  with  syphilis,  pro- 
longed suppuration,  disease  of  the  bone,  or  tuberculosis,  and  there  is  evidence 
of  enlargement  of  the  liver  and  spleen.  A  suspicious  circumstance  is  the 
existence  of  polyuria  with  a  large  amount  of  albumin  in  the  urine  and  few 
casts,  or  when,  in  these  constitutional  affections,  a  large  quantity  of  clear, 
pale  urine  is  passed,  even  without  the  presence  of  albumin. 

The  prognosis  depends  rather  on  the  condition  with  which  the  nephritis  i& 
associated.    As  a  rule  it  is  grave. 

IX.     PYELITIS. 

(Consecutive  Nephritis ;  Pyelonephritis  ;  Pyonephrosis.) 

Definition. — Inflammation  of  the  pelvis  of  the  kidney  and  the  conditions 
which  result  from  it. 

Etiology. — Pyelitis  in  almost  all  cases  is  induced  by  bacterial  invasion 
and  multiplication,  rarely  by  the  irritation  of  various  substances  such  as  tur- 
pentine, cubebs,  or  sugar  (diabetes).  Normally  the  kidney  can  eliminate  with- 
out harm  to  itself,  apparently,  various  bacteria  carried  to  it  by  the  blood-cur- 
rent from  the  intestinal  tract  or  some  focus  of  infection;  and  it  probably 


704  DISEASES  OF   THE  KIDNEYS. 

becomes  infected  onh'  where  its  resistance  is  lowered,  as  a  resnlt  of  some  gen- 
eral cause,  as  ana?mia,  malnutrition,  or  intercurrent  disease,  or  of  some  local 
cause,  as  nephritis,  displacement,  congestion  due  to  pressure  of  neoplasms  upon 
the  ureter,  twisted  ureter  (Dietl's  crisis),  or  of  operation,  or  where  the  num- 
ber or  virulence  of  the  micro-organisms  is  increased.  These  same  factors  prob- 
ably play  an  important  role  also  in  the  other  common  cau.se3  of  pyelitis,  ascend- 
ing infection  from  an  infected  bladder  (cystitis),  and  tuberculous  infection. 
Other  causes  described  are  various  fevers,  cancer,  hydatids,  the  ova  of  certain 
parasites,  cold,  and  overexertion.  Calculus  seems  not  to  be  a  common  cause. 
It  is  a  not  uncommon  complication  of  pregnancy  (French,  Goulstonian  Lec- 
tures, 1908).  In  T.  E.  Brown's  series  of  20  cases,  the  colon  bacillus  was 
obtained  7  times,  the  tubercle  bacillus  6,  the  proteus  bacillus  4,  a  white 
staphylococcus  twice,  while  in  1  case  cultures  were  negative. 

Morbid  Anatomy. — In  the  early  stages  of  pyelitis  the  mucous  membrane 
is  turbid,  somewhat  swollen,  and  may  show  ecchymoses  or  a  gra3dsh  pseudo- 
membrane.  The  urine  in  the  pelvis  is  cloudy,  and,  on  examination,  numbers 
of  epithelial  cells  are  seen. 

In  the  calculous  pyelitis  there  may  be  only  slight  turbidity  of  the  mem- 
brane, which  has  been  called  by  some  catarrhal  pyelitis.  More  commonly  the 
mucosa  is  roughened,  gra}ish  in  color,  and  thick.  Under  these  circumstances 
there  is  almost  always  more  or  less  dilatation  of  the  calyces  and  flattening  of 
the  papillge.  Following  this  condition  there  may  be  (a)  extension  of  the  sup- 
purative process  to  the  kidney  itself,  forming  a  pyelonephritis ;  ( & )  a  gradual 
dilatation  of  the  calyces  with  atrophy  of  the  kidney  substance,  and  finally  the 
production  of  the  condition  of  pyonephrosis,  in  which  the  entire  organ  is  rep- 
resented by  a  sac  of  pus  with  or  without  a  thin  shell  of  renal  tissue,  (c)  After 
the  kidney  structure  has  been  destroyed  by  suppuration,  if  the  obstruction  at 
the  orifice  of  the  pelvis  persists,  the  fluid  portions  may  be  absorbed  and  the 
pus  become  inspissated,  so  that  the  organ  is  represented  by  a  series  of  sacculi 
containing  grapsh,  putty-like  masses,  which  may  become  impregnated  with 
lime  salts. 

Tuberculous  pyelitis,  as  already  described,  usualh^  starts  upon  the  apices 
of  the  p}Tamids,  and  may  at  first  be  limited  in  extent.  Ultimately  the  condi- 
tion produced  may  be  similar  to  that  of  calculous  pyelitis.  Pyonephrosis  is 
quite  as  frequent  a  sequence,  while  the  final  transformation  of  the  pus  into 
a  putty-like  material  impregnated  with  salts,  forming  the  so-called  scrofulous 
kidney,  is  even  commoner. 

The  pyelitis  consecutive  to  cystitis  is  generally  bilateral,  and  the  kidneys 
are  sometimes  involved,  forming  the  so-called  surgical  hidneys — acute  suppura- 
tive nephritis.  There  are  lines  of  suppuration  extending  along  the  pyramids, 
or  small  abscesses  in  the  cortex,  often  just  beneath  the  capsule;  or  there  may 
be  wedge-shaped  abscesses.  The  pus  organisms  either  pass  up  the  tubules  or, 
as  Steven  has  shown,  through  the  hinphatics. 

Symptoms. — The  forms  associated  with  the  fevers  rarely  cause  any  symp- 
toms, even  when  the  process  is  extensive.  In  mild  grades  there  is  pain  in  the 
back  or  there  may  be  tenderness  on  deep  pressure  on  the  affected  side.  The 
urine,  turbid  and  containing  pus  cells,  some  mucus,  and  occasional  red  blood- 
cells,  is  acid  or  alkaline,  depending  on  the  infecting  microbe;  usually  the  albu- 
minuria is  of  higher  grade  comparatively  than  the  pjTiria. 


PYELITIS.  705 

Before  the  condition  of  pyuria  is  established  there  may  be  attacks  of  pain 
on  the  affected  side  (not  reaching  the  severe  agony  of  renal  colic),  rigors,  high 
fever,  and  sweats.  Under  these  circumstances  the  urine,  which  may  have  been 
■clear,  becomes  turbid  or  smoky  from  the  presence  of  blood,  and  may  contain 
large  numbers  of  mucus  cells  and  transitional  epithelium.  These  cases  are 
not  common,  but  I  have  twice  had  opportunity  of  studying  such  attacks  for 
a  prolonged  period.  In  one  patient  the  occurrence  of  the  rigor  and  fever  could 
sometimes  be  predicted  from  the  change  in  the  condition  of  the  urine.  Such 
cases  occur,  I  believe,  in  association  with  calculi  in  the  pelvis. 

The  statement  is  not  infrequently  made  that  the  epithelium  in  the  urine 
in  pyelitis  is  distinctive  and  characteristic.  This  is  erroneous,  as  may  be  read- 
ily demonstrated  by  comparing  scrapings  of  the  mucosa  of  the  renal  pelvis  and 
■of  the  bladder.  In  both  the  epithelium  belongs  to  what  is  called  the  transi- 
tional variety,  and  in  both  regions  the  same  conical,  fusiform,  and  irregular 
cells  with  long  tails  are  found,  and  yet  in  pyelitis  more  of  these  tailed  cells 
occur,  for  in  cystitis  one  must  often  search  long  for  them. 

When  the  pyelitis,  whether  calculous  or  tuberculous,  has  become  chronic 
and  discharges,  the  symptoms  are : 

(1)  Pyuria. — The  pus  is  in  variable  amount,  and  may  be  intermittent. 
Thus,  as  is  often  the  case  when  only  one  kidney  is  involved,  the  ureter  may  be 
temporarily  blocked,  and  normal  urine  is  passed  for  a  time;  then  there  is  a 
sudden  outflow  of  the  pent-up  pus  and  the  urine  becomes  purulent.  Coin- 
cident with  this  retention,  a  tumor  mass  may  be  felt  on  the  side  affected. 
The  pus  has  the  ordinary  characters,  but  the  transitional  epithelium  is  not  so 
abundant  at  this  stage  and  comes  from  the  bladder  or  from  the  pelvis  of  the 
healthy  side.  Occasionally  in  rapidly  advancing  pyelonephritis,  portions  of 
the  kidney  tissue,  particularly  of  the  apices  of  the  pyramids,  may  slough  away 
and  appear  in  the  urine;  or,  as  in  a  remarkable  specimen  shown  to  me  by 
Tyson,  solid  cheesy  moulds  of  the  calyces  are  passed.  Casts  from  the  kidney 
tubules  are  sometimes  present.  The  reaction  of  the  urine  depends  entirely 
upon  the  infecting  microbe,  whether  the  condition  is  unilateral  or  bilateral, 
and  whether  the  bladder  is  also  infected,  when  vesical  irritability  and  fre- 
quent micturition  may  be  present.  Polyuria  is  usually  present  in  the  chronic 
cases. 

(3)  Intermittent  fever  associated  with  rigors  is  usually  present  in  cases 
of  suppurative  pyelitis.  The  chills  may  recur  at  regular  intervals,  and  the 
cases  are  often  mistaken  for  malaria.  Owen-Eees  called  attention  to  the  fre- 
quent occurrence  of  these  rigors,  which  form  a  characteristic  feature  of  both 
calculous  and  tuberculous  pyelitis.  Ultimately  the  fever  assumes  a  hectic 
type  and  the  rigors  may  cease. 

(3)  The  general  condition  of  the  patient  often  indicates  prolonged  sup- 
puration. There  is  more  or  less  wasting  with  anaemia  and  a  progressive  fail- 
ure of  health.  Secondary  abscesses  may  develop  and  the  clinical  picture  be- 
comes that  of  pyaemia.  In  some  instances,  particularly  of  tuberculous  pyelitis, 
the  clinical  course  may  resemble  that  of  typhoid  fever.  There  are  instances 
of  pyuria  recurring,  at  intervals,  for  many  years  without  impairment  of  the 
bodily  vigor.    Some  of  the  chronic  cases  have  practically  no  discomfort. 

(4)  Physical  examination  in  chronic  pyelitis  usually  reveals  tenderness 
on  the  affected  side  or  a  definite  swelling,  which  may  vary  much  in  size  and 

46 


706  DISEASES  OF   THE  KIDNEYS. 

■altimately  attain  large  dimensions  if  the  kidney  becomes  enormously  distended. 
as  in  pyonephrosis. 

(5)  Occasionally  nervous  symptoms,  which  may  be  associated  with  dysp- 
noea, supervene,  or  the  termination  may  be  by  coma,  not  unlike  that  of  dia- 
betes. These  have  been  attributed  to  the  absorption  of  the  decomposing  mate- 
rials in  the  urine,  whence  the  so-called  ammonisemia.  A  form  of  paraplegia 
has  been  described  in  connection  with  some  cases  of  abscess  of  the  kidney, 
but  whether  due  to  a  myelitis  or  to  a  peripheral  neuritis  has  not  yet  been 
determined. 

In  suppurative  nephritis  or  surgical  kidney  following  cystitis,  the  patient 
complains  of  pain  in  the  back,  the  fever  becomes  high,  irregular,  and  asso- 
ciated with  chills,  and  in  acute  cases  a  typhoid  state  may  precede  the  fatal 
event. 

Diagnosis. — Between  the  tuberculous  and  the  calculous  forms  of  pyelitis 
it  may  be  difficult  or  impossible  to  distinguish,  except  by  the  detection  of 
tubercle  bacilli  in  the  pus.  The  examination  for  bacilli  should  be  made  sys- 
tematically, and  in  suspicious  cases  intraperitoneal  injections  of  guinea-pigs 
should  also  be  made.  From  perinephric  abscess  pyonephrosis  is  distinguished 
by  the  more  definite  character  of  the  tumor,  the  absence  of  oedematous  swell- 
ing in  the  lumbar  region,  and,  most  important  of  all,  the  history  of  the  case. 
The  urine,  too,  in  perinephric  abscess  may  be  free  from  pus.  There  are  cases, 
however,  in  which  it  is  difficult  indeed  to  make  a  satisfactory  diagnosis.  A 
patient,  whom  I  saw  with  Fussell,  had  had  cystitis  through  her  pregnancy, 
subsequently  pus  in  the  urine  for  several  months,  and  then  a  large  fluctuating 
abscess  developed  in  the  right  lumbar  region.  It  did  not  seem  possible,  either 
before  or  during  the  operation,  to  determine  whether  the  case  was  a  simple 
pyonephrosis  or  whether  there  had  been  a  perinephric  abscess  caused  by  the 
pyelitis. 

Suppurative  pyelitis  and  cystitis  are  apt  to  be  confounded,  and  perineal 
section  is  not  infrequently  performed  on  the  supposition  of  the  existence  of 
the  latter.  The  two  conditions  may,  of  course,  coexist  and  prove  puzzling, 
but  the  history,  the  higher  relative  grade  of  albuminuria  in  pyelitis  (Eosen- 
feld,  Goldberg,  T.  E.  Brown),  the  polyuria,  the  mode  of  development,  the 
local  signs  in  one  lumbar  region,  and  the  absence  of  pain  in  the  bladder,  should 
be  sufficient  to  differentiate  the  affections.  In  women,  by  catheterization  of 
the  ureters,  it  may  be  definitely  determined  whether  the  pus  comes  from  the 
kidneys  or  from  the  bladder.    The  cystoscope  may  be  used  for  this  purpose. 

Prognosis. — Cases  coming  on  during  the  fevers  usually  recover.  Tuber- 
culous pyelitis  may  terminate  favorably  by  inspissation  of  the  pus  and  con- 
version into  a  putty-like  substance  with  deposition  of  lime  salts.  With  pyo- 
nephrosis the  dangers  are  increased.  Perforation  may  occur  into  the  perito- 
naeum, the  patient  may  be  worn  out  by  the  hectic  fever,  or  amyloid  disease  may 
develop. 

Treatment. — In  mild  cases  fluids  should  be  taken  freely,  particularly  the 
alkaline  mineral  waters,  to  which  potassium  citrate  may  be  added. 

The  treatment  of  the  calculous  form  will  be  considered  later.  Practically 
there  are  no  remedies  which  have  much  influence  upon  the  pyuria.  Some 
of  the  recently  described  urinary  antiseptics,  as  urotropin,  etc.,  seem  to  be  of 
value,  especially  in  the  acute  cases.     Tonics  should  be  given,  a  nourishing 


HYDRONEPHROSIS.  707 

diet,  and  milk  and  butter-milk  may  be  taken  freely.  When  the  tumor  has 
formed  or  even  before  it  is  perceptible,  if  the  symptoms  are  serious  and  severe, 
the  kidney  should  be  explored,  and,  if  necessary,  nephrotomy  or  nephrectomy 
should  be  performed. 

X.     HYDRONEPHROSIS. 

Definition. — Dilatation  of  the  pelvis  and  calyx  of  the  kidney  with  atrophy 
of  its  substance,  caused  by  the  accumulation  of  non-purulent  fluids,  the  result 
of  obstruction. 

Etiology. — The  condition  may  be  congenital,  owing  to  some  abnormality 
in  the  ureter  or  urethra.  The  tumor  produced  may  be  large  enough  to  retard 
labor.  Sometimes  it  is  associated  with  other  malformations.  There  is  a 
condition  of  moderate  dilatation,  apparently  congenital,  which  is  not  connected 
with  any  obstruction  in  the  ducts. 

In  some  instances  there  has  been  contraction  or  twisting  of  the  ureter, 
or  it  has  been  inserted  into  the  kidney  at  an  acute  angle  or  at  a  high  level. 
In  adult  life  the  condition  may  be  due  to  lodgment  of  a  calculus,  or  to  a  cica- 
tricial stricture  following  ulcer. 

There  is  a  remarkable  condition  of  hypertrophy  and  dilatation  of  the 
bladder  and  ureters  associated  with  congenital  defect  of  the  abdominal  mus- 
cles. The  bladder  may  form  a  large  abdominal  tumor  and  the  ureters  may  be 
as  large  and  visible  as  coils  of  the  small  intestine. 

New  growths,  such  as  tubercle  or  cancer,  occasionally  induce  hydronephro- 
sis; more  commonly,  pressure  upon  the  ureter  from  without,  particularly 
tumors  of  the  ovaries  and  uterus.  Occasionally  cicatricial  bands  compress  the 
ureter.  Obstruction  within  the  bladder  may  result  from  cancer,  from  hyper- 
trophy of  the  prostate  with  cystitis,  and  in  the  urethra  from  stricture.  It  is 
stated  that  slight  grades  of  hydronephrosis  have  been  found  in  patients  with 
excessive  polyuria. 

In  whatever  way  produced,  when  the  ureter  is  blocked  the  secretion  accu- 
mulates in  the  pelvis  and  infundibula.  Sometimes  acute  inflammation  fol- 
lows, but  more  commonly  the  slow,  gradual  pressure  causes  atrophy  of  the 
papillffi  with  gradual  distention  and  wasting  of  the  organ.  In  acquired  cases 
from  pressure,  even  when  dilatation  is  extreme,  there  may  usually  be  seen  a 
thin  layer  of  renal  structure.  In  the  most  extreme  stages  the  kidney  is  repre- 
sented by  a  large  cyst,  which  may  perhaps  show  on  its  inner  surface  imperfect 
septa.  The  fluid  is  thin  and  yellowish  in  color,  and  contains  traces  of  urinary 
salts,  urea,  uric  acid,  and  sometimes  albumin.  The  secretion  may  be  turbid 
from  admixture  with  small  quantities  of  pus. 

Total  occlusion  does  not  always  lead  to  a  hydronephrosis,  but  may  be  fol- 
lowed by  atrophy  of  the  kidney.  It  appears  that  when  the  obstruction  is  inter- 
mittent or  not  complete  the  greatest  dilatation  is  apt  to  follow.  The  sac  may 
be  enormous,  and  cause  an  abdominal  tumor  of  the  largest  size.  The  condition 
has  even  been  mistaken  for  ascites.  Enlargement  of  the  other  kidney  may 
compensate  for  the  defect.  Hypertrophy  of  the  left  side  of  the  heart  usually 
follows. 

Symptoms. — When  small,  it  may  not  be  noticed.  The  congenital  cases 
when  bilateral  usually  prove  fatal  within  a  few  days;  when  unilateral,  the 


708  DISEASES  OF  THE  KIDNEYS. 

tumor  may  not  be  noticed  for  some  time.  It  increases  progressively  and  has 
all  the  characters  of  a  tumor  in  the  renal  region.  In  adult  life  many  of  the 
cases,  due  to  pressure  by  tumors,  as  in  cancer  of  the  uterus  and  enlargement 
of  the  prostate,  etc.,  give  rise  to  no  symptoms. 

There  are  remarkable  instances  of  intermittent  hydronephrosis  in  which 
the  tumor  suddenly  disappears  with  the  discharge  of  a  large  quantity  of 
clear  fluid.  The  sac  gradually  refills,  and  the  process  may  be  repeated  for 
years.  In  these  cases  the  obstruction  is  unilateral ;  a  cicatricial  stricture  exists, 
or  a  valve  is  present  in  the  ureter,  or  the  ureter  enters  the  upper  part  of  the 
pelvis.    Many  of  the  cases  are  in  women  and  associated  with  movable  kidney. 

The  examination  of  the  abdomen  shows,  in  unilateral  hydronephrosis,  a 
tumor  occupying  the  renal  region.  When  of  moderate  size  it  is  readily  recog- 
nized, but  when  large  it  may  be  confounded  with  ovarian  or  other  tumors. 
In  young  children  it  may  be  mistaken  for  sarcoma  of  the  kidney  or  of  the 
retroperitoneal  glands,  the  common  cause  of  abdominal  tumor  in  early  life. 
Aspiration  alone  would  enable  us  to  differentiate  between  hydronephrosis  and 
tumor.  The  large  hydronephrotic  sac  is  frequently  mistaken  for  ovarian 
tumor.  The  latter  is,  as  a  rule,  more  mobile,  and  rarely  fills  the  deeper  por- 
tion of  the  lumbar  region  so  thoroughly.  The  ascending  colon  can  often  be 
detected  passing  over  the  renal  tumor,  and  examination  per  vaginam,  particu- 
larly under  ether,  will  give  important  indications  as  to  the  condition  of  the 
ovaries.  In  doubtful  cases  the  sac  should  be  aspirated.  The  fluid  of  the  renal 
cyst  is  clear,  or  turbid  from  the  presence  of  cell  elements,  rarely  colloid  in  char- 
acter ;  the  specific  gravit}^  is  low ;  albumin  and  traces  of  urea  and  uric  acid  are 
usually  present ;  and  the  epithelial  elements  in  it  may  be  similar  to  those  found 
in  the  pelvis  of  the  kidney.  In  old  sacs,  however,  the  fluid  may  not  be  char- 
acteristic, since  the  urinary  salts  disappear,  but  in  one  case  of  several  years' 
duration  oxalates  of  lime  and  urea  were  found. 

Perhaps  the  greatest  difiiculty  is  offered  by  the  condition  of  hydronephrosis 
in  a  movable  kidney.  Here,  the  history  of  sudden  disappearance  of  the  tumor 
with  the  passage  of  a  large  quantity  of  clear  fluid  would  be  a  point  of  great 
importance  in  the  diagnosis.  In  those  rare  instances  of  an  enormous  sac  fill- 
ing the  entire  abdomen,  and  sometimes  mistaken  for  ascites,  the  character  of 
the  fluid  might  be  the  only  point  of  difference.  The  tumor  of  pyonephrosis 
may  be  practically  the  same  in  physical  characteristics.  Fever  is  usually 
present,  and  pus  is  often  found  in  the  urine.  In  these  cases,  when  in  doubt, 
exploratory  puncture  should  be  made. 

The  outlook  in  hydronephrosis  depends  much  upon  the  cause.  When  sin- 
gle, the  condition  may  never  produce  serious  trouble,  and  the  intermittent 
eases  may  persist  for  years,  and  finally  disappear.  Occasionally  the  cyst  rup- 
tures into  the  peritonaeum,  more  rarely  through  the  diaphragm  into  the  lung. 
A  remarkable  case  of  this  kind  was  under  the  care  of  my  colleague,  Halsted. 
A  man,  aged  twenty-one,  had,  from  his  second  year,  attacks  of  abdominal  pain 
in  which  a  swelling  would  appear  between  the  hip  and  costal  margin  and  sub- 
side with  the  passage  of  a  large  amount  of  urine.  In  January,  1888,  the  sac 
discharged  through  the  right  lung.  Reaccumulations  occurred  on  several 
occasions,  and  on  June  9,  1891,  the  sac  was  opened  and  drained.  He  remains 
well,  though  there  is  still  a  sinus  through  which  a  clear,  probably  urinous, 
fluid  is  discharged. 


NEPHROLITHIASIS.  709 

The  sac  may  discharge  spontaneously  through  the  ureter  and  the  fluid 
never  reaccumulate.  In  bilateral  hydronephrosis  there  is  a  danger  that  uraemia 
may  supervene.  There  are  instances,  too,  in  which  blocking  of  the  ureter  on 
the  soimd  side  by  calculus  has  been  followed  by  urasmia.  And,  lastly,  the  sac 
may  suppurate,  and  the  condition  change  to  one  of  pyonephrosis. 

Treatment. — Cases  of  intermittent  hydronephrosis  which  do  not  cause 
serious  symptoms  should  be  let  alone.  It  is  stated  that,  in  sacs  of  moderate 
size,  the  obstruction  has  been  overcome  by  shampooing.  If  practised,  it  should 
be  done  with  great  care.  When  the  sac  reaches  a  large  size  aspiration  may  be 
performed  and  repeated  if  necessary.  Puncture  should  be  made  in  the  flank, 
midway  between  the  ilium  and  the  last  rib.  If  the  fluid  reaccumulates  and 
the  sac  becomes  large,  it  may  be  incised  and  drained,  or,  as  a  last  resort,  the 
kidney  may  be  removed.  In  women  a  carefully  adapted  pad  and  bandage  will 
sometimes  prevent  the  recurrence  of  an  intermittent  hydronephrosis. 

XI.    NEPHROLITHIASIS    (Renal  Calculus). 

Definition.^The  formation  in  the  kidney  or  in  its  pelvis  of  concretions, 
by  the  deposition  of  certain  of  the  solid  constituents  of  the  urine. 

Etiology  and  Pathology. — In  the  kidney  substance  itself  the  separation 
of  the  urinary  salts  produces  a  condition  to  which,  unfortunately,  the  term 
infarct  has  been  applied.  Three  varieties  may  be  recognized:  (1)  The  uric- 
acid  infarct,  usually  met  with  at  the  apices  of  the  pyramids  in  new-born  chil- 
dren and  during  the  first  weeks  of  life.  The  priapism  and  attacks  of  cry- 
ing in  the  new-born  have  been  attributed  to  the  passage  of  these  infarcts 
(Southworth) ;  (2)  the  sodium-urate  infarct,  sometimes  associated  with 
ammonium  urate,  which  forms  whitish  lines  at  the  apices  of  the  pyra- 
mids and  is  met  with  chiefly,  but  not  always,  in  gouty  persons;  and  (3)  the 
lime  infarcts,  forming  very  opaque  white  lines  in  the  pyramids,  usually  in 
old  people. 

In  the  pelvis  and  calyces  concretions  of  the  following  forms  occur:  (a) 
Small  gritty  particles,  renal  sand,  ranging  in  size  from  the  individual  grains 
of  the  uric-acid  sediment  to  bodies  1  or  3  mm.  in  diameter.  These  may  be 
passed  in  the  urine  for  long  periods  without  producing  any  symptoms,  since 
they  are  too  fine  to  be  arrested  in  their  downward  passage. 

(&)  Larger  concretions,  ranging  in  size  from  a  small  pea  to  a  bean,  and 
either  solitary  or  multiple  in  the  calyces  and  pelvis.  It  is  the  smaller  of  these 
calculi  which,  in  their  passage,  produce  the  attacks  of  renal  colic.  They  may 
be  rounded  and  smooth,  or  present  numerous  irregular  projections. 

(c)  The  dendritic  form  of  calculus.  The  orifice  of  the  ureter  may  be 
blocked  by  a  Y-shaped  stone.  The  pelvis  itself  may  be  occupied  by  the  con- 
cretion, which  forms  a  more  or  less  distinct  mould.  These  are  the  remark- 
able coral  calculi,  which  form  in  the  pelvis  complete  moulds  of  infundibula 
and  calyces,  the  latter  even  presenting  cup-like  depressions  corresponding  to 
the  apices  of  the  papillae.  Some  of  these  casts  in  stone  of  the  renal  pelvis  are 
as  beautifully  moulded  as  HyrtFs  corrosion  preparations. 

Chemically  the  varieties  of  calculi  are :  ( 1 )  Uric  acid  and  urates,  most 
important,  and  forming  the  renal  sand,  the  small  solitary,  or  the  large  dendritic 
stones.     They  .are  very  hard,  the  surface  is  smooth,  and  the  color  reddish. 


710  DISEASES  OF  THE  KIDNEYS. 

The  larger  stones  are  usually  stratified  and  very  dense.  ITsually  the  uric 
acid  and  the  urates  are  mixed,  but  in  children  stones  composed  of  urates  alone 
may  occur. 

(3)  Oxalate  of  lime,  which  forms  mulberry-shaped  calculi,  studded  with 
points  and  spines.  They  are  often  very  dark  in  color,  intensely  hard,  and 
are  a  mixture  of  oxalate  of  lime  and  uric  acid. 

(3)  Phosphatic  calculi  are  composed  of  the  calcium  phosphate  and  the 
ammonio-magnesium  phosphate,  sometimes  mixed  with  a  small  amount  of 
calcium  carbonate.  They  are  quite  common,  although  the  phosphatic  salts 
are  often  deposited  about  the  uric  acid  or  the  calcium-oxalate  stones. 

(i)  Rare  forms  of  calculi  are  made  up  of  cystine,  xanthine,  carbonate  of 
lime,  indigo,  and  urostealith. 

The  mode  of  formation  of  calculi  has  been  much  discussed.  They  may 
be  produced  by  an  excess  of  a  sparingly  soluble  abnormal  ingredient,  such 
as  cystine  or  xanthine;  more  frequently  by  the  presence  of  uric  acid  in  a 
very  acid  urine  which  favors  its  deposition.  Sir  William  Eoberts  thus  briefly 
states  the  conditions  which  lead  to  the  formation  of  the  uric-acid  concretions : 
high  acidity,  poverty  in  salines,  low  pigmentation,  and  high  percentage  of 
uric  acid.  Ord  suggests  that  albumin,  mucus,  blood,  and  epithelial  threads 
may  be  the  starting-point  of  stone.  The  demonstration  of  organisms  in  the 
centre  of  renal  calculi  renders  it  probable  that  in  many  cases  the  nucleus  of 
the  stone  is  an  agglutinated  mass  of  bacteria. 

Eenal  calculi  are  most  common  in  the  early  and  later  periods  of  life.  They 
are  moderately  frequent  in  this  country,  but  there  do  not  appear  to  be  spe- 
cial districts,  corresponding  to  the  "  stone  counties  "  in  England.  Men  are 
more  often  affected  than  women.  Sedentary  occupations  seem  to  predispose 
to  stone. 

The  effects  of  the  calculi  are  varied.  It  is  by  no  means  uncommon  to  find 
a  dozen  or  more  stones  of  various  sizes  in  the  calyces  without  any  destruction 
of  the  mucous  membrane  or  dilatation  of  the  pelvis.  A  turbid  urine  fills  the 
pelvis  in  which  there  are  numerous  cells  from  the  epithelial  lining.  There 
are  cases  of  this  sort  in  which,  apparently,  the  stones  may  go  on  forming 
and  are  passed  for  years  without  seriously  impairing  the  health  and  without 
inconvenience,  except  the  attacks  of  renal  colic.  Still  more  remarkable  are  the 
cases  of  coral-like  calculi,  which  may  occupy  the  entire  pelvis  and  calyces  with- 
out causing  pyelitis,  but  wliich  gradually  lead  to  more  or  less  induration  of 
the  kidney.  The  most  serious  effects  are  when  the  stone  excites  a  suppura- 
tive pyelitis  and  pyonephrosis. 

Symptoms. — Patients  may  pass  gravel  for  years  without  having  an  attack 
of  renal  colic,  and  a  stone  may  never  lodge  in  the  ureter.  In  other  instances, 
the  formation  of  calculi  goes  on  year  by  year  and  the  patient  has  recurring 
attacks  such  as  have  been  so  graphically  described  by  ]\Iontaigne  in  his  own 
case.  A  patient  may  pass  an  enormous  number  of  calculi.  Some  years  ago 
I  was  consulted  by  a  commercial  traveller,  an  extremely  vigorous  man,  who 
for  many  years  had  had  repeated  attacks  of  renal  colic,  and  had  passed  several 
hundred  calculi  of  various  sizes.  His  collection  filled  an  ounce  bottle.  A 
patient  may  pass  a  single  calculus,  and  never  be  troubled  again.  The  large 
coral  calculi  may  excite  no  s^Tiiptoms.  In  a  remarkable  specimen  of  the  kind, 
presented  to  the  McGill  Medical  Museum  by  J.  A.  Macdonald,  the  patient. 


NEPHROLITHIASIS.  7 1 1 

a  middle-aged  woman,  died  suddenly  with  ursemie  symptoms.  There  was  no 
pyelitis,  but  the  kidneys  were  sclerotic. 

Renal,  colic  ensues  when  a  stone  enters  the. ureter,  or  follows  an  acute  pyeli- 
tis. An  attack  may  set  in  abruptly  without  apparent  cause,  or  may  follow 
a  strain  in  lifting.  It  is  characterized  by  agonizing  pain,  which  starts  in  the 
flank  of  the  affected  side,  passes  down  the  ureter,  and  is  felt  in  the  testicle 
and  along  the  inner  side  of  the  thigh.  The  pain  may  also  radiate  through 
the  abdomen  and  chest,  and  be  very  intense  in  the  back.  In  severe  attacks 
there  are  nausea  and  vomiting  and  the  patient  is  collapsed.  The  perspiration 
breaks  out  upon  the  face  and  the  pulse  is  feeble  and  quick.  A  chill  may  pre- 
•cede  the  outbreak,  and  the  temperature  may  rise  as  high  as  103°.  No  one 
has  more  graphically  described  an  attack  of  "  the  stone  "  than  Montaigne,* 
who  was  a  sufferer  for  many  years :  "  Thou  art  seen  to  sweat  with  pain,  to 
look  pale  and  red,  to  tremble,  to  vomit  well-nigh  to  blood,  to  suffer  strange 
contortions  and  convulsions,  by  starts  to  let  tears  drop  from  thine  eyes,  to 
urine  thick,  black,  and  frightful  water,  or  to  have  it  suppressed  by  some  sharp 
and  craggy  stone,  that  cruelly  pricks  and  tears  thee."  The  symptoms  persist 
for  a  variable  period.  In  short  attacks  they  do  not  last  longer  than  an  hour; 
in  other  instances  they  continue  for  a  day  or  more,  with  temporary  relief. 
Micturition  is  frequent,  occasionally  painful,  and  the  urine,  as  a  rule,  is 
bloody.  There  are  instances  in  which  a  large  amount  of  clear  urine  is  passed, 
probably  from  the  other  kidney.  In  rare  cases  the  secretion  of  urine  is  com- 
pletely suppressed,  even  when  the  kidney  on  the  opposite  side  is  normal,  and 
death  may  occur  from  uremia.  This  most  frequently  happens  when  the  second 
kidney  is  extensively  diseased,  or  when  only  a  single  kidney  exists.  A  num- 
ber of  cases  of  this  kind  have  been  recorded.  The  condition  has  been  termed, 
by  Sir  William  Eoberts,  obstructive  suppression.  It  is  met  with  also  when 
cancer  compresses  both  ureters  or  involves  their  orifices  in  the  bladder.  The 
patient  may  not  appear  to  be  seriously  ill  at  first,  and  ursemie  symptoms  may 
not  develop  for  a  week,  when  twitching  of  the  muscles,  great  restlessness,  and 
sometimes  drowsiness  supervene,  but,  strange  to  say,  neither  convulsions  nor 
coma.  Death  takes  place  usually  within  twelve  days  from  the  onset  of  the 
obstruction. 

After  the  attack  of  colic  has  passed  there  is  more  or  less  aching  on  the 
affected  side,  and  the  patient  can  usually  tell  from  which  kidney  the  stone 
has  come.  Examination  during  the  attack  is  usually  negative.  Very  rarely 
the  kidney  becomes  palpable.  Tenderness  on  the  affected  side  is  common. 
In  very  thin  persons  it  may  be  possible,  on  examination  of  the  abdomen,  to 
feel  the  stone  in  the  ureter ;  or  the  patient  may  complain  of  a  grating  sensation. 

When  the  calculi  remain  in  the  kidney  they  may  produce  very  definite  and 
characteristic  symptoms,  of  which  the  following  are  the  most  important : 

(1)  Pain^  usually  in  the  back,  which  is  often  no  more  than  a  dull  soreness, 
but  which  may  be  severe  and  come  on  in  paroxysms.  It  is  usually  on  the 
side  affected,  but  may  be  referred  to  the  opposite  kidney,  and  there  are  in- 
stances in  which  the  pain  has  been  confined  to  the  sound  side.  It  radiates 
in  the  direction  of  the  ureter,  and  may  be  felt  in  the  scrotum  or  even  in  the 
penis.    Pains  of  a  similar  nature  may  occur  in  movable  kidneys,  and  there  are 

*  Essays,  Book  III,  13. 


712  DISEASES  OF  THE  KIDNEYS. 

several  instances  on  record  in  which  surgeons  have  incised  the  kidney  for 
stone  and  found  none.  In  an  instance  in  which  pain  was  present  for  a  couple 
of  years  the  exploration  revealed  only  a  contracted  kidney. 

(2)  HcBmaturia. — Although  this  occurs  most  frequently  when  the  stone 
becomes  engaged  in  the  ureter,  it  may  also  come  on  when  the  stones  are  in 
the  pelvis.  The  bleeding  is  seldom  profuse,  as  in  cancer,  but  in  some  instances 
may  persist  for  a  long  time.  It  is  aggravated  by  exertion  and  lessened  by  rest. 
Frequently  it  onl}^  gives  to  the  urine  a  smok}^  hue.  The  urine  may  be  free  for 
days,  and  then  a  sudden  exertion  or  a  prolonged  ride  may  cause  smokiness, 
or  blood  may  be  passed  in  considerable  quantities. 

(3)  Pyelitis. —  (a)  There  may  be  attacks  of  severe  pain  in  the  back,  not 
amounting  to  actual  colic,  which  are  initiated  by  a  heavy  chill  followed  by 
fever,  in  which  the  temperature  may  reach  lO-i"  or  105°,  followed  by  profuse 
sweating.  The  urine,  which  has  been  clear,  may  become  turbid  and  smoky 
and  contain  blood  and  abundant  epithelium  from  the  pelvis.  Attacks  of  this 
description  may  recur  at  intervals  for  months  or  even  years,  and  are  generally 
mistaken  for  malaria,  unless  special  attention  is  paid  to  the  urine  and  to  the 
existence  of  the  pain  in  the  back.  This  renal  intermittent  fever,  due  to  the 
presence  of  calculi,  is  analogous  to  the  hepatic  intermittent  fever,  due  to 
gall-stones,  and  in  both  it  is  important  to  remember  that  the  most  intense 
paroxysms  may  occur  without  any  evidence  of  suppuration. 

( h )  More  frequently  the  s}Tnptoms  of  purulent  pyelitis,  which  have  already 
been  described,  are  present;  pain  in  the  renal  region,  recurring  chills,  and 
pus  in  the  urine,  with  or  without  indications  of  pyonephrosis. 

(4)  Pyuria. — There  are  instances  of  stone  in  the  kidney  in  which  pus 
occurs  continuously  or  intermittently  in  the  urine  for  many  years.  On  many 
occasions  between  1875  and  1884  I  examined  the  urine  of  a  physician  who  had 
passed  calculi  when  a  student  in  1845,  and  had  pus  in  the  urine  at  intervals 
to  1891.  In  spite  of  the  prolonged  suppuration  he  had  remarkable  mental 
and  bodily  vigor. 

Patients  with  stone  in  the  kidney  are  often  robust,  high  livers,  and  gouty. 
Attacks  of  dyspepsia  are  not  uncommon,  or  they  may  have  severe  headaches. 

Diagnosis. — Eenal  may  be  mistaken  for  intestinal  colic,  particularly  if  the 
distention  of  the  bowels  is  marked,  or  for  biliary  colic.  The  situation  and 
direction  of  the  pain,  the  retraction  and  tenderness  of  the  testicle,  the  occur- 
rence of  haematuria,  and  the  altered. character  of  the  urine  are  distinctive  fea- 
tures. Attention  may  again  be  called  to  the  fact  that  attacks  simulating  renal 
colic  are  associated  with  movable  kidney,  or  even,  it  has  been  supposed,  without 
mobility  of  the  kidney,  with  the  accumulation  of  the  oxalates  or  uric  acid  in 
the  pelvis  of  the  kidney.  The  diagnosis  between  a  stone  in  the  kidney  and 
stone  in  the  bladder  is  not  always  easy,  though  in  the  latter  the  pain  is 
particularly  about  the  neck  of  the  bladder,  and  not  limited  to  one  side.  In 
the  uric-acid  or  uratic  renal  stone,  the  urine  is  acid,  thus  aiding  us  in  differ- 
entiating it  from  a  bladder  stone,  when  alkaline  urine  is  the  rule.  It  is 
stated  that  certain  differences  occur  in  the"  sjnnptoms  produced  by  different 
sorts  of  calculi.  The  large  uric-acid  calculi  less  frequently  produce  severe 
sjrtnptoms.  On  the  other  hand,  as  the  oxalate  of  lime  is  a  rougher  calculus, 
it  is  apt  to  produce  more  pain  (often  of  a  radiating  character)  than  the 
lithic-acid  form,  and  to  cause  haemorrhage.     In  both  these  forms  the  urine 


TUMORS  OF  THE  KIDNEY.  713 

is  acid.  The  phosphatic  calculi  are  stated  to  produce  the  most  intense  pain, 
and  the  urine  is  commonly  alkaline.  The  Eoentgen  rays  are  becoming  of  more 
and  more  value  in  determining  the  presence  and  position  of  a  stone. 

Treatment. — In  the  attacks  of  renal  colic  great  relief  is  experienced  by 
the  hot  bath,  which  is  sometimes  sufficient  to  relax  the  spasm  When  the  pain 
is  very  intense  morphia  should  be  given  hypodermically  and  inhalations  of 
chloroform  may  be  necessary  until  the  effects  of  the  anodyne  are  manifest. 
Local  applications  are  sometimes  grateful — hot  poultices,  or  cloths  wrung  out 
of  hot  water.  The  patient  may  drink  freely  of  hot  lemonade,  soda  water,  or 
barley  water.  Occasionally  change  in  posture  or  inversion  will  give  great 
relief.  Surgical  interference  should  be  considered  in  all  cases,  especially  when 
the  stone  is  large  or  the  associated  pyelitis  severe. 

In  the  intervals  the  patient  should,  as  far  as  possible,  live  a  quiet  life, 
avoiding  sudden  exertion  of  all  sorts.  The  essential  feature  in  the  treatment 
is  to  keep  the  urine  abundant  and,  in  the  uric-acid  or  uratic  cases,  alkaline. 
The  patient  should  drink  daily  a  large  but  definite  quantity  of  mineral  waters  * 
or  distilled  water,  which  is  just  as  satisfactory.  The  citrate  or  bicarbonate  of 
potash  may  be  added.  The  aching  pains  in  the  back  are  often  greatly  relieved 
by  this  treatment.  Many  patients  find  benefit  from  a  stay  at  Saratoga,  Bed- 
ford, Poland,  or  other  mineral  springs  in  the  United  States,  or  at  Vichy  or 
Ems  in  Europe. 

The  diet  should  be  carefully  regulated,  and  similar  to  that  indicated  in  the 
early  stages  of  gout.  Sir  William  Eoberts  recommends  what  is  known  as  the 
solvent  treatment  for  uric-acid  calculi.  The  citrate  of  potash  is  given  in  large 
doses,  half  a  drachm  to  a  drachm,  every  three  hours  in  a  tumblerful  of  water. 
This  should  be  kept  up  for  several  months.  I  have  had  no  success  with  this 
treatment,  nor,  when  one  considers  the  character  of  the  uric-acid  stones 
usually  met  with  in  the  kidney,  does  it  seem  likely  that  any  solvent  action 
could  be  exercised  upon  them  by  changes  in  the  urine.  This  treatment  should 
be  abandoned  if  the  urine  becomes  ammoniacal. 

The  value  of  piperazine  as  a  solvent  of  uric-acid  gravel  or  of  uric-acid 
stones  has  been  much  discussed  of  late.  While  outside  the  body  a  watery  solu- 
tion of  the  drug  has  this  power  in  a  marked  degree,  the  amount  excreted  in 
the  urine  as  given  in  the  ordinary  doses  of  15  grains  daily  seems  to  have  very 
little  influence.  Several  observers  have  shown  that  the  percentage  of  piper- 
azine excreted  in  the  urine,  when  taken  in  doses  of  from  1  to  3  grammes,  has, 
when  tested  outside  of  the  body,  little  or  no  influence  as  a  solvent  (Fawcett, 
Gordon) . 

XII.     TUMORS    OF    THE    KIDNEY. 

These  are  benign  and  malignant.  Of  the  benign  tumors,  the  most  com- 
mon are  the  small  nodular  fibromata  which  occur  frequently  in  the  pyra- 
mids, and  occasionally  lipoma,  angioma,  or  lymphadenoma.  The  adenomata 
may  be  congenital.  In  one  of  my  cases  the  kidneys  were  greatly  enlarged, 
contained  small  cysts,  and  numerous  adenomatous  structures  throughout  both 
organs. 

*  Some  of  these,  if  we  judge  by  the  laudatory  reports,  are  as  potent  as  the  waters  of  Cor- 
sena,  declared  by  Montaigne  to  be  "  powerful  enough  to  break  stones." 


714  DISEASES  OF  THE  KIDNEYS. 

Malignant  growths — cancer  or  sarcoma — may  be  either  primary  or  second- 
ary. The  sarcomata  are  the  most  common,  either  alveolar  sarcoma  or  the 
remarkable  form  containing  striped  muscular  fibres — rhabdomyoma.  They 
are  very  common  tumors  in  children.  One  of  the  most  common  and  important 
renal  tumors  is  the  hypernepliroma,  growing  in  or  upon  the  organ  from  the 
adrenal  tissue — the  aberrant  "  rests  "  of  Grawitz.  A.  0.  J.  Kelly,  Eamsay, 
and  Ellis  have  made  important  contributions  to  our  knowledge  of  this  form. 
Of  163  cases  only  6  were  extra-renal  (Ellis).  They  may  be  small  and  in  the 
renal  cortex  or  form  large  tumors  with  extensive  metastases,  particularly 
in  the  lungs.  Kelly  states  that  most  of  the  primary  carcinomas  and  alveolar 
sarcomas  of  the  kidney  are  really  hypernephromata. 

The  tumors  attain  a  very  large  size,  and  almost  fill  the  abdomen.  In  chil- 
dren they  may  be  enormous.  Morris  states  that  in  a  boy  at  the  Middlesex  Hos- 
pital the  tumor  weighed  31  pounds.  They  grow  rapidly,  are  often  soft,  and 
haemorrhage  frequently  takes  place  into  them.  In  the  sarcomata,  invasion  of 
the  pelvis  or  of  the  renal  vein  is  common.  The  rhabdomyomata  rarely  form 
very  large  tumors,  and  death  occurs  shortly  after  birth.  In  one  of  my  cases 
the  child  at  the  age  of  three  years  and  a  half  died  suddenly  of  embolism  of 
the  pulmonary  artery  and  tricuspid  orifice  by  a  fragment  of  the  tumor,  which 
had  grown  into  the  renal  vein. 

Symptoms. — The  following  are  the  most  important:  (1)  Haematuria  in 
one-half  the  cases,  which  may  be  the  first  indication.  The  blood  is  fluid  or 
clotted,  and  there  may  be  very  characteristic  moulds  of  the  pelvis  of  the  kidney 
and  of  the  ureter.  It  would  no  doubt  be  possible  for  such  to  form  in  the 
hsematuria  from  calculus,  but  I  have  never  met  with  a  case  of  blood-casts 
of  the  pelvis  and  of  the  ureter,  either  alone  or  together,  except  in  cancer.  It 
is  rare  indeed  that  cancer  elements  can  be  recognized  in  the  urine,  and  yet 
the  diagnosis  has  been  made  in  this  way. 

(3)  Pain  is  an  uncertain  symptom.  In  several  of  the  largest  tumors  which 
have  come  under  my  observation  there  has  been  no  discomfort  from  beginning 
to  close.  When  present,  it  is  of  a  dragging,  dull  character,  situated  in  the 
flank  and  radiating  down  the  thigh.  The  passage  of  the  clots  may  cause  great 
pain.  In  one  case  the  growth  was  at  first  upward,  and  the  symptoms  for  some 
months  were  those  of  pleurisy. 

(3)  Progressive  emaciation.  The  loss  of  flesh  is  usually  marked  and 
advances  rapidly.  There  may,  however,  be  a  very  large  tumor  without 
emaciation. 

Physical  Sigxs. — In  almost  all  instances  tumor  is  present.  When  small 
and  on  the  right  side,  it  may  be  very  movable;  in  some  instances,  occupying 
a  position  in  the  iliac  fossa,  it  has  been  mistaken  for  ovarian  tumor.  The 
large  growths  fill  the  flank  and  gradually  extend  toward  the  middle  line, 
occupying  the  right  or  left  half  of  the  abdomen.  Inspection  may  show  two  or 
three  hemispherical  projections  corresponding  to  distended  sections  of  the 
organ.  In  children  the  abdomen  may  reach  an  enormous  size  and  the  veins 
are  prominent  and  distended.  On  bimanual  palpation  the  tumor  is  felt  to 
occupy  the  lumbar  region  and  can  usually  be  lifted  slightly  from  its  bed;  in 
some  cases  it  is  very  movable,  even  when  large ;  in  others  it  is  fixed,  firm,  and 
solid.  The  respiratory  movements  have  but  slight  influence  upon  it.  Eapidly 
growing  renal  tumors  are  soft,  and  on  palpation  may  give  a  sense  of  fluctua- 


CYSTIC  DISEASE  OF  THE  KIDNEY.  715 

tion.    A  point  of  considerable  importance  is  the  fact  that  the  colon  crosses  the. 
tumor,  and  can  usually  be  detected  without  difficulty. 

Diagnosis. — In  children  very  large  abdominal  tumors  are  either  renal  or 
retroperitoneal.  The  retroperitoneal  sarcoma  (Lobstein's  cancer)  is  more  cen- 
tral, but  may  attain  as  large  a  size.  If  the  case  is  seen  only  toward  the  end,  a 
differential  diagnosis  may  be  impossible ;  but  as  a  rule  the  sarcoma  is  less  mov- 
able. It  is  to  be  remembered  that  these  tumors  may  invade  the  kidney.  On 
the  left  side  an  enlarged  spleen  is  readily  distinguished,  as  the  edge  is  very 
distinct  and  the  notch  or  notches  well  marked ;  it  descends  during  respiration, 
and  the  colon  lies  behind,  not  in  front  of  it.  On  the  right  side  growths  of  the 
liver  are  occasionally  confounded  with  renal  tumors;  but  such  instances  are 
rare,  and  there  can  usually  be  detected  a  zone  of  resonance  between  the  upper 
margin  of  the  renal  tumor  and  the  ribs.  Late  in  the  disease,  however,  this  is 
not  possible,  for  the  renal  tumor  is  in  close  union  with  the  liver. 

A  malignant  growth  in  a  movable  kidney  may  be  very  deceptive  and  may 
simulate  cancer  of  the  ovary  or  myoma  of  the  uterus.  The  great  mobility 
upward  of  the  renal  growth  and  the  negative  result  of  examination  of  the 
pelvic  viscera  are  the  reliable  points. 

When  the  growth  is  small  and  the  patient  in  good  condition  removal  of  the 
organ  may  be  undertaken,  but  the  percentage  of  cases  of  recovery  is  very  small, 
only  5.4  per  cent  (Gr.  Walker). 

XIII.     CYSTIC    DISEASE    OF    THE    KIDNEY. 

The  following  varieties  of  cysts  are  met  with : 

I.  The  small  cysts,  already  described  in  connection  with  the  chronic 
nephritis,  which  result  from  dilatation  of  obstructed  tubules  or  of  Bowman's 
capsules.  There  are  cases  very  difficult  to  classify,  in  which  the  kidneys  are 
greatly  enlarged,  and  very  cystic  in  middle-aged  or  elderly  persons,  and  yet 
not  so  large  as  in  the  congenital  form. 

II.  Solitary  cysts,  ranging  in  size  from  a  marble  to  an  orange,  or  even 
larger,  are  occasionally  found  in  kidneys  which  present  no  other  changes.  In 
exceptional  cases,  they  may  form  tumors  of  considerable  size.  Newman  oper- 
ated on  one  which  contained  25  ounces  of  blood.  They,  too,  in  all  probability, 
result  from  obstruction. 

III.  The  polycystic  kidneys  in  which  the  greatly  enlarged  organs,  weighing 
even  as  much  as  six  pounds,  are  represented  by  a  conglomeration  of  cysts,  vary- 
ing in  size  from  a  pea  to  a  marble.  Little  or  no  renal  tissue  may  be  noticeable, 
although  in  microscopical  sections  it  is  seen  that  a  considerable  amount  re- 
mains in  the  interspaces.  The  cysts  contain  a  clear  or  turbid  fluid,  sometimes 
reddish-brown  or  even  blackish  in  color,  and  may  be  of  a  colloidal  consistence. 
Albumin,  blood  crystals,  cholesterin,  with  triple  phosphates  and  fat  drops  are 
found  in  the  contents.  Urea  and  uric  acid  are  rarely  present.  The  cysts 
are  lined  by  a  flattened  epithelium.  They  occur  in  the  foetus,  and  sometimes 
are  of  such  a  size  as  to  obstruct  labor.  In  the  adult  they  are  usually  bilateral, 
and  there  is  every  reason  to  believe  that  they  begin  in  early  life  and  increase 
gradually.  Indeed,  a  progressive  growth  has  been  noticed  in  some  cases  (Alfred 
King).  They  may  be  found  in  connection  with  cystic  disease  of  the  liver  and 
other  organs.    It  is  difficult  to  account  for  the  origin  of  this  remarkable  con- 


716  DISEASES  OF  THE  KIDNEYS. 

dition^  which  some  regard  as  a  defect  of  development  rather  than  a  patho- 
logical change,  and  point  to  the  association  in  the  fatal  cases  of  other  anoma- 
lies, as  imperforate  anus,  Shattock  and  Bland  Sutton  have  suggested  that 
the  anomaly  of  development  is  a  failure  of  complete  differentiation  of  the 
Wolffian  bodies,  but  embryologists  whom  I  have  consulted  on  this  point  tell 
me  that  this  is  most  unlikely.  Others  believe  the  condition  to  be  a  new  growth 
— a  sort  of  mucoid  endothelioma. 

It  is  interesting  to  note  that  several  members  of  a  family  may  be  affected. 
I  have  reported  an  instance  in  which  mother  and  son  were  the  subjects  of 
the  disease. 

Symptoms. — Of  five  cases  which  I  have  seen  in  adults  the  condition  was 
recognized  during  life  in  four.     The  features  are  characteristic. 

(a)  Bilateral  tumors  in  the  renal  regions,  which  may  increase  in  size 
under  observation.  They  may  cause  great  enlargement  of  the  upper  zone  of 
the  abdomen.  The  colon  and  stomach  are  in  front  of  the  tumors,  on  the 
surface  of  which  in  very  thin  subjects  thie  cysts  may  be  palpable. 

(&)   Haematuria,  which  may  recur  at  intervals  for  years. 

(c)  The  signs  of  a  chronic  interstitial  nephritis — (1)  pallor  or  muddy 
complexion;  in  rare  instances  a  bronzing  of  the  skin;  (2)  sclerosis  of  the 
arteries;  (3)  hypertrophy  of  the  heart  with  accentuated  second  sounds; 
(4)  urine  abundant,  of  low  specific  gravity,  with  albumin,  and  hyaline  and 
granular  tube-casts,  and  in  one  of  my  cases  there  were  cholesterin  crystals. 
Death  occurs  from  urasmia  or  the  cardio-vascular  complications  of  chronic 
Bright's  disease.  A  rare  event  is  rupture  of  a  cyst  with  the  formation  of  a 
perinephric  abscess  and  peritonitis.  In  two  of  my  cases  the  skin  became  much 
pigmented. 

While  both  kidneys  are,  as  a  rule,  involved,  one  may  be  much  smaller  than 
the  other. 

Operation  is  rarely  indicated,  unless  the  condition  is  found  to  be  uni- 
lateral, in  which  case  Morris  has  removed  the  kidney  in  several  instances,  and 
the  patients  have  remained  well  for  years. 

IV.  Occasionally  the  kidneys  and  liver  present  numerous  small  cysts  scat- 
tered through  the  substance.  The  spleen  and  the  thyroid  also  may  be  involved, 
and  there  may  be  congenital  malformation  of  the  heart.  The  cysts  in  the 
kidney  are  small,  and  neither  so  numerous  nor  so  thickly  set  as  in  the  con- 
glomerate form,  though  in  these  cases  the  condition  is  probably  the  result  of 
some  congenital  defect.  There  are  cases,  however,  in  which  the  kidneys  are 
very  large.  It  is  more  common  in  the  lower  animals  than  in  man.  I  have 
seen  several  instances  of  it  in  the  hog ;  in  one  case  the  liver  weighed  40  pounds, 
and  was  converted  into  a  mass  of  simple  cysts.  The  kidneys  were  less  involved. 
Charles  Kennedy  found  references  to  12  cases  of  combined  cystic  disease  of  the 
liver  and  kidneys. 

The  echinoccocus  cysts  have  been  described  under  the  section  on  parasites. 
Paranephric  cysts  (external  to  the  capsule)  are  rare;  they  may  reach  a  large 
size. 


PERINEPHRIC   ABSCESS.  717 


XIV.     PERINEPHRIC    ABSCESS. 

Suppuration  in  the  connective  tissue  about  the  kidney  may  follow  (1) 
blows  and  injuries;  (2)  the  extension  of  inflammation  from  the  pelvis  of  the 
kidney,  the  kidney  itself,  or  the  ureters;  (3)  perforation  of  the  bowel,  most 
commonly  the  appendix,  in  some  instances  the  colon;  (4)  extension  of  sup- 
puration from  the  spine,  as  in  caries,  or  from  the  pleura,  as  in  empyema ;  ( 5 ) 
as  a  sequel  of  the  fevers,  particularly  in  children. 

Post  mortem  the  kidney  is  surrounded  by  pus,  particularly  at  the  posterior 
part,  though  the  pus  may  lie  altogether  in  front,  between  the  kidney  and  the 
peritonaeum.  Usually  the  abscess  cavity  is  extensive.  The  pus  is  often  offen- 
sive and  may  have  a  distinctly  fgecal  odor  from  contact  with  the  large  bowel. 
It  may  burrow  in  various  directions  and  burst  into  the  pleura  and  be  dis- 
charged through  the  lungs.  A  more  frequent  direction  is  down  the  psoas 
muscle,  when  it  appears  in  the  groin,  or  it  may  pass  along  the  iliacus  fascia 
and  appear  at  Poupart's  ligament.  It  may  perforate  the  bowel  or  rupture  into 
the  peritonaeum ;  sometimes  it  penetrates  the  bladder  or  vagina. 

Post  mortem  we  occasionally  find  a  condition  of  chronic  perinephritis  in 
which  the  fatty  capsule  of  the  kidney  is  extremely  firm,  with  numerous  bands 
■of  fibrous  tissue,  and  is  stripped  off  from  the  proper  capsule  with  the  greatest 
difficulty.     Such  a  condition  probably  produces  no  symptoms. 

Symptoms. — There  may  be  intense  pain,  aggravated  by  pressure,  in  the 
lumbar  region.  In  other  instances,  the  onset  is  insidious,  without  pain  in  the 
renal  region ;  on  examination  signs  of  deep-seated  suppuration  may  be  detected. 
On  the  affected  side  there  is  usually  pain,  which  may  be  referred  to  the  neigh- 
borhood of  the  hip-joint  or  to  the  joint  itself,  or  radiate  down  the  thigh  and  be 
associated  with  the  retraction  of  the  testis.  The  patient  lies  with  the  thigh 
flexed,  so  as  to  relax  the  psoas  muscle,  and  in  walking  throws,  as  far  as  pos- 
sible, the  weight  on  the  opposite  leg.  He  also  keeps  the  spine  immobile, 
assumes  a  stooping  posture  in  walking,  and  has  great  difficulty  in  voluntarily 
addueting  the  thigh  (Gibney). 

There  may  be  pus  in  the  urine  if  the  disease  has  extended  from  the  pelvis 
or  the  kidney,  but  in  other  forms  the  urine  is  clear.  When  pus  has  formed 
there  are  usually  chills  with  irregular  fever  and  sweats.  On  examination, 
deep-seated  induration  is  felt  between  the  last  rib  and  the  crest  of  the  ilium. 
Bimanual  palpation  may  reveal  a  distinct  tumor  mass.  (Edema  or  puffiness 
of  the  skin  is  frequently  present. 

Dia^osis. — The  diagnosis  is  usually  easy;  when  doubt  exists  the  aspirator 
needle  should  be  used.  We  can  not  always  differentiate  the  primary  forms 
from  those  due  to  perforation  of  the  kidney  or  of  the  bowel.  This,  however, 
makes  but  little  difference,  for  the  treatment  is  identical.  It  is  usually  pos- 
sible by  the  history  and  examination  to  exclude  diseases  of  the  vertebra.  In 
children  hip- joint  disease  may  be  suspected,  but  the  pain  is  higher,  and  there 
is  no  fulness  or  tenderness  over  the  hip-joint  itself. 

The  treatment  is  clear — early,  free,  and  permanent  drainage. 


SECTION    VIII. 

DISEASES   OF  THE  BLOOD  A^D  DUCTLESS 

GLANDS. 

I.    ANiEMIA. 

Definition. — Anaemia  may  be  defined  as  a  reduction  in  the  amount  of  the 
blood  as  a  whole  or  of  its  corpuscles,  oligocythaemia,  or  of  certain  of  its  more 
important  constituents,  such  as  albumin  and  haemoglobin. 

Pseudo-Ancemia. — The  state  of  the  skin  and  mucous  membranes  is  usually 
a  safe  guide  in  judging  of  the  presence  of  anaemia.  There  are  certain  con- 
ditions in  which  this  is  deceptive,  and  a  marked  pallor  may  exist  with  nearly 
normal  corpuscles  and  hemoglobin.  ( 1 )  The  pallor  of  nausea  and  the  anaemia 
following  a  drinking-bout  (Katzenjammer !)  ;  (2)  the  apparent  anaemia  of 
Bright's  disease,  of  certain  cases  of  heart  disease,  of  early  arterio-sclerosis 
(Stengel);  (3)  of  the  morphia  hahitue,  sometimes  of  the  lead  worker;  and 
(4)  of  certain  perfectly  healthy  individuals  who  are,  so  to  speak,  born  pale 
and  stay  pale — these  are  some  of  the  conditions  in  which  vdth  a  pseudo- 
anaemia  there  is  a  normal  or  nearly  normal  blood-count  and  color  index. 

Anaemia  may.  be  local  or  general. 

Local  Anaemia. — Tissue  irrigation  with  blood  is  primarily  from  the  heart, 
but  in  all  extensive  systems  of  this  sort  provision  is  made  at  the  local  terri- 
tories for  variations  in  the  supply,  according  to  the  needs  of  a  part.  The 
sluices  are  arranged  by  means  of  the  stop-cock  action  of  the  arteries,  which 
contract  or  expand  under  the  iniluence  of  the  vaso-motor  ganglia,  central  and 
'peripheral.  If  the  sluices  of  one  large  district  are  too  widely  open,  so  much 
blood  may  enter  that  other  important  regions  have  not  enough  to  keep  them 
at  work.  Local  anaemia  of  the  brain,  causing  swooning,  ensues  when  the 
mesenteric  channels,  capable  of  holding  all  the  blood  of  the  body,  are  wide 
open.  Emotional  stimuli,  reflex  from  pain,  etc.,  removal  of  pressure,  as  after 
tapping  in  ascites,  may  cause  this.  It  is  probable  that  many  of  the  nervous 
and  other  symptoms  in  enteroptosis  are  due  to  the  relative  anaemia  of  the 
cerebral  and  spinal  systems,  owing  to  the  persistent  overflowing  of  the  mesen- 
teric reservoir.  We  know  very  little  of  local  anaemia  of  the  various  organs, 
but  possibly  functional  disturbance  in  the  liver,  kidneys,  pancreas,  heart,  etc., 
may  result  from  a  permanently  low  pressure  in  the  local  blood  "  mains." 
Anaemia  from  spasm  of  the  arterial  walls  is  seen  in  Eaynaud's  disease,  which 
usually  affects  the  peripheral  vessels,  causing  local  syncope  of  the  fingers,  but 
it  may  occur  in  the  visceral  vessels,  particularly  of  the  brain,  and  cause  tem- 
porary hemiplegia,  aphasia,  etc. 
718 


ANjEMIA.  719 

General  anaemia  may  be:  (1)  Secondary  or  symptomatic;  (2)  primary, 
essential,  or  cytogenic. 

Secondary  Anemia. 

Under  this  division  comes  a  large  proportion  of  all  cases.  The  following 
are  the  most  important  groups,  based  on  the  etiology : 

(1)  Ansemia  from  hsemorrhage,  either  traumatic  or  spontaneous.  The 
loss  of  blood  may  be  rapid,  as  in  lesions  of  large  vessels,  in  injury  or  in  rup- 
ture of  aneurisms,  in  ulcer  of  the  stomach  or  duodenum,  or  in  post-partum 
haemorrhage.  If  the  loss  is  excessive,  death  results  from  lowering  of  the 
arterial  pressure.  In  sudden  profuse  haemorrhage  the  loss  of  3  or  4  pounds 
of  blood  may  prove  fatal.  In  the  rupture  of  an  aneurism  into  the  pleura  the 
loss  of  blood  may  amount  to  7^  pounds,  the  largest  quantity  I  have  known  to 
be  shed  into  one  cavity.  In  a  case  of  haematemesis  the  patient  lost  over  10 
pounds  of  blood  in  one  week  and  yet  recovered  from  the  immediate  effects. 
Even  after  very  severe  haemorrhage  the  number  of  red  blood-corpuscles  is  not 
reduced  so  greatly  as  in  forms  of  idiopathic  anaemia.  Thus  in  one  case  Just 
mentioned,  at  the  termination  of  the  week  of  bleeding  there  were  nearly 
1,390,000  red  blood-corpuscles  to  the  cubic  millimetre.  The  process  of  regen- 
eration goes  on  with  great  rapidity,  and  in  some  "  bleeders  "  a  week  or  ten 
days  suffice  to  re-establish  the  normal  amount.  The  watery  and  saline  con- 
stituents of  the  blood  are  readily  restored  by  absorption  from  the  gastro- 
intestinal tract.  The  albuminous  elements  also  are  quickly  renewed,  but  it 
may  take  weeks  or  months  for  the  corpuscles  to  reach  the  normal  standard. 
The  haemoglobin  is  restored  more  slowly  than  the  corpuscles.  Chart  XVI, 
page  720,  illustrates  the  rapid  fall  and  gradual  restitution  in  a  case  of 
severe  purpura  hemorrhagica.  In  September  the  blood-count  was :  red  blood- 
corpuscles,  5,350,000;  leucocytes,  5,500;  hemoglobin,  94  per  cent. 

The  microscopical  characters  of  the  blood  after  severe  hemorrhage  may 
not  be  greatly  changed.  The  red  corpuscles  show,  usually,  rather  more 
marked  differences  in  size  than  normally,  while  the  average  size  may  be  a 
trifle  reduced;  there  may  be  a  moderate  poikilocytosis.  The  corpuscles  are 
paler  than  normally.  Nucleated  red  corpuscles  appear,  almost  always,  soon 
after  the  haemorrhage;  they  are,  however,  not  numerous,  except  when  their 
large  number  indicates  the  so-called  blood  crisis.  These  are  small  bodies  of 
about  the  same  size  as  a  normal  red  corpuscle  with  a  small,  round,  deeply 
staining  nucleus.  Free  nuclei  may  be  found.  The  colorless  corpuscles  are, 
at  first,  increased  in  number.  There  is  a  moderate  leucocytosis,  the  differen- 
tial count  showing  an  increase  in  the  multinuclear  neutrophiles  with  a  dimi- 
nution in  the  small  mononuclear  elements.  During  recovery  the  leucocytosis 
diminishes.  The  color  index  is  low,  as  the  haemoglobin  regenerates  more  slowly 
and  the  corpuscles  are  smaller  and  lighter. 

The  reduction  in  haemoglobin  is  always  proportionately  greater  than  that 
in  the  corpuscles. 

In  some  instances  a  rapidly  fatal  anemia  may  follow  a  single  severe 
hemorrhage,  as  in  post-partum  cases,  or  repeated  small  hemorrhages,  as  in 
purpura.  Here  the  appearances  of  the  red  corpuscles  are  much  the  same, 
except  in  the  total  absence  of  nucleated  red  corpuscles. 

The  leucocytes  in  these  cases  are  usually  reduced  in  number;  the  poly- 


720 


DISEASES  OF  THE  BLOOD  AND  DUCTLESS  GLANDS. 


nuclear  elements  are  present  in  a  relatively  diminished  proportion,  while  the 
small  mononiiclear  forms  are  numerous.  Post  mortem  there  is  a  total  absence 
of  any  regenerative  activity  on  the  part  of  the  bone-marrow. 

The  above  description  is  of  the  blood  changes  after  one  severe  haemorrhage. 
In  the  case  of  repeated  haemorrhages  the  picture  depends  upon  the  interval 


APRIL.       1                                MAY.                           !                        JUNE.                               1    JULY. 

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BLACK,  RED  COF?PUSCLES. 


RED,  HAEMOGLOBIN, 


MEAN  NORM, 
NUMBER  OF 

WHITE 
CORPUSCLES 


BLUE,   COLOJ?LeSS  CORPUSCLES. 


Chart  XVI. — Illustrates  the  RAPmiTv  with  which  Ax^mia  is  Produced  in  Purpura 

HEMORRHAGICA   AXD    THE    GRADUAL    ReCOVERT. 


between  the  losses  of  blood:  if  long  enough  to  allow  complete  regeneration 
each  time  the  total  amount  of  blood  lost  may  be  excessive  and  yet  the  patient 
recover  rapidly  after  the  last  as  in  a  case  of  phthisis  mentioned  by  Ehrlich 
who  lost  by  h^emoptj'sis  twenty  kilogrammes  of  blood  in  six  and  a  half  months. 

If,  however,  the  intervals  are  so  short  that  recovery  from  each  is  not 
possible  there  soon  occurs  a  chronic  anaemia  with  very  tardy  regeneration;  a 
hydrgemic  plasma,  low  color  index,  and  l}Tnphoc}i:osis. 

( 2 )  Anaemia  is  frequently  produced  by  long-continued  drain  on  the  albn- 
minous  materials  of  the  blood,  as  in  chronic  suppuration  and  Bright^s  disease. 
Prolonged  lactation  acts  in  the  same  way.  Eapidly  growing  tumors  may 
cause  a  profound  anaemia,  as  in  gastric  cancer.  The  characters  of  the  blood 
here  may  be  much  the  same  as  iu  the  acute  cases.  Usually  the  poikilocytosis 
is  more  marked ;  in  severe  cases  it-  may  be  excessive.     The  presence,  however, 


ANEMIA.  721 

of  the  very  large  corpuscles,  such  as  one  sees  in  pernicious  angemia,  is  not 
noted,  the  average  size  appearing  to  be  rather  smaller  than  normal. 

Nucleated  red  corpuscles  are  usually  scanty.  In  long-continued  chronic 
secondary  anaemias  occasional  larger  nucleated  red  corpuscles  may  be  seen, 
bodies  with  larger  palely  staining  nuclei;  in  some  of  these  cells  karyokinetic 
figures  occur.  Nucleated  red  corpuscles  with  fragmentary  nuclei  may  also 
be  seen. 

The  leucocytes  may  be  increased  in  number,  though  in  some  severe  chronic 
cases  there  may  be  a  diminution. 

(3)  Anaemia  from  Inanition. — This  may  be  brought  about  by  defective 
food  supply,  or  by  conditions  which  interfere  with  the  proper  reception  and 
preparation  of  the  food,  as  in  cancer  of  the  oesophagus  and  chronic  dyspepsia. 
The  reduction  of  the  blood  mass  may  be  extreme,  but  the  plasma  suffers  pro- 
portionately more  than  the  corpuscles,  which,  even  in  the  wasting  of  cancer 
of  the  oesophagus,  may  not  be  reduced  more  than  one-half  or  three-fourths. 
The  reduction  in  the  plasma  may  be  so  great  that  the  corpuscles  show  a 
relative  increase. 

(4)  Toxic  anaemia  is  induced  by  the  action  of  certain  poisons  on  the 
blood,  such  as  lead,  mercury,  and  arsenic,  among  inorganic  substances,  and 
the  virus  of  syphilis  and  malaria  among  organic  poisons.  They  act  either 
by  directly  destroying  the  red  blood-corpuscles,  as  in  malaria,  or  by  increas- 
ing the  rate  of  ordinary  consumption.  The  anaemia  of  pyrexia  may  in  part 
be  due  to  a  toxic  action,  but  is  also  caused  in  part  by  the  disturbance  of 
digestion  and  interference  with  the  function  of  the  blood-making  organs. 

Pkimaey  or  Essential  Anemia. 
1.  Chlorosis. 

Definition. — An  anaemia  of  unknown  cause,  occurring  in  young  girls,  char- 
acterized by  a  marked  relative  diminution  of  the  haemoglobin. 

Etiology. — It  is  a  disease  of  girls,  more  often  of  blondes  than  of  brunettes. 
It  is  doubtful  if  males  are  ever  affected.  I  have  never  seen  true  chlorosis  in 
a  boy.  The  age  of  onset  is  between  the  fourteenth  and  seventeenth  years; 
under  the  age  of  twelve  cases  are  rare.  Eecurrences,  which  are  common,  may 
extend  into  the  third  decade.  Of  the  essential  cause  of  the  disease  we  know 
nothing.  There  exists  a  lowered  energy  in  the  blood-making  organs,  asso- 
ciated in  some  obscure  way  with  the  evolution  of  the  sexual  apparatus  in 
women.  Hereditary  influences,  particularly  chlorosis  and  tuberculosis,  play  a 
part  in  some  cases.  Sometimes,  as  Virchow  pointed  out,  the  condition  exists 
with  a  defective  development  (hypoplasia)  of  the  circulatory  and  generative 
organs. 

The  disease  is  most  common  among  the  ill-fed,  overworked  girls  of  large 
towns,  who  are  confined  all  day  in  close,  badly  lighted  rooms,  or  have  to  do 
much  stair-climbing.  Cases  occur,  however,  under  the  most  favorable  con- 
ditions of  life,  but  not  often  in  country-bred  girls,  as  Maudlin  sings  in  the 
Compleat  Angler.  Lack  of  proper  exercise  and  of  fresh  air,  and  the  use  of 
improper  food  are  important  factors.  Emotional  and  nervous  disturbances 
may  be  prominent — so  prominent  that  certain  writers  have  regarded  the  dis- 
ease as  a  neurosis.  De  Sauvages  speaks  of  a  chlorose  par  amour.  Newly 
47 


722         DISEASES  OF  THE  BLOOD  AND  DUCTLESS  GLANDS. 

arrived  Irish  girls  were  very  prone  to  the  disease  in  Montreal.  The  "  corset 
and  chlorosis  "  expresses  0.  Eosenbach's  opinion.  Menstrual  disturbances  are 
not  uncommon,  but  are  probably  a  sequence,  not  a  cause,  of  chlorosis.  Sir 
Andrew  Clark  believed  that  constipation  plays  an  important  role,  and  that 
the  condition  is  in  reality  a  coprcemia  due  to  the  absorption  of  poisons — leuco- 
maines  and  ptomaines — from  the  large  bowel,  a  view  which  does  not  seem 
very  reasonable,  considering  the  great  frequency  of  constipation  both  in 
women  and  in  men. 

Symptoms. —  (a)  General. — The  symptoms  of  chlorosis  are  those  of 
anaemia.  The  subcutaneous  fat  is  well  retained  or  even  increased  in  amount. 
The  complexion  is  peculiar;  neither  the  blanched  aspect  of  haemorrhage  nor 
the  muddy  pallor  of  grave  anaemia,  but  a  curious  yellow-green  tinge,  which 
has  given  to  the  disease  its  name,  and  its  popular  designation,  the  green  sick- 
ness. Occasionally  the  skin  shows  areas  of  pigmentation,  particularly  about 
the  joints.  In  cases  of  moderate  grade  the  color  may  be  deceptive,  as  the 
cheeks  have  a  reddish  tint,  particularly  on  exertion  (chlorosis  rubra).  The 
subjects  complain  of  breathlessness  and  palpitation,  and  there  may  be  a  tend- 
ency to  fainting — symptoms  which  often  lead  to  the  suspicion  of  heart  or 
lung  disease.  Puffiness  of  the  face  and  swelling  of  the  ankles  may  suggest 
nephritis.  The  disposition  often  changes,  and  the  girl  becomes  low-spirited 
and  irritable.  The  eyes  have  a  peculiar  brilliancy  and  the  sclerotics  are  of  a 
bluish  color. 

(&)  Special  Features. — Blood. — The  drop  as  expressed  looks  pale. 
Johann  Duncan,  in  1867,  first  called  attention  to  the  fact  that  the  essential 
feature  was  not  a  great  reduction  in  the  number  of  the  corpuscles,  but  a 
quantitative  change  in  the  haemoglobin.  The  corpuscles  themselves  look  pale. 
In  63  consecutive  cases  examined  at  my  clinic  by  Thayer,  the  average  num- 
ber per  cubic  millimetre  of  the  red  blood-corpuscles  was  4,096,544,  or  over 
80  per  cent,  whereas  the  percentage  of  haemoglobin  for  the  total  number  was 
42.3  per  cent.  The  accompanying  chart  illustrates  well  these  striking  differ- 
ences. There  may,  however,  be  well-marked  actual  anemia.  The  lowest  blood- 
count  in  the  series  of  cases  referred  to  above  was  1,933,000.  There  may  be 
all  the  physical  characteristics  and  symptoms  of  a  profound  anaemia  with  the 
number  of  the  blood-corpuscles  nearly  at  the  normal  standard.  Thus  in  one 
instance  the  globular  richness  was  over  85  per  cent,  with  the  haemoglobin 
about  35.  No  other  form  of  anaemia  presents  this  feature,  at  least  with  the 
same  constancy  and  in  the  same  degree.  The  importance  of  the  reduction  in 
the  haemoglobin  depends  upon  the  fact  that  it  is  the  iron-containing  elements 
of  the  blood  with  which  in  respiration  the  oxygen  enters  into  combination. 
This  marked  diminution  in  the  iron  has  also  been  determined  by  chemical 
analysis  of  the  blood.  The  microscopical  characteristics  of  the  blood  are  as 
follows :  In  severe  cases  the  corpuscles  may  be  extremely  irregular  in  size  and 
shape — poikilocytosis,  which  may  occasionally  be  as  marked  as  in  some  cases 
of  pernicious  anaemia.  The  large  forms  of  red  blood-cells  are  not  as  com- 
mon, and  the  average  size  is  stated  to  be  below  normal.  The  color  of  the 
corpuscles  is  noticeably  pale  and  the  deficiency  may  be  seen  either  in  indi- 
vidual corpuscles  or  in  the  blood  mixture  prepared  for  counting.  Nucleated 
red  corpuscles  (normoblasts)  are  not  very  uncommon,  and  may  vary  greatly 
in  numbers  in  the  same  case  at  different  periods.     The  leucocytes  may  show 


ANEMIA. 


723 


a  slight  increase;  the  average  in  the  63  cases  above  referred  to  was  8,467  per 
cubic  millimetre. 

(c)  Gasteo-intestinal  Symptoms. — The  appetite  is  capricious,  and  pa- 
tients often  have  a  longing  for  unusual  articles,  particularly  acids.  In  some 
instances  they  eat  all  sorts  of  indigestible  things,  such  as  chalk  or  even  earth. 
Superacidity  of  the  gastric  juice  is  commonly  associated  with  chlorosis.  In 
19  out  of  21  cases  in  Eiegel's  clinic  this  condition  was  found  to  exist.  In 
the  other  two  instances  the  acidity  was  normal  or  a  trifle  increased.    Distress 


JANUARY.                                         FEBRUARY. 

MARCH. 

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'number  or 

WHITE 
CORPUSCLES 


BLACK,  RED  CORPUSCLES. 


RED,  HAEMOGLOBIN. 

Chart  XVII. — Chlorosis. 


BLUE,  COLORLESS  CORPUSCLES, 


after  eating  and  even  cardialgic  attacks  may  be  associated  with  it.  Con- 
stipation is  a  common  symptom,  and,  as  already  mentioned,  has  been  regarded 
as  an  important  element  in  causing  the  disease.  A  majority  of  chlorotic  girls 
who  wear  corsets  have  gastroptosis,  and  on  inflation  the  stomach  will  be  found 
vertically  placed;  sometimes  the  organ  is  very  much  dilated.  The  motor 
power  is  usually  well  retained.  Enteroptosis  with  palpable  right  kidney  is 
not  uncommon. 


724         DISEASES   OF   THE  BLOOD  AND  DUCTLESS  GLANDS. 

(d)  CiECULATORY  SYMPTOMS. — Palpitation  of  the  heart  occurs  on  exer- 
tion, and  may  be  the  most  distressing  s}Taptom  of  which  the  patient  com- 
plains. Percussion  may  show  slight  increase  in  the  transverse  dulness.  A 
systolic  murmur  is  heard  at  the  apex  or  at  the  base;  more  commonly  at  the 
latter,  but  in  extreme  cases  at  both.  A  diastolic  murmur  is  rarely  heard. 
The  systolic  murmur  is  usually  loudest  in  the  second  left  intercostal  space, 
where  there  is  sometimes  a  distinct  pulsation.  The  exact  mode  of  production 
is  still  in  dispute.  Balfour  holds  that  it  is  produced  at  the  mitral  orifice  by 
relative  insufficiency  of  the  valves  in  the  dilated  condition  of  the  ventricle. 
On  the  right  side  of  the  neck  over  the  jugular  vein  a  continuous  murmur 
may  be  heard,  the  hruit  de  diahJe.  or  humming-top  murmur. 

The  pulse  is  usually  full  and  soft.  Visible  impulse  is  present  in  the  veins 
of  the  neck,  as  noted  by  Lancisi.  Pulsation  in  the  peripheral  veins  is  some- 
times seen.  Thrombosis  in  the  veins  may  occur,  most  commonly  in  the 
femoral,  but  in  other  instances  in  the  cerebral  sinuses  there  may  be  multiple 
thrombi.  In  86  cases  the  veins  of  the  legs  were  affected  in  48,  the  cerebral 
sinuses  in  29  (Lichtenstern).  The  chief  danger  in  thrombosis  of  the  extremi- 
ties is  pulmonary  embolism,  which  occurred  in  13  of  52  cases  collected  by 
Welch. 

As  in  all  forms  of  essential  antemia,  fever  is  not  uncommon.  Chlorotic 
patients  suffer  frequently  from  headache  and  neuralgia,  which  may  be  parox- 
ysmal. The  hands  and  feet  are  often  cold.  Dermatographia  is  common. 
Hysterical  manifestations  are  not  infrequent.  Menstrual  disturbances  are  very 
common — amenorrhoea  or  dysmenorrhosa.  With  the  improvement  in  the  blood 
condition  this  function  is  usually  restored. 

Diagnosis. — The  green  sickness,  as  it  is  sometimes  called,  is  in  many  in- 
stances recognized  at  a  glance.  The  well-nourished  condition  of  the  girl,  the 
peculiar  complexion,  which  is  most  marked  in  brunettes,  and  the  white  or 
bluish  sclerotics  are  very  characteristic.  A  special  danger  exists  in  mistak- 
ing the  apparent  anasmia  of  the  early  stage  of  pulmonary  tuberculosis  for 
chlorosis.  Mistakes  of  this  sort  may  often  be  avoided  by  the  very  simple 
test  furnished  by  allowing  a  drop  of  blood  to  fall  on  a  white  towel  or  a  piece 
of  blotting  paper — a  deficiency  in  hgemoglobin  is  readily  appreciated.  The 
palpitation  of  the  heart  and  shortness  of  breath  frequently  suggest  heart-dis- 
ease, and  the  oedema  of  the  feet  and  general  pallor  cause  the  cases  to  be  mis- 
taken for  Bright's  disease.  In  the  great  majority  of  cases  the  characters  of 
the  blood  readily  separate  chlorosis  from  other  forms  of  angemia. 

2.  Idiopathic  or  Progressive  Pernicious  AncBmia. 

The  disease  was  first  clearly  described  by  Addison,  who  called  it  idio- 
pathic ansmia.  Charming  and  Gusserow  described  the  cases  occurring  post 
partum,  but  to  Biermer  we  owe  a  revival  of  interest  in  the  subject. 

Etiology. — The  existence  of  a  separate  disease  worthy  of  the  term  pro- 
gressive pernicious  anamia  has  been  doubted,  but  there  are  very  many 
cases  in  which,  as  Addison  says,  there  exist  none  of  the  usual  causes  or 
concomitants  of  anemia.  Clinically  there  are  several  different  groups  which 
present  the  characters  of  a  progressive  and  pernicious  anaemia  and  are  etiolog- 
ically  different.     Thus,  a  fatal  anaemia  may  be  due  to  the  presence  of  para- 


ANEMIA.  725 

sites,  or  may  follow  haemorrhage,  or  be  associated  with  chronic  atrophy  of  the 
stomach;  but  when  we  have  excluded  all  these  causes  there  remains  a  group 
which,  in  the  words  of  Addison,  is  characterized  by  a  "  general  anaemia 
occurring  without  any  discoverable  cause  whatever,  cases  in  which  there  had 
been  no  previous  loss  of  blood,  no  exhausting  diarrhoea,  no  chlorosis,  no 
purpura,  no  renal,  splenic,  miasmatic,  glandular,  strumous,  or  malignant 
disease." 

William  Hunter  considers  that  the  idiopathic  anaemia  described  by  Addi- 
son and  the  progressive  pernicious  anaemia  of  Biermer  are  different  affections. 
That  described  by  Addison  is  a  distinct  disease,  while  that  described  by  Bier- 
mer is  "  a  frequently  recurring  group  of  symptoms  met  with  in  very  different 
conditions  of  disease."  Hunter  holds  that  there  are  two  important  factors 
in  the  disease,  (a)  haemolysis  and  (&)  a  chronic  septic  infection  often  asso- 
ciated with  a  specific  glossitis,  and  oral,  gastric,  and  intestinal  sepsis. 

Idiopathic  anaemia  is  widely  distributed.  It  is  of  frequent  occurrence 
in  the  Swiss  cantons,  and  it  is  common  in  the  United  States.  It  affects  mid- 
dle-aged persons,  but  instances  in  children  have  been  described.  Of  the  81 
cases  in  my  hospital  series  36  were  above  fifty  years  of  age;  only  1  was  under 
twenty,  Griffith  mentions  about  10  cases  occurring  under  twelve  years  of 
age.  The  youngest  patient  I  have  seen  was  a  boy  of  ten.  Males  are  more 
frequently  affected  than  females.  Of  550  cases  collected  by  Colman,  323  were 
in  men  and  227  in  women,  Sinkler  and  Eshner  record  3  cases  in  one  family, 
the  father  and  two  girls. 

With  the  following  conditions  may  be  associated  a  profound  anaemia  not 
always  to  be  distinguished  clinically  from  Addison's  idiopathic  form : 

(a)  Pregnancy  and  Parturition. — The  symptoms  may  occur  during  preg- 
nancy, as  in  19  of  29  cases  of  this  group  in  Eichhorst's  table.  More  com- 
monly, in  my  experience,  the  condition  has  been  post  partum. 

(&)  Atrophy  of  the  Stomach. — This  condition,  early  recognized  by  Flint 
and  Fenwick,  may  certainly  cause  a  progressive  pernicious  anaemia.  By  mod- 
ern methods  it  may  now  be  possible  to  exclude  this  extreme  gastric  atrophy. 

(c)  Parasites. — The  most  severe  form  may  be  due  to  the  presence  of  para- 
sites, and  the  accounts  of  cases  depending  upon  the  anchylostoma  and  the 
bothriocephalus  describe  a  progressive  and  often  pernicious  anaemia. 

After  the  exclusion  of  these  forms  there  remain  a  large  proportion,  which 
correspond  to  Addison's  description.  The  researches  of  Quincke  and  his  stu- 
dent Peters  showed  that  there  was  an  enormous  increase  in  the  iron  in  the 
liver,  and  they  suggested  that  the  affection  was  probably  due  to  increased 
hemolysis.  This  has  been  strongly  supported  by  the  extensive  observations 
of  Hunter,  who  has  also  shown  that  the  urine  excreted  is  darker  in  color  and 
contains  pathological  urobilin.  The  lemon  tint  of  the  skin  or  the  actual 
jaundice  is  attributed,  on  this  view,  to  an  overproduction.  To  explain  the 
haemolysis,  it  has  been  thought  that  in  the  condition  of  faulty  gastro-intestinal 
digestion,  which  is  so  commonly  associated  with  these  cases,  poisonous  mate- 
rials are  developed,  which  when  absorbed  cause  destruction  of  the  corpuscles. 
Certainly  the  case  for  haemolysis  is  very  strong,  and  is  supported  by  the  experi- 
mental work  of  Bunting,  who  has  been  able  to  produce  in  animals  a  condition 
the  counterpart  of  pernicious  anaemia  in  man. 

Stockman  suggests  that  repeated  small  capillary  haemorrhages — chiefly  in- 


726         DISEASES  OF  THE  BLOOD  AND  DUCTLESS  GLANDS. 

ternal — ^play  an  important  role  in  the  causation  of  the  disease,  which  also 
explains,  he  holds,  the  existence  of  a  great  excess  of  iron  in  the  liver. 

On  the  other  hand,  F.  P.  Henry,  Stephen  Mackenzie,  Eindfleisch,  and  other 
authorities  incline  to  the  belief  that  the  essence  of  the  disease  is  in  defective 
haemogenesis,  in  consequence  of  which  the  red  blood-corpuscles  are  abnor- 
mally vulnerable. 

Morbid  Anatomy. — The  body  is  rarely  emaciated.  A  lemon  tint  of  the 
skin  is  present  in  a  majority  of  the  cases.  The  muscles  often  are  intensely 
red  in  color,  like  horse-flesh,  while  the  fat  is  light  yellow.  Haemorrhages  are 
common  on  the  skiu  and  serous  surfaces.  The  heart  is  usually  large,  flabby, 
and  empty.  In  one  instance  I  obtained  only  2  drachms  of  blood  from  the 
right  heart,  and  between  3  and  4  from  the  left.  The  muscle  substance  of  the 
heart  is  intensely  fatty,  and  of  a  pale,  light-yellow  color.  In  no  affection  do 
we  see  more  extreme  fatty  degeneration.  The  lungs  show  no  special  changes. 
The  stomach  in  many  instances  is  normal,  but  in  some  cases  of  fatal  anaemia 
the  mucosa  has  been  extensively  atrophied.  In  the  case  described  by  Henry 
and  myself  the  mucous  membrane  had  a  smooth,  cuticular  appearance,  and 
there  was  complete  atrophy  of  the  secreting  tubules.  The  liver  may  be  enlarged 
and  fatty.  In  most  of  my  autopsies  it  was  normal  in  size,  but  usually  fatty. 
The  iron  is  in  excess,  a  striking  contrast  to  the  condition  in  cases  of  secondary 
anemia.  It  is  deposited  in  the  outer  and  middle  zones  of  the  lobules,  and  in 
two  specimens,  which  I  examined,  seemed  to  have  such  a  distribution  that  the 
bile  capillaries  were  distinctly  outlined.  This,  Hunter  states,  is  a  special  and 
characteristic  lesion,  possibly  peculiar  to  pernicious  anaemia. 

The  spleen  shows  no  important  changes.  In  one  of  Palmer  Howard's 
cases  the  organ  weighed  only  1  ounce  and  5  drachms.  The  iron  pigment  is 
usually  in  excess.  The  lymph-glands  may  be  of  a  deep  red  color.  The  amount 
of  iron  pigment  is  increased  in  the  kidneys,  chiefly  in  the  convoluted  tubules. 
The  bone-marrow  is  usually  red,  lymphoid  in  character,  showing  great  num- 
bers of  nucleated  red  corpuscles,  especially  the  larger  forms  called  by  Ehrlich 
gigantoblasts.  Cases  in  which  the  bone-marrow  shows  no  signs  of  activity 
have  been  described  as  aplastic  ancemia.  Lichtheim  and  others  have  found 
sclerosis  in  the  posterior  columns  of  the  cord. 

Symptoms. — The  patient  may  have  been  in  previous  good  health,  but  in 
many  cases  there  is  a  history  of  gastro-intestinal  disturbance,  mental  shock, 
or  worry.  The  description  given  by  Addison  presents  the  chief  features  of  the 
disease  in  a  masterly  way.  "  It  makes  its  approach  in  so  slow  and  insidious 
a  manner  that  the  patient  can  hardly  flx  a  date  to  the  earliest  feeling  of  that 
languor  which  is  shortly  to  become  so  extreme.  The  countenance  gets  pale, 
the  whites  of  the  eyes  become  pearly,  the  general  frame  flabby  rather  than 
wasted,  the  pulse  perhaps  large,  but  remarkably  soft  and  compressible,  and 
occasionally  with  a  slight  jerk,  especially  under  the  slightest  excitement. 
There  is  an  increasing  indisposition  to  exertion,  with  an  uncomfortable  feeling 
of  faintness  or  breathlessness  in  attempting  it;  the  heart  is  readily  made  to 
palpitate;  the  whole  surface  of  the  body  presents  a  blanched,  smooth,  and 
waxy  appearance;  the  lips,  gums,  and  tongue  seem  bloodless,  the  flabbiness 
of  the  solids  increases,  the  appetite  fails,  extreme  languor  and  faintness  super- 
vene, breathlessness  and  palpitations  are  produced  by  the  most  trifling  exertion 
or  emotion;  some  slight  oedema  is  probably  perceived  about  the  ankles;  the 


ANEMIA. 


72T 


debility  becomes  extreme — the  patient  can  no  longer  rise  from  bed;  the  mind 
occasionally  wanders;  he  falls  into  a  prostrate  and  half-torpid  state,  and  at 
length  expires;  nevertheless,  to  the  very  last,  and  after  a.  sickness  of  several 
months'  duration,  the  bulkiness  of  the  general  frame  and  the  amount  of  obes- 
ity often  present  a  most  striking  contrast  to  the  failure  and  exhaustion  observ- 
able in  every  other  respect." 

The  Blood. — The  red  corpuscles  may  fall  to  one-fifth  or  less  of  the  nor- 
mal number.  The  average  count  in  my  81  (in  103  admissions)  hospital  cases 
was  1,575,000  per  cubic  millimetre — ^that  is,  in  81  per  cent  of  the  cases  under 


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MEAN   NORM, 
NUMBER  OF 

WHITE 
CORPUSCLES 


BLACK,  RED  CORPUSCLES. 


RED,  HAEMOGLOBIN. 


BLUE,  COLORLESS  CORPUSCLES. 


Chart  XVIII. — Pernicious  An-smia. 


2,000,000  and  in  12  per  cent  under  1,000,000  cells — and  the  haemoglobin  was 
about  30  per  cent.  The  haemoglobin  is  relatively  increased,  so  that  the  indi- 
vidual globular  richness  is  plus,  a  condition  exactly  the  opposite  to  that  which 
occurs  in  chlorosis  and  the  secondary  anemia,  in  which  the  corpuscular  rich- 


728         DISEASES  OF  THE  BLOOD  AND  DUCTLESS  GLANDS. 

ness  in  coloring  matter  is  minus.  The  relative  increase  in  the  haemoglobin  is 
probably  associated  with  the  average  increase  in  the  size  of  the  red  blood-cor- 
puscles. Chart  XVIII,  page  727,  illustrates  these  points.  Microscopically  the 
red  blood-corpuscles  present  a  great  variation  in  size,  and  there  can  be  seen 
large  giant  forms,  megaloc3''tes,  which  are  often  ovoid  in  form,  measuring 
8,  11,  or  even  15  /a  in  diameter — a  circumstance  which  Henry  regards  as  indi- 
cating a  reversion  to  a  lower  type.  Laache  thinks  these  pathognomonic,  and 
they  certainly  form  a  constant  feature.  There  are  also  small  round  cells, 
microcytes,  from  2  to  6  ^i  in  diameter,  and  of  a  deep  red  color.  The  corpus- 
ces  show  a  remarkable  irregularity  in  form;  they  are  elongated  and  rodlike 
or  pyriform;  one  end  of  a  corpuscle  may  retain  its  shape  while  the  other  is 
narrow  and  extended.  To  this  condition  of  irregularity  Quincke  gave  the 
name  poikilocytosis. 

Nucleated  red  blood-corpuscles  are  almost  always  present,  as  pointed  out 
by  Ehrlich.  It  may  require  a  long  search  to  find  them.  There  are  two  tj'pes, 
normoblasts  and  megaloblasts,  which  Ehrlich  regards  as  almost  distinctive  of 
this  anaemia.  There  are  frequently  forms  intermediate  between  these  two 
groups  which  often  have  irregular  nuclei.  A  relatively  large  number  of 
megaloblasts  usually  indicates  a  grave  outlook.  Though  these  large  forms  are 
most  characteristic,  occasionally  forms  closely  similar  to  them  may  be  found 
in  the  graver  secondary  anaemias — e.  g.,  bothriocephalus  anaemia,  anchylosto- 
miasis — and  in  leukaemia.  Karyokinetic  figures  may  be  seen  in  these  bodies. 
Red  corpuscles  with  fragmenting  nuclei  are  common  in  pernicious  anaemia. 
Blood  crises  were  first  described  under  this  name  by  v.  Noorden.  He  con- 
sidered the  phenomenon  one  of  active  blood  regeneration,  causing  the  appear- 
ance in  the  peripheral  blood  of  large  numbers  of  nucleated  reds;  which  remain 
for  a  few  days,  and  are  followed  by  a  decided  gain  in  the  blood-count.  This 
may  be  true  in  secondary  anaemias,  but  in  pernicious  anaemia  they  are  often 
part  of  the  terminal  picture  with  declining  count  of  red  corpuscles  and  leuco- 
cytes,  and  the  presence  of  large  numbers  of  nucleated  reds  which  may  continue 
even  for  nineteen  weeks,  as  if  the  marrow  were  making  convulsive  but  fruitless 
efforts  to  restore  the  blood.  There  were  20  crises  in  13  of  my  81  cases,  and  in 
5  they  were  terminal  events.  Three-fourths  of  these  crises  were  megaloblastic 
in  character,  in  the  others  the  cells  were  chiefly  normoblasts.  In  the  highest 
crisis  there  were  14,388  normoblasts,  460  intermediates,  and  138  megaloblasts 
per  cubic  millimetre.  Bensangon  and  Labbe  mention  a  crisis  with  10,000 
normoblasts  and  960  megaloblasts  per  cubic  millimetre  (the  intermediates 
were  probably  counted  with  the  latter).  Only  5  of  the  20  crises  were  followed 
by  a  real  gain  in  the  count  of  red  cells,  and  these  were  of  normoblastic  type. 
The  leucocjdies  are  generally  normal  or  diminished  in  number,  even  to  500 
per  cubic  millimetre ;  and  a  marked  relative  increase  in  the  small  mononuclear 
forms — in  one  of  my  cases  even  79  per  cent,  yet  with  absolute  number  normal 
— ^with  a  diminution  in  the  pohmuclear  leucocytes,  is  often  noted.  ]\Iyeloc}i:es 
are  usually  found,  and  in  one  of  my  cases  were  8  per  cent.  The  blood-plates  are 
either  absent  or  very  scanty. 

The  cardio-vascular  symptoms  are  important  and  are  noted  in  the  de- 
scription given  above.  Haemic  murmurs  are  usually  present.  The  larger 
arteries  pulsate  visibly  and  the  throbbing  in  them  may  be  distressing  to  the 
patient.    The  pulse  is  full  and  frequently  suggests  the  water-hammer  beat  of 


ANJEMIA.  729 

aortic  insufficiency.  The  capillary  pulse  is  frequently  to  be  seen.  The  super- 
ficial veins  are  often  prominent,  and  I  have  seen  well-marked  pulsation  in 
them.  Haemorrhages  occurred,  either  in  the  skin  or  from  the  mucous  sur- 
faces, in  12  cases  of  my  series.  Eetinal  haemorrhages  are  common.  There  are 
rarely  symptoms  in  the  respiratory  organs. 

Gastro-intestinal  symptoms,  such  as  dyspepsia,  nausea,  and  vomiting,  may 
be  present  throughout  the  disease.  Diarrhoea  is  not  infrequent.  The  urine  is 
usually  of  a  low  specific  gravity  and  sometimes  pale,  but  in  other  instances  it  is 
of  a  deep  sherry  color,  shown  by  Hunter  and  Mott  to  be  due  to  great  excess 
of  urobilin.     Fever  was  present  in  three-fourths  of  my  cases. 

The  slcin  has  most  frequently  a  lemon- tint,  sometimes  positively  icteroid; 
in  a  few  cases  there  is  pallor  without  any  change  in  color,  while  in  a  third 
group  the  skin  is  pigmented,  so  that  Addison's  disease  is  suspected.  This 
occurs  in  a  few  instances  in  which  arsenic  has  not  been  given;  as  a  rule  it 
follows  the  administration  of  this  drug.  The  pigmentation  may  be  patchy 
and  associated  with  areas  of  leucoderma.  The  nervous  symptoms  are  of  great 
interest.  Extensive  changes  may  be  present  in  the  cord  without  any  symp- 
toms during  life.  In  a  majority  of  the  cases  the  numbness  comes  on  in  the 
legs  and  feet,  less  often  in  the  hands,  and  in  a  few  instances  there  is  pain  of 
great  severity.  Gradually  the  signs  of  postero-lateral  sclerosis  become  well 
marked.  In  a  third  group,  described  by  Eisien  Eussell,  Batten,  and  Collier, 
the  nervous  symptoms — indicating  a  postero-lateral  sclerosis — come  first  and 
the  anaemia  follows ;  but  the  cases  have  not  always  the  features  of  the  progres- 
sive pernicious  disease. 

Diagnosis. — The  disease  is  not  often  recognized  by  the  general  practi- 
tioner. The  1-emon-yellow  tint  of  the  skin  leads  to  the  diagnosis  of  jaundice; 
the  pigmentation  suggests  Addison  s  disease;  the  anaemia,  puffy  face,  swollen 
ankles,  and  albumin  in  the  urine.  Bright' s  disease ;  the  shortness  of  breath  and 
palpitation,  heart-disease;  the  pallor  and  gastric  symptoms,  cancer  of  the 
stomach.  The  retention  of  fat,  the  insidious  onset,  the  absence  of  signs  of  local 
disease,  and  the  blood  features  already  discussed  are  the  most  important  diag- 
nostic points.  From  cancer  of  the  stomach  it  is  distinguished  by  (1)  the 
absence  of  wasting;  (2)  the  high-color  index  of  the  blood  and  the  lower  cor- 
puscular count,  reaching  frequently  below  one  million  per  cubic  millimetre; 
(3)  the  absence  of  the  fairly  characteristic  reactions  of  the  stomach  contents; 
and  (4)  the  marked  improvement  in  the  first  attacks  with  rest,  fresh  air, 
diet,  and  arsenic. 

Prognosis. — In  the  true  Addisonian  cases  the  ultimate  outlook  is  bad;  of 
late  years  the  proportion  of  cases  of  temporary  recovery  has  increased.  Of  the 
81  cases  from  my  wards,  death  occurred  in  27  while  under  observation.  Counts 
taken  in  18  of  the  fatal  cases  on  the  day  of  death  were  all  below  700,000  red 
cells  per  cmm.  The  average  duration  of  these  was  one  year.  One  patient  recov- 
ered completely.  He  was  admitted  in  1890  with  a  history  of  one  year,  was  dis- 
charged well,  and  returned  in  1896  with  cancer  of  the  stomach.  One  patient 
is  in  good  health  six  years  and  another  four  years  after  the  onset.  In  Pye- 
Smith's  article  in  the  Guy's  Hospital  Eeports  he  mentions  20  cases  of  recovery. 
Colman,  in  a  recent  article,  states  that  one  of  these  cases  treated  with  arsenic 
in  1880  was  alive  and  well  in  March,  1900.  The  history  is  usually  not  one  of 
progressive  advance  but  of  alternate  periods  of  gain  and  loss.     In  my  series 


730         DISEASES  OF  THE  BLOOD  AND  DUCTLESS  GLANDS. 

a  red  coimt  below  one  million  has  been  a  bad  omen.  The  presence  of  many 
megaloblasts  is  unfavorable.  They  were  relatively  eleven  times  more  numerous 
in  the  fatal  cases  of  my  series  than  in  those  that  recovered.  That  a  large  rela- 
tive percentage  of  small  mononuclears  was  of  bad  import  is  not  supported  by 
my  cases.  Those  that  recovered  had  a  slightly  higher  average  percentage  than 
the  fatal  cases.  The  blood  crises  are  usually  of  ill  omen.  Patients  who  do 
not  take  arsenic  well  usually  do  badly.  Gastro-intestinal  disturbances  are 
serious.  There  are  remarkable  acute  cases  which  may  prove  fatal  withia  ten 
days,  as  in  a  patient  I  saw  with  Finley,  of  Montreal. 

Treatment  of  Anaemia. — Secoxdaey  Ax^mia. — The  traumatic  cases  do 
best,  and  with  plenty  of  good  food  and  fresh  air  the  blood  is  readily  restored. 
The  extraordinary  rapidit}-  with  which  the  normal  percentage  of  red  blood- 
corpuscles  is  reached  without  any  medication  whatever  is  an  important  lesson. 
The  cause  of  the  hjemorrhage  should  be  sought  and  the  necessary  indica- 
tions met.  The  large  group  depending  on  the  drain  on  the  albuminous  mate- 
rials of  the  blood,  as  in  Bright' s  disease,  suppuration,  and  fever,  is  difficult  to 
treat  successfully,  and  so  long  as  the  cause  keeps  up  it  is  impossible  to  restore 
the  normal  blood  condition.  The  anaemia  of  inanition  requires  plenty  of 
nourishing  food.  When  dependent  on  organic  changes  in  the  gastro-intestinal 
mucosa  not  much  can  be  expected  from  either  food  or  medicine.  In  the  toxic 
cases  due  to  mercury  and  lead,  the  poison  must  be  eliminated  and  a  nutritious 
diet  given  with  full  doses  of  iron.  In  a  great  majority  of  these  cases  there  is 
deficient  blood  formation,  and  the  indications  are  briefly  three:  plenty  of 
food,  an  open-air  life,  and  iron.  As  a  rule  it  makes  but  little  difference  what 
form  of  the  drug  is  administered. 

Chloeosis. — The  treatment  of  chlorosis  affords  one  of  the  most  brilliant 
instan-ces — of  which  we  have  but  three  or  four — of  the  specific  action  of  a  rem- 
edy. Apart  from  the  action  of  quinine  in  malarial  fever,  and  of  mercury  and 
iodide  of  potassium  in  s}"philis,  there  is  no  other  drug  the  beneficial  effects  of 
which  we  can  trace  with  the  accuracy  of  a  scientific  experiment.  It  is  a  minor 
matter  how  the  iron  cures  chlorosis.  In  a  week  we  give  to  a  case  as  much  iron 
as  is  contained  in  the  entire  blood,  as  even  in  the  worst  case  of  chlorosis  there 
is  rarely  a  deficit  of  more  than  2  grammes  of  this  metal.  Iron  is  present  in 
the  feeces  of  chlorotic  patients  before  they  are  placed  upon  any  treatment, 
so  that  the  disease  does  not  result  from  any  deficiency  of  available  iron  in  the 
food.  Bunge  believes  that  it  is  the  sulphur  which  interferes  with  the  digestion 
and  assimilation  of  this  natural  iron.  The  sulphides  are  produced  in  the 
process  of  fermentation  and  decomposition  in  the  faeces,  and  interfere  with 
the  assimilation  of  the  normal  iron  contained  in  the  food.  By  the  adminis- 
tration of  an  inorganic  preparation  of  iron,  with  which  these  sulphides  unite, 
the  natural  organic  combmations  in  the  food  are  spared. 

In  stud5fing  charts  of  chlorosis,  it  is  seen  that  there  is  an  increase  in  the 
red  blood-corpuscles  under  the  influence  of  the  iron,  and  in  some  instances 
the  globular  richness  rises  above  normal.  The  increase  in  the  hsemoglobin  is 
slower  and  the  maximum  percentage  may  not  be  reached  for  a  long  time.  I 
have  for  years  in  the  treatment  of  chlorosis  used  with  the  greatest  success 
Blaud's  pills,  made  and  given  according  to  the  formula  in  JTiemejo-'s  text-book, 
in  which  each  pill  contains  2  grains  of  the  sulphate  of  iron.  During  the  first 
week  one  pill  is  given  three  times  a  day;  in  the  second  week,  two  pills;  in 


LEUKEMIA.  731 

the  third  week,  three  pills,  three  times  a  day.  This  dose  should  be  continued 
for  four  or  five  weeks  at  least  before  reduction.  An  important  feature  in  the 
treatment  is  to  persist  in  the  use  of  the  iron  for  at  least  three  months,  and,  if 
necessary,  subsequently  to  resume  it  in  smaller  doses,  as  recurrences  are  so 
common.  The  diet  should  consist  of  good,  easily  digested  food.  Special  care 
should  be  directed  to  the  bowels,  and  if  constipation  is  present  a  saline  purge 
should  be  given  each  morning.  Such  stress  did  Sir  Andrew  Clark  lay  on  the 
importance  of  constipation  in  chlorosis,  that  he  stated  that  if  limited  to  the 
choice  of  one  drug  in  the  treatment  of  the  disease  he  would  choose  a  purga- 
tive. In  many  instances  the  dyspeptic  symptoms  may  be  relieved  by  alkalies. 
Dilute  hydrochloric  acid,  manganese,  phosphorus,  and  oxygen  have  been  recom- 
mended.   Eest  in  bed  is  important  in  severe  cases. 

Treatment  of  Pernicious  Anemia. — There  are  five  essentials :  first,  a 
diagnosis;  secondly,  rest  in  bed  for  weeks  or  even  months,  if  possible  (thirdly) 
in  the  open  air;  fourthly,  all  the  good  food  the  patient  can  take;  the  outlook 
depends  on  the  stomach ;  fifthly,  arsenic ;  Fowler's  solution  in  increasing  doses, 
beginning  with  Til,  iii  or  v  three  times  a  day,  and  increasing  th,  i  each  week  until 
the  patient  takes  TTl,  xv  or  xx  three  times  a  day.  Other  forms  of  arsenic  may  be 
tried,  as  the  sodium  cacodylate  or  the  atoxyl  hypodermically.  Accessories  are 
oil  inunctions;  bone-marrow,  which  has  the  merit  of  a  recommendation  by 
Galen;  in  some  cases  iron  seems  to  do  good.  Care  should  be  taken  of  the 
mouth  and  teeth.  After  recovery  the  patient  should  be  told  to  watch  the 
earliest  indications  of  return  of  the  trouble  and  at  once  resume  the  arsenic. 

II.     LEUKiEMIA. 

Definition. — An  affection  characterized  by  persistent  increase  in  the  white 
blood-corpuscles,  associated  with  changes,  either  alone  or  together,  in  the 
spleen,  lymphatic  glands,  or  bone-marrow. 

The  disease  was  described  almost  simultaneously  by  Yirchow  and  by  Ben- 
nett, who  gave  to  it  the  name  leucocythsemia.  It  is  ordinarily  seen  in  two 
main  types,  though  combinations  and  variations  may  occur: 

(1)  Spleno-medullary  leukaemia,  in  which  the  changes  are  especially 
localized  in  the  spleen  and  the  bone-marrow,  while  the  blood  shows  a  great 
increase  in  elements  which  are  derived  especially  from  the  latter  tissue,  a  con- 
dition which  Miiller  has  termed  "  myelsemia."  Ehrlich  prefers  to  call  this 
type  of  the  disease  "  myelogenous  leukaemia,"  believing  the  part  played  by 
the  spleen  in  the  process  to  be  purely  passive. 

(2)  Lymphatic  leukaemia,  in  which  the  changes  are  chiefly  localized  in 
the  l3rmphatic  apparatus,  the  blood  showing  an  especial  increase  in  those  ele- 
ments derived  from  the  lymph-glands. 

Etiology. — We  know  nothing  of  the  conditions  under  which  the  disease 
arises.  It  is  not  uncommon  in  America.  There  have  been  37  cases  in  my 
wards  in  fifteen  years,  of  which  24  were  of  the  spleno-myelogenous  and  13 
of  the  lymphatic  type.  There  were  21  males  and  16  females.  Four  were 
colored.  There  were  24  below  the  age  of  forty  years.  The  disease  is  most 
common  in  the  middle  period  of  life.  The  youngest  of  my  patients  was  a 
child  of  eight  months,  and  cases  are  on  record  of  the  disease  as  early  as  the 
eighth  or  tenth  week.     It  may  occur  as  late  as  the  seventieth  year.     Males 


732         DISEASES  OF  THE  BLOOD  AND  DUCTLESS  GLANDS. 

are  more  prone  to  the  affection  than  females.  Birch-Hirschfeld  states  that 
of  200  cases  collected  from  the  literature,  135  were  males  and  65  females. 

A  tendency  to  haemorrhage  has  been  noted  in  many  cases,  and  some  of  the 
patients  have  suffered  repeatedly  from  nose-bleeding.  In  women  the  disease 
is  most  common  at  the  climacteric.  There  are  instances  in  which  it  has 
occurred  during  pregnancy.  The  case  described  by  J.  Chalmers  Cameron,  of 
Montreal,  is  in  this  respect  remarkable,  as  the  patient  passed  through  three 
pregnancies,  bearing  on  each  occasion  non-leuksemic  children.  The  case  is 
interesting,  too,  as  showing  the  hereditary  character  of  the  affection,  as  the 
grandmother  and  mother,  as  well  as  a  brother,  suffered  from  symptoms 
strongly  suggestive  of  leuksemia.  One  of  the  patient's  children  had  leukaemia 
before  the  mother  showed  any  signs,  and  a  second  died  of  the  disease.  This 
patient  gradually  recovered  from  the  third  confinement,  and  the  red  blood- 
corpuscles  had  risen  to  4,000,000  per  cubic  millimetre,  and  the  ratio  of  white 
to  red  was  1  to  200.  Sanger  has  reported  a  case  in  which  a  healthy  mother 
bore  a  leukaemic  child. 

Malaria  is  believed  by  some  to  be  an  etiological  factor.  Of  150  cases 
analyzed  by  Gowers,  there  was  a  history  of  malaria  in  30 ;  of  my  hospital  cases 
comparatively  few  gave  a  history  of  it.  The  disease  has  followed  injury  or 
a  blow.  The  lower  animals  are  subject  to  the  affection,  and  cases  have  been 
described  in  horses,  dogs,  oxen,  cats,  swine,  and  mice. 

Morbid  Anatomy. — The  wasting  may  be  extreme,  and  dropsy  is  sometimes 
present.  There  is  in  many  cases  a  remarkable  condition  of  polyasmia;  the 
heart  and  veins  are  distended  with  large  blood-clots.  In  Case  XI  of  my 
series  the  weight  of  blood  in  the  heart  chambers  alone  was  620  grammes. 
There  may  be  remarkable  distention  of  the  portal,  cerebral,  pulmonary,  and 
subcutaneous  veins.  The  blood  is  usually  clotted,  and  the  enormous  increase 
in  the  leucocytes  gives  a  pus-like  appearance  to  the  coagula,  so  that  it  has 
happened  more  than  once,  as  in  Virchow's  memorable  case,  that  on  opening 
the  right  auricle  the  observer  at  first  thought  he  had  cut  into  an  abscess.  The 
coagula  have  a  peculiar  greenish  color,  somewhat  like  the  fat  of  a  turtle.  Some- 
times this  is  so  intense  as  to  suggest  the  color  of  chloroma,  described  later. 
The  alkalinity  of  the  blood  is  diminished.  The  fibrin  is  increased.  The 
character  of  the  corpuscles  will  be  described  under  the  symptoms.  Charcot's 
octahedral  crystals  may  separate  from  the  blood  after  death.  The  specific 
gravity  of  the  blood  is  somewhat  lowered.  There  may  be  pericardial  ecchy- 
moses. 

In  the  spleno-meduUary  form  the  spleen  is  greatly  enlarged.  Strong  adhe- 
sions may  unite  it  to  the  abdominal  wall,  the  diaphragm,  or  the  stomach. 
The  capsule  may  be  thickened;  the  vessels  at  the  hilus  are  enlarged.  The 
weight  may  range  from  2  to  18  pounds.  The  organ  is  in  a  condition  of  chronic 
hyperplasia.  It  cuts  with  resistance,  has  a  uniformly  reddish-brown  color, 
and  the  Malpighian  bodies  are  invisible.  Grayish-white,  circumscribed, 
lymphoid  tumors  may  occur  throughout  the  organ,  contrasting  strongly  with 
the  reddish-brown  matrix.  In  the  early  stage  the  swollen  spleen  pulp  is  softer, 
and  it  is  stated  that  rupture  has  occurred  from  the  intense  hypersemia. 

There  is  an  extraordinary  hyperplasia  of  the  red  marrow.  Instead  of  a  fatty 
tissue,  the  medulla  of  the  long  bones  may  resemble  the  consistent  matter  which 
forms  the  core  of  an  abscess,  or  it  may  be  dark  brown  in  color.    There  may  be 


LEUKEMIA.  733 

haemorrhagic  infarctions.  There  may  be  much  expansion  of  the  shell  of 
bone,  and  localized  swellings  which  are  tender  and  may  even  yield  to  firm 
pressure.  Histologically,  there  are  found  in  the  medulla  large  numbers  of 
nucleated  red  corpuscles  in  all  stages  of  development,  numerous  cells  with 
eosinophilic  granules,  both  small  polynuclear  forms  and  large  almost  giant 
mononuclear  elements.  There  are  also  many  large  cells  with  single  large 
nuclei  and  neutrophilic  granules — the  cellules  medullaires  of  Cornil — the 
myelocytes  which  are  found  in  the  blood.  Great  numbers  of  polynuclear  leu- 
cocytes are  also  present,  as  well  as  a  certain  number  of  small  mononuclear  ele- 
ments. 

In  the  lymphatic  forms  of  the  disease  there  is  a  general  lymphatic  en- 
largement, which  is  usually  associated  with  a  certain  amount  of  enlargement 
•of  the  spleen.  In  the  cases  of  lymphatic  leukaemia  the  cervical,  axillary, 
mesenteric,  and  inguinal  groups  may  be  much  enlarged,  but  the  glands  are 
usually  soft,  isolated,  and  movable.  They  may  vary  considerably  in  size  during 
the  course  of  the  disease.  In  acute  cases  the  tonsils  and  the  lymph  follicles 
of  the  tongue,  pharynx,  and  mouth  may  be  enlarged. 

In  some  instances  there  are  leukaemic  enlargements  in  the  solitary  and 
agminated  glands  of  Peyer.  In  a  case  of  Willcocks'  there  were  growths  on 
the  surface  of  the  stomach  and  gastro-splenie  omentum.  The  thymus  is  rarely 
involved,  though  it  has  been  enlarged  in  some  of  the  acute  cases.  The  bone- 
marrow  in  these  cases  may  be  replaced  by  a  lymphoid  tissue.  Nucleated  red 
■corpuscles  and  the  normal  granular  marrow  elements  may  be  greatly  reduced 
in  number. 

The  liver  may  be  enlarged,  and  in  a  case  described  by  Welch  it  weighed 
•over  13  pounds.  The  enlargement  is  usually  due  to  a  diffuse  leukaemic  infiltra- 
tion. The  columns  of  liver  cells  are  widely  separated  by  leucocytes,  which  are 
partly  within  and  partly  outside  the  lobular  capillaries.  There  may  be  definite 
leukaemic  growths. 

There  are  rarely  changes  of  importance  in  the  lungs.  The  kidneys  are 
•often  enlarged  and  pale,  the  capillaries  may  be  distended  with  leucocytes,  and 
leuksemic  tumors  may  occur.  The  skin  may  be  involved,  as  in  a  case  described 
by  Kaposi. 

Leukaemic  tumors  in  the  organs  are  not  common.  In  159  cases  collected 
by  Gowers  there  were  only  13  instances  of  leukaemic  nodules  in  the  liver  and 
10  in  the  kidneys.  These  new  growths  probably  develop  from  leucocytes  which 
leave  the  capillaries.  Bizzozero  has  shown  that  the  cells  which  compose  them 
are  in  active  fission. 

Symptoms. — The  onset  is  insidious,  and,  as  a  rule,  the  patient  seeks  advice 
for  progressive  enlargement  of  the  abdomen  and  shortness  of  breath,  or  for 
the  enlarged  glands  or  the  pallor,  palpitation,  and  other  symptoms  of  anae- 
mia. Bleeding  at  the  nose  is  common.  Gastro-intestinal  symptoms  may  precede 
the  onset.  Occasionally  the  first  symptoms  are  of  a  very  serious  nature.  In 
•one  of  the  cases  of  my  series  the  boy  played  lacrosse  two  days  before  the  onset 
•of  the  final  haematemesis ;  and  in  another  case  a  girl,  who  had,  it  was  sup- 
posed, only  a  slight  chlorosis,  died  of  fatal  haemorrhage  from  the  stomach - 
"before  any  suspicion  had  been  aroused  as  to  the  true  condition. 

Anaemia  is  not  a  necessary  accompaniment  of  all  stages  of  the  disease;  the 
subjects  may  look  very  healthy  and  well. 


734         DISEASES  OF  THE  BLOOD  AND  DUCTLESS  GLANDS. 

As  has  been  stated,  the  disease  is  most  commonly  seen  in  two  main  types, 
though  combinations  may  occnr. 

(1)  Spleno-medullaey  Leue^mia.— This  is  much  the  commonest  type 
of  the  disease.  The  gradual  increase  in  the  volume  of  the  spleen  is  the  most 
prominent  symptom  in  a  majority  of  the  cases.  Pain  and  tenderness  are  com- 
mon, though  the  progressive  enlargement  may  be  painless.  A  creakii]^  fremi- 
tus may  be  felt  on  palpation.  The  enlarged  organ  extends  downward  to  the 
right,  and  may  be  felt  just  at  the  costal  edge,  or  when  large  it  may  extend  as 
far  over  as  the  navel.  In  many  cases  it  occupies  fully  one-half  of  the  abdo- 
men, reaching  to  the  pubes  below  and  extending  beyond  the  middle  line.  As 
a  rule,  the  edge,  in  some  the  notch  or  notches,  can  be  felt  distinctly.  Its  size 
varies  greatly  from  time  to  time.  It  may  be  perceptibly  larger  after  meals. 
A  haemorrhage  or  free  diarrhoea  may  reduce  the  size.  The  pressure  of  the 
enlarged  organ  may  cause  distress  after  eating;  in  one  ease  it  caused  fatal 
obstruction  of  the  bowels.  A  murmur  may  sometimes  be  heard  over  the  spleen, 
and  Gerhardt  has  described  a  pulsation  in  it. 

The  pulse  is  usually  rapid,  soft,  compressible,  but  often  full  in  volume. 
There  are  rarely  any  cardiac  symptoms.  The  apex  beat  may  be  lifted  an  inter- 
space by  the  enlarged  spleen.  Toward  the  close  oedema  may  occur  in  the 
feet  or  general  anasarca.  Haemorrhage  is  common.  There  may  be  most 
extensive  purpura,  or  hsemorrhagic  exudate  into  pleura  or  peritonaeum.  Epis- 
taxis  is  the  most  frequent  form.  Ha3moptysis  and  haematuria  are  rare. 
Bleeding  from  the  gums  may  be  present.  Hamatemesis  proved  fatal  in  two 
of  my  eases,  and  in  a  third  a  large  cerebral  haemorrhage  rapidly  killed.  The 
leukemic  retinitis  is  a  part  of  the  haemorrhagic  manifestations.  J.  Hughes 
Bennett's  first  leukaemic  patient  died  suddenly,  without  obvious  cause. 

Local  gangrene  may  develop,  with  signs  of  intense  infection  and  high  fever. 
There  are  very  few  pulmonary  symptoms.  The  shortness  of  breath  is  due, 
as  a  rule,  to  the  anaemia.  Toward  the  end  there  may  be  oedema  of  the  lungs, 
or  pneumonia  may  carry  off  the  patient.  The  gastro-intestinal  symptoms  are 
rarely  absent.  ISTausea  and  vomiting  are  early  features  in  some  cases.  Diar- 
rhoea may  be  very  troublesome,  even  fatal.  Intestinal  haemorrhage  is  not 
common.  There  may  be  a  dysenteric  process  in  the  colon.  Jaundice  rarely 
occurs,  though  in  one  case  of  my  series  there  were  recurrent  attacks.  Ascites 
may  be  a  prominent  symptom,  probably  due  to  the  presence  of  the  splenic 
tumor.  A  leuksemic  peritonitis  also  may  be  present,  due  to  new  growths  in 
the  membranes. 

The  nervous  system  is  not  often  involved.  Facial  paralysis  has  been  noted. 
Headache,  dizziness,  and  fainting  spells  are  due  to  anaemia.  The  patients  are 
usually  tranquil.     Coma  may  follow  cerebral  haemorrhage. 

The  special  senses  are  often  affected.  There  is  a  peculiar  retinitis,  due 
chiefly  to  the  extravasation  of  blood,  but  there  may  be  aggregations  of  leuco- 
cytes, forming  small  leukaemic  growths.  Optic  neuritis  is  rare.  Deafness  has 
frequently  been  observed;  it  may  appear  early  and  possibly  is  due  to  haemor- 
rhage. Features  suggestive  of  Meniere's  disease  may  come  on  quite  suddenly, 
due  to  leukaemic  infiltration  or  haemorrhage  into  the  semi-circular  canal. 

The  urine  presents  no  constant  changes.  The  uric  acid  excreted  is  always 
in  excess. 

Priapism  is  a  curious  symptom  which  has  been  present  in  a  large  num- 


LEUKEMIA. 


735 


ber  of  cases.    It  may,  as  in  one  of  our  cases,  be  the  first  symptom.     In  one 
of  my  cases  it  persisted  for  seven  weeks.    The  cause  is  not  known. 

Fever  was  present  in  two-thirds  of  my  series.  Periods  of  pyrexia  may 
alternate  with  prolonged  intervals  of  freedom.  The  temperature  may  range 
from  103°  to  103°. 


1890. 

1891.                                                            ] 

SEPT. 

OCT. 

NOV. 

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BLACK,  RED  CORPUSCLES. 


RED,  HAEMOGLOBIN. 


BLUE,  COLORLESS  CORPUSCLES. 


Chart  XIX. — Leuk.^mia. 


Blood. — In  all  forms  of  the  disease  the  diagnosis  must  be  made  by  the 
examination  of  the  blood,  as  it  alone  offers  distinctive  features. 

The  most  striking  change  in  the  more  common  form,  the  spleno-myelog- 
enous,  is  the  increase  in  the  colorless  corpuscles.     The  average  in  one  of  my 


736         DISEASES  OF  THE  BLOOD  AND  DUCTLESS  GLANDS. 

series  was  398,700  per  cubic  millimetre,  and  the  average  ratio  to  the  red  cells 
was  1  to  10.  The  proportion  may  be  1  to  5,  or  may  even  reach  1  to  1.  There 
are  instances  on  record  in  which  the  number  of  leucocytes  has  exceeded  that 
of  the  red  corpuscles.    The  leucocytes  may  vary  greatly  within  short  intervals. 

The  small  mononuclear  forms  are  little  if  at  all  increased ;  relatively  they 
are  greatly  diminished.  The  eosinophdes  are  present  in  normal  or  increased 
relative  proportion,  so  that  there  is  a  great  total  increase,  and  their  presence 
is  a  striking  feature  in  the  stained  blood-slide.  The  polynuclear  neutrophiles  . 
may  be  in  normal  proportion ;  more  frequently  they  are  relatively  diminished, 
and  in  the  later  stages  they  may  form  but  a  small  proportion  of  the  colorless 
elements.  Marked  differences  in  size  between  individual  poljoiuclear  leucocytes 
may  be  noted;  the  same  is  true  of  the  eosinophiles.  The  most  characteristic 
features  of  the  blood  in  this  form  of  leukaemia  is  the  presence  of  cells  which 
do  not  occur  in  normal  blood.  They  appear  to  be  derived  from  the  marrow, 
and  are  called  by  Ehrlich  myelocytes.  They  are  large  mononuclear  neutro- 
philic cells,  which  may  vary  much  in  size.  They  comprise  about  30  per  cent 
of  the  colorless  cells.  Nicked  nuclei  are  common.  Miiller  has  recently  found 
many  large  mononuclear  elements  with  karyokinetic  figures  in  leukaemic  blood 
and  in  the  marrow.  These  probably  correspond  to  the  myelocytes  of  Ehrlich 
as  well  as  to  the  "  cellules  meduUaires  "  of  Cornil.  Polynuclear  cells  with 
coarse  basophilic  granules,  "  Mastzellen,"  are  always  present  in  this  form  of 
leuksemia  in  considerable  numbers.  The  granules  do  not  staia  in  Ehrlich's 
triacid  mixture,  and  the  cells  may  be  recognized  as  polynuclear  non-granular 
elements.  These  cells,  which  form  only  about  0.28  per  cent  of  the  leucocytes 
of  normal  blood,  may  be  even  more  numerous  than  the  eosinophiles. 

Nucleated  red  blood-corpuscles  are  present  in  considerable  numbers.^ 
These  are  usually  "normoblasts,"  but  cells  with  larger  paler  nuclei,  some 
showing  evidences  of  mitosis,  may  be  seen.  Eed  cells  with  fragmented  nuclei 
are  common,  while  true  megaloblasts  may  be  found.  The  average  number  of 
red  cells  in  one  of  my  series  was  2,850,000  per  cubic  millimetre.  In  no  case 
was  the  count  below  two  million.  The  average  haemoglobin  was  42  per  cent. 
The  blood  chart  on  page  735  is  from  a  case  of  leukaemia  with  an  enor- 
mously enlarged  spleen.  Among  other  points  about  leuksemic  blood  may  be 
mentioned  the  feebleness  of  the  amoeboid  movement,  as  noted  by  Cavafy, 
which  may  be  accounted  for  by  the  large  number  of  mononuclear  elements 
present,  as  the  polynuclear  alone  are  stated  to  possess  this  power.  The  blood- 
plates  exist  in  variable  numbers;  they  may  be  remarkably  abundant.  The 
fibrin  network  between  the  corpuscles  is  usually  thick  and  dense.  In  blood 
slides  which  are  kept  for  a  short  time,  Charcot's  octahedral  crystals  separate, 
and  in  the  blood  of  leukaemia  the  haemoglobin  shows  a  remarkable  tendency  to 
crystallize. 

2.  Lymphatic  Leukemia. — This  form  of  leukaemia  is  rare.  There  were 
13  out  of  37  in  my  hospital  series,  of  which  5  were  acute.  The  superficial 
glands  are  usually  most  involved,  but  even  when  affected  it  is  rare  to  see  such 
large  bunches  as  in  Hodgkin's  disease.  External  lymph  tumors  are  rare.  Lym- 
phatic leukaemia  is  often  more  rapid  and  fatal  in  its  course,  though  chronic 
cases  may  occur.    It  is  more  common  in  young  subjects. 

The  histological  characters  of  the  blood  in  lymphatic  leukaemia  differ 
materially  from  those  in  the  spleno-medullary  form.     The  increase  in  the 


LEUKEMIA.  737 

■colorless  elements  is  never  so  great  as  in  the  preceding  form ;  a  proportion  of 
1  to  10  would  be  extreme.  The  number  of  both  white  and  red  cells  showed 
great  variations  in  my  series.  This  increase  takes  place  solely  in  the  lympho- 
cytes, all  other  forms  of  leucocytes  being  present  in  greatly  diminished  rela- 
tive proportion.  In  one  of  my  cases  over  99  per  cent  of  all  the  leucocytes 
were  lymphocytes.  In  some  cases,  as  Cabot  has  pointed  out,  this  increase 
takes  place  largely  in  the  smaller  forms,  while  in  others  the  large  lympho- 
<3ytes — cells  nearly  as  large  as  polynuclear  leucocytes^predominate.  Eosino- 
philes  and  nucleated,  red  corpuscles  are  rare.    Myelocytes  are  not  present. 

Combined  forms  of  leukaemia  are  not  common. 

Leukancemia. — This  term  was  used  by  Leube  to  describe  a  condition  which 
showed  features  both  of  leukaemia  and  severe  anaemia.  Some  of  the  cases  of 
acute  leukaemia  come  under  this  head,  but  it  must  be  regarded  rather  as  a  clin- 
ical term  than  a  pathological  condition.  The  symptoms  are  often  suggestive  of 
an  acute  infection.  The  onset  may  be  sudden,  and  is  frequently  with  severe 
tonsillitis,  so  that  the  throat  condition  is  the  most  striking  feature.  The  promi- 
nent symptoms  are  fever,  weakness,  haemorrhages,  extreme  pallor,  and  a  rapid 
downward  course.  General  glandular  enlargement  is  frequently,  although  not 
constantly  present.  The  liver  and  spleen  are  usually  enlarged.  The  duration 
varies  from  a  few  days  to  three  months.  The  rapid  fall  in  the  haemoglobin 
and  in  the  number  of  red  cells  is  striking.  In  half  the  reported  cases  the 
red  count  was  below  1,500,000  per  cmm.  With  this  there  is  a  high  color 
index.  The  acute  forms  are  usually  of  the  lymphocytic  type,  although  a  few 
cases  of  acute  myelogenous  leukaemia  have  been  reported.  In  the  former  the 
predominating  lymphocyte  is  usually  the  large  form,  although  in  a  few  acute 
■cases  with  haemorrhages  the  small  lymphocytes  have  been  the  more  numerous. 

Diagnosis. — The  recognition  of  leukaemia  can  be  determined  only  by  micro- 
scopical examination  of  the  blood.  The  clinical  features  may  be  identical 
with  those  of  ordinary  splenic  angemia,  or  of  Hodgkin's  disease.  An  inter- 
esting question  arises  whether  real  increase  in  the  leucocytes  is  the  only  cri- 
terion of  the  existence  of  the  disease.  Thus,  for  instance,  in  the  case  whose 
chart  is  given  on  page  735,  the  patient  came  under  observation  in  September, 
1890,  with  2,000,000  red  blood-corpuscles  per  cubic  millimetre,  30  per  cent 
-of  haemoglobin,  and  500,000  white  blood-corpuscles  per  cubic  millimetre — a 
proportion  of  1  to  4.  As  shown  by  the  chart,  throughout  September,  Octo- 
ber, November,  and  December,  this  ratio  was  maintained.  Early  in  January, 
under  treatment  with  arsenic,  the  white  corpuscles  began  to  decrease,  and 
gradually,  as  shown  in  the  chart,  the  normal  ratio  was  reached.  At  this  time 
could  it  be  said  that  the  case  was  one  of  leukaemia  without  increase  in  the 
number  of  leucocytes  ?  The  blood  examination  showed  that  nucleated  red  cor- 
puscles in  large  numbers  as  well  as  myelocytes,  elements  which  are  but  rarely 
found  in  normal  blood,  were  still  present  in  numbers  sufficient  to  suggest,  if 
the  patient  had  come  under  observation  for  the  first  time,  that  leukaemia  might 
occur.  In  another  of  our  cases  the  blood  became  normal  and  the  spleen 
tumor  disappeared  twice  in  one  year  (McCrae).  Altogether  I  have  seen  four 
cases  in  which  the  leucocyte  count  became  normal,  in  three  the  splenic  enlarge- 
ment persisted. 

Association  with  other  Diseases. — Tuberculosis,  of  which  Dock  has  col- 
lected 27  cases,  occurs  occasionally  without  any  special  influence  on  the  course. 
48 


738         DISEASES  OF  THE  BLOOD  AND  DUCTLESS  GLANDS. 

Intercurrent  infections  are  not  uncommon — influenza,  typhoid  fever,  sepsis — 
often  with  remarkable  influence,  particularly  on  the  leucocytes.  In  Dock's  case 
within  a  couple  of  weeks  after  an  attack  of  influenza  they  fell  from  367,070 
to  7,500  per  cmm.  Various  other  conditions  influence  the  disease,  and  the 
excess  of  leucocytes  has  disappeared  after  the  use  of  arsenic,  quinine,  tuber- 
culin, nuclein,  and  the  X-rays. 

Prognosis. — Eecovery  occasionally  occurs.  A  great  majority  of  the  cases 
prove  fatal  within  two  or  three  years.  Unfavorable  signs  are  a  tendency  to 
haemorrhage,  persistent  diarrhoea,  early  dropsy,  and  high  fever.  Eemarkable 
variations  are  displayed  in  the  course,  and  a  transient  improvement  may  take 
place  for  weeks  or  even  months.  The  pure  lymphatic  form  seems  to  be  of 
particular  malignancy,  some  cases  proving  fatal  in  from  three  to  eight  weeks. 
In  one  of  my  cases  the  leukaemia  lasted  between  eleven  and  twelve  years.  The 
diagnosis  was  made  by  the  late  W.  H.  Draper,  and  when  I  saw  the  patient, 
ten  years  after  the  onset,  the  cervical,  axillary,  and  inguinal  glands  were  greatly 
enlarged;  the  leucocytes  were  243,000  per  cubic  millimetre,  above  90  per  cent 
of  them  being  lymphocytes.  The  longest  course  of  my  hospital  series  of  the 
lymphatic  type  was  three  years,  and  of  the  spleno-myelogenous  about  the 
same  duration. 

Treatment. — Fresh  air,  good  diet,  and  abstention  from  mental  worry  and 
care,  are  the  important  general  indications.  The  indicatio  morhi  can  not  be 
met.  There  are  certain  remedies  which  have  an  influence  upon  the  disease. 
Of  these,  arsenic,  given  in  large  doses,  is  the  best.  I  have  repeatedly  seen 
improvement  under  its  use.  On  the  other  hand,  there  are  curious  remissions 
in  the  disease,  as  mentioned  above,  which  render  therapeutical  deductions  very 
fallacious. 

Quinine  may  be  given  in  eases  with  a  malarial  history.  Iron  may  be 
of  value  in  some  cases,  as  may  also  inhalations  of  oxygen.  Treatment  with 
the  X-rays  should  be  tried.  Some  observers  have  reported  very  good  results. 
Personally,  I  have  not  seen  any  very  striking  improvement. 

Excision  of  the  leuksemic  spleen  has  been  performed  43  times,  with  5 
recoveries  (J.  C.  "Warren). 

Chloroma  is  a  rare  form  of  leukaemia  in  which  there  is  a  tumor-like  hyper- 
plasia of  the  bone-marrow  with  growths  of  a  greenish  color  ("  green  cancer  ") 
in  the  bones,  particularly  of  the  head  and  orbit,  and  in  the  organs.  There  is 
anaemia  and  marked  leukaemia.  Dock  has  collected  22  cases  reported  since 
1893.  The  chief  symptoms  are  progressive  weakness,  pallor,  exophthalmos 
with  the  tumor  formations.  Sometimes  there  are  skin  eruptions,  in  Bram- 
well's  case  of  a  greenish  color.    The  cause  of  the  remarkable  color  is  unknown. 


ni.    HODGKIN'S    DISEASE. 

Definition. — An  affection  characterized  by  progressive  enlargement  of  the 
lymphatic  glands  (beginning  usually  on  one  side  of  the  neck)  and  spleen,  with 
the  formation  in  the  liver,  spleen,  lungs,  and  other  organs  of  nodular  growths, 
associated  with  a  secondary  anaemia,  without  leukaemia. 

Hodgkin,  in  1832,  recorded  a  series  of  cases  of  enlargement  of  the  lym- 
phatic glands  and  spleen.     As  with  Addison's  disease,  to  Wilks  we  owe  a 


HODGKIN'S  DISEASE.  739 

clear  conception  of  the  aifection  with  which  he  associated  the  name  of  the 
distinguished  morbid  anatomist  of  Guy's  Hospital.* 

Clinically  the  cases  resemble  certain  forms  of  leukaemia,  lympho-sarcoma, 
and  lymphatic  tuberculosis;  some  recent  writers  even  deny  the  existence  of 
a  separate  malady,  Hodgkin's  disease. 

Many  names  have  been  given  to  the  condition — ansemia  lymphatica 
(Wilks),  adenie  (Trousseau),  pseudo-leukfemia  (Cohnheim),  and  generalized 
lymphadenoma. 

The  names  malignant  lymphoma  (Billroth)  and  lympho-sarcoma  have 
also  been  given  to  a  form  of  progressive  enlargement  of  the  lymph-glands, 
but  they  should  be  restricted  to  primary  sarcoma  of  these  structures,  a  very 
different  affection  anatomically,  though  clinically  it  may  resemble  Hodgkin's 
disease. 

Etiolo^. — A  majority  of  the  cases  occur  in  young  persons.  Of  43  cases 
collected  by  Mitchell  Clark,  37  were  in  males.  Ten  occurred  below  ten  years 
of  age  and  33  below  the  fortieth  year.  Heredity,  syphilis,  and  tuberculosis  are 
doubtful  factors.  Local  irritation  about  the  throat  and  mouth — regions  drain- 
ing into  the  cervical  glands — often  precedes  the  onset  of  the  swelling  (Trous- 
seau). The  true  nature  of  the  disease  is  unknown.  Certain  features  suggest 
that  it  may  be  an  acute  infection — the  rapidly  fatal  course  of  some  cases,  the 
frequency  with  which  the  disease  starts  in  the  cervical  glands,  and  the  not 
infrequent  preliminary  involvement  of  the  tonsils,  the  gradual  extension  from 
one  gland-group  to  another,  and  the  recurring  exacerbations  of  fever.  A  pos- 
sible instance  of  direct  infection  is  quoted  by  Murray  in  Allbutt's  system. 
The  results  of  bacteriological  study  are  as  yet  uncertain. 

Eelation  to  Malignant  Disease. — Much  confusion  has  come  from  the 
use  of  the  terms  lympho-sarcoma  and  malignant  lymphoma  to  designate  cases 
of  Hodgkin's  disease.  The  two  conditions  are  quite  different.  We  know  of 
no  malignant  growth  the  metastases  of  which  occur  in  one  form  of  tissue  only. 
Sarcoma  invades  the  capsule  of  the  gland  and  the  adjacent  textures,  and 
does  not  limit  its  extension  from  one  gland-group  to  another.  Histologically 
there  are  radical  differences  between  lympho-sarcoma  and  Hodgkin's  disease. 

Eelation  to  Tuberculosis. — Of  late  the  view  has  been  advanced  that 
Hodgkin's  disease  is  only  a  peculiar  form  of  lymphatic  tuberculosis,  a  view 
supported  by  Sternberg,  Crowder,  Musser,  Sailer,  and  others.  There  is  an 
acute  tuberculous  adenitis  and  a  chronic  form  (see  p.  306),  either  of  which 
may  closely  resemble  Hodgkin's  disease.  The  statement  of  the  relationship  is 
based  upon  (1)  the  presence  of  tubercle  bacilli  in  the  glands  in  a  certain 
number  of  cases  of  Hodgkin's  disease,  and  (2)  the  successful  inoculation  of 
animals,  even  when  the  glands  did  not  show  tubercle  bacilli  microscopically. 
Opposed  to  this  are  the  facts  that  (1)  in  a  large  majority  of  all  cases  bacilli 
are  not  present  in  the  glands,  and  the  inoculation  experiments  are  negative 
(Westphal) ;  (2)  the  histological  changes  in  the  glands  in  Hodgkin's  disease 
are  specific  and  distinctive  (Eeed)  ;  (3)  the  tuberculin  test  in  typical  cases 
of  the  disease  is  negative  (Reed)  ;  and  (4)  the  tuberculosis  when  present  is 
in  many  cases,  at  least,  a  terminal  infection. 

*  Students  have  now  easy  access  to  the  original  account  (which  appeared  in  the  Trans- 
actions of  the  Eoyal  Med.  and  Chirur.  Society,  1832),  in  the  New  Sydenham  Society  Memoirs, 
1902, 


740         DISEASES  OF  THE  BLOOD  AND  DUCTLESS  GLANDS. 

Morbid  Anatomy. — The  superficial  l}Tnph-glands  are  found  most  exten- 
sively involved,  and  from  the  cer^dcal  groups  they  form  continuous  chains  unit- 
ing the  mediastinal  and  axillary  glands.  The  masses  may  pass  beneath  the  pec- 
toral muscles  and  even  beneath  the  scapula?.  Of  the  internal  glands,  those 
of  the  thorax  are  most  often  affected,  and  the  tracheal  and  bronchial  groups 
may  form  large  masses.  The  trachea  and  the  aorta  with  its  branches  may  be 
completely  surrounded;  the  veins  may  be  compressed,  rarely  the  aorta  itself. 
The  masses  perforate  the  sternum  and  invade  the  lung  deeply.  The  retro- 
peritoneal glands  may  form  a  continuous  chain  from  the  diaphragm  to  the 
inguinal  canals.  They  may  compress  the  ureters,  the  lumbar  and  sacral 
nerves,  and  the  iliac  veins.  They  may  adhere  to  the  broad  ligament  and  the 
uterus  and  simulate  fibroids.  At  an  early  stage  the  glands  are  soft  and  elastic; 
later  they  may  become  firm  and  hard.  Fusion  of  contiguous  glands  does  not 
often  occur,  and  they  tend  to  remain  discrete,  even  after  attaining  a  large  size. 
The  capsule  is  not  infiltrated,  nor  are  adjacent  tissues  invaded.  On  section  the 
gland  presents  a  grayish-white  semi-translucent  appearance,  broken  by  inter- 
secting strands  of  fibrous  tissue;  there  is  no  caseation  or  necrosis  unless  a 
secondary  infection  has  occurred. 

The  spleen  is  enlarged  in  75  per  cent  of  the  cases;  in  young  children  the 
enlargement  may  be  great,  but  the  organ  rarely  reaches  the  size  of  the  spleen 
in  ordinary  leukaemia.  In  more  than  half  of  the  cases  lymphoid  growths  are 
present. 

The  marrow  of  the  long  bones  may  be  converted  into  a  rich  lymphoid 
tissue.  The  lymphatic  structures  of  the  tonsillar  ring  and  of  the  intestines 
may  show  marked  hyperplasia.  The  liver  is  often  enlarged,  and  may  present 
scattered  nodular  tumors,  which  may  also  occur  in  the  kidneys. 

Histology. — The  study  of  D.  M.  Eeed,*  from  the  laboratory  of  my  col- 
league, Dr.  Welch,  suggests  that  there  is  a  specific  histological  picture  in 
Hodgkin's  disease  characterized  by  (1)  proliferation  of  the  endothelial  and 
reticular  cells;  (2)  the  formation  of  hmphoid  cells  (uniform  in  size  and 
shape)  from  the  mother  cells  of  the  h-mph-nodes  and  from  the  endothelial 
cells  of  the  reticulum;  (3)  characteristic  giant  cells,  formed  from  proliferating 
endothelial  cells,  which  differ  from  the  giant  cells  of  tuberculosis;  (4)  great 
proliferation  of  the  connective-tissue  stroma  leading  to  fibrosis ;  and,  lastly, 
eosinophile  cells,  which  form  a  marked  feature  in  a  large  proportion  of  the 
cases.  The  metastatic  nodules  present  the  same  structure  as  the  glandular 
growths. 

When  tuberculosis  occurs  as  a  secondary  infection  the  two  processes  may 
be  readily  differentiated  in  sections  of  the  glands. 

Symptoms. — Enlargement  of  the  glands  on  one  side  of  the  neck  is  usu- 
ally the  first  symptom.  It  is  rare  that  other  superficial  groups  or  the  deeper 
glands  are  first  attacked.  A  chronic  tonsillitis  may  precede  the  onset. 
Months,  or  even  several  years,  may  elapse  before  the  glands  on  the  other  side 
of  the  neck  or  in  the  axilla  are  involved.  Usually  there  is  a  progressive 
growth,  until  quite  large  groups  are  formed,  in  which,  however,  the  individual 
glands  may  be  felt.  There  is  not  often  any  pain.  The  inguinal  glands  may 
soon  be  involved  and  grow  rapidly,  but  in  many  cases  they  do  not  reach  the 

*  Johns  Hopkins  Hospital  Reports,  vol.  x,  1902. 


HODGKIN'S  DISEASjE.  741 

size  of  the  cervical  groups.  During  what  may  be  called  the  first  stage  of  the 
disease  the  patient's  general  condition  is  good.  It  may  be  many  months  before 
the  internal  lymph-glands  become  involved,  and  they  may  never  enlarge  suffi- 
ciently to  cause  symptoms.  The  spleen  enlarges  in  a  majority  of  cases.  In 
rare  instances  the  lymphoid  tumors  may  be  felt  on  the  surface  of  the  enlarged 
liver  and  spleen. 

As  the  disease  advances  the  symptoms  fall  into  two  groups — those  due 
to  pressure  of  the  enlarged  glands,  and  the  progressive  cachexia.  The  axillary 
groups  may  cause  swelling  and  pain  in  the  hands  and  arms.  The  inguinal 
glands  may  press  on  the  nerves  and  cause  great  pain,  with  swelling  of  the  feet. 
Involvement  of  the  mediastinal  glands  is  indicated  by  paroxysmal  cough, 
attacks  of  pain,  dyspnoea,  and  sometimes  most  intense  cyanosis  of  the  upper 
part  of  the  body.  Pleural  effusion,  disturbed  heart  action,  and  pupillary 
changes  are  rarer  events.  The  cases  with  paraplegia  from  invasion  of  the 
spine  and  the  cord,  are,  as  a  rule,  lympho-sarcoma. 

The  general  symptoms  of  the  disease  are: 

Anemia  of  a  secondary  type,  not  marked  at  first,  and  even  in  the  later 
stages  the  red  corpuscles  rarely  fall  below  2,000,000  per  cubic  millimetre.  The 
leucocytes  may  be  normal  in  number  or  there  may  be  an  early  leucocytosis,  or 
at  any  time  during  the  course  there  may  be  a  transient  increase.  The  small 
mononuclear  forms  may  be  relatively  increased.  In  very  rare  instances  a  ter- 
minal leukgemia  occurs,  but,  as  C.  F.  Martin  suggests,  these  cases  may  be  true 
leukaemia  from  the  start. 

Fever. — A  majority  of  the  cases  present  (1)  a  slight  irregular  fever; 
(2)  later  in  the  disease  there  may  be  a  daily  rise  of  three  or  four  degrees, 
sometimes  with  a  chill  and  sweat;  (3)  in  a  few  rare  instances  Pel  has  de- 
scribed remarkable  periods  of  fever  of  ten  to  fourteen  days'  duration,  alter- 
nating with  intervals  of  complete  apyrexia.  They  occurred  in  two  of  my  cases. 
Ebstein  described  it  as  a  form  of  chronic  recurring  fever.  It  is  probably  due 
to  an  intercurrent  infection, 

Cachexia.-^A  remarkable  grade  of  emaciation  ultimately  follows,  associ- 
ated with  great  asthenia,  and  sometimes  anasarca  from  the  anaemia. 

Bronzing  of  the  skin  may  occur,  apart  from  the  use  of  arsenic.  An  obsti- 
nate pruritus  and  recurring  boils  may  add  to  the  patient's  distress. 

Diagnosis.— (a)  Tuberculosis. — It  is  not  sufficiently  recognized  that  there 
are  both  acute  and  chronic  forms  of  general  tuberculous  adenitis  (see  p.  306), 
but  such  cases, do  not  often  present  difficulty  in  diagnosis.  In  the  case  of 
enlargement  of  the  glands  on  one  side  of  the  neck  beginning  in  a  young  per- 
son, it  is  often  not  at  all  easy  to  determine  whether  the  disease  is  tuberculosis 
or  beginning  Hodgkin's  disease.  Two  points  should  be  decided.  First,  under 
cocaine  one  of  the  small  glands  of  the  affected  side  should  be  excised  and  the 
structure  carefully  studied  in  the  light  of  Dr.  Eeed's  recent  observations.  The 
histological  changes  differ  markedly  in  Hodgkin's  disease  from  those  in  tuber- 
culosis. Secondly,  tuberculin  should  be  used  if  the  patient  is  afebrile.  In 
early  tuberculosis  of  the  glands  of  the  neck  the  reaction  is  prompt  and  decisive. 
The  large  experience  on  this  point  in  the  wards  of  my  colleague,  Halsted,  is 
conclusive  as  to  the  efficiency  (and  the  harmlessness)  of  the  method.  In  the 
later  stages,  when  many  groups  of  glands  are  involved  and  the  cachexia  is  well 
advanced,  the  tuberculin  reaction  may  be  present  in  Hodgkin's  disease,  but 


742         DISEASES  OF  THE  BLOOD  AND  DUCTLESS  GLANDS. 

even  then  the  histological  changes  are  distinctive.  Other  points  to  be  noted  are 
the  tendency  in  the  tuberculous  adenitis  to  coalescence  of  the  glands,  adhesion 
to  the  skin,  Tvith  suppuration,  etc.,  and  the  liability  to  tuberculosis  of  the  lung 
or  pleura. 

(6)  Leukemia. — As  a  rule,  the  blood  examination  gives  the  diagnosis  at 
a  glance,  as  Hodgkin's  disease  presents  only  a  slight  leucocytosis.  A  dif- 
ficult)^ arises  only  in  those  rare  instances  of  leuksemia,  usually  the  acute  l}Tn- 
phatic  form,  in  which  the  leucocytes  gradually  decrease  or  in  wliich  the  number 
for  a  time  may  become  normal.  Histologically  there  are  striking  differences 
between  the  structure  of  the  glands  in  the  two  conditions. 

(c)  Ltmpiio-saecoma. — Clinically  the  cases  may  resemble  Hodgkin's  dis- 
ease very  closely,  and  in  the  literature  the  two  diseases  have  been  confounded. 
The  glands,  as  a  rule,  form  larger  masses,  the  capsules  are  involved,  and 
adjacent  structures  are  attacked.  Pressure  signs  in  the  chest  and  abdomen  are 
much  more  common  in  hmipho-sarcoma.  But  the  easiest  and  most  satisfactory 
mode  of  diagnosis  is  examination  of  sections  of  a  gland,  as  the  structure  is  very 
different  from  that  seen  in  Hodgkin's  disease.  The  blood  condition,  the  type 
of  fever,  etc.,  need  a  more  careful  study  in  this  group  of  cases. 

Course. — There  are  acute  cases  in  which  the  enlargements  spread  rapidly 
and  death  follows  in  three  or  four  months.  As  a  rule,  the  disease  lasts  for 
two  or  three  years.  Eemarkable  periods  of  quiescence  may  occur,  in  which  the 
glands  diminish  in  size,  the  fever  disappears,  and  the  general  condition  im- 
proves. Even  a  large  group  of  glands  may  almost  completely  disappear,  or 
a  tumor  mass  on  one  side  of  the  neck  may  subside  while  the  inguinal  glands 
are  enlarging.  Usually  a  cachexia  with  anaemia  and  swelling  of  the  feet  pre- 
cedes death.  A  fatal  event  may  occur  early  from  great  enlargement  of  the 
mediastinal  glands. 

Treatment. — When  the  glands  are  small  and  limited  to  one  side  of  the 
neck,  operation  should  be  advised;  even  when  both  sides  of  the  neck  are  in- 
volved, if  there  are  no  signs  of  mediastinal  growth,  operation  is  justifiable. 
The  course  of  the  disease  may  be  delayed,  even  if  cure  does  not  follow. 

There  is  a  possibility  that  the  X-rays  may  do  good  in  selected  cases.  Cer- 
tainly the  glands  have  been  reduced  in  size,  but  I  know  of  no  case  in  which 
complete  cure  has  been  reported.  Local  treatment  of  the  glands  seems  to  do 
but  little  good. 

Arsenic  is  the  only  drug  which  has  a  positive  value  in  the  disease.  In 
some  cases  the  effects  on  the  glands  are  striking.  It  may  be  given  in  the  form 
of  Fowler's  solution  in  increasing  doses.  Eecoveries  have  been  reported  (?). 
Ill  effects  from  the  larger  doses  are  rare.  Peripheral  neuritis  followed  the 
use  of  I  iv,  5j,  TT],  xviij  during  a  period  of  less  than  three  months.  Phosphorus 
is  recommended  by  Gowers  and  Broadbent,  and  may  be  tried  if  arsenic  is  not 
well  borne.  Quinine,  iron,  and  cod-liver  oil  are  useful  as  tonics.  For  the 
pressure  pains  morphia  should  be  given. 

IV.     PURPURA. 

Strictly  speaking,  purpura  is  a  symptom,  not  a  disease;  but  under  this 
term  are  conveniently  arranged  a  number  of  affections  characterized  by  extrav- 
asations of  the  blood  into  the  skin.     In  the  present  state  of  our  knowledge  a 


PURPURA.  743 

satisfactory  classification  can  not  be  made.  W.  Koch  groups  all  forms,  includ- 
ing haemophilia,  under  the  designation  hcemorrhagic  diathesis,  believing  that 
intermediate  forms  link  the  mild  purpura  simplex  and  the  most  intense  pur- 
pura hsemorrhagica.  For  a  full  discussion  of  the  subject  and  an  analysis  of 
my  cases,  see  Pratt's  article  in  my  "  System  of  Medicine,"  Vol.  IV. 

The  purpuric  spots  vary  from  1  to  3  or  4  mm.  in  diameter.  When  small 
and  pin-point-like  they  are  called  petechise;  when  large,  they  are  known  as 
€cchymoses.  At  first  bright  red  in  color,  they  become  darker,  and  gradually 
fade  to  brownish  stains.    They  do  not  disappear  on  pressure. 

In  all  cases  of  purpura  the  coagulation  time  of  the  blood  should  be  esti- 
mated (Wright) ;  the  coagulometer  is  a  useful  clinical  instrument  for  the  pur- 
pose. Normal  blood  clots  in  the  tubes  in  from  three  to  five  minutes.  In  some 
forms  of  purpura  the  coagulation  time  is  retarded  to  ten  or  fifteen  minutes, 
and  in  haemophilia  it  has  been  delayed  to  fifty  minutes. 

The  following  is  a  provisional  grouping  of  the  cases : 

Symptomatic  Purpura. — (a)  Infectious. — In  pyaemia,  septicemia,  and 
malignant  endocarditis  (particularly  in  the  last  affection),  ecchymoses  may 
he  very  abundant.  In  typhus  fever  the  rash  is  always  purpuric.  Measles,  scar- 
let fever,  and  more  particularly  small-pox  and  cerebro-spinal  fever,  have  each  a 
Tariety  characterized  by  an  extensive  purpuric  rash. 

(&)  Toxic. — The  virus  of  snakes  produces  with  great  rapidity  extrava- 
sation of  blood' — a  condition  which  has  been  very  carefully  studied  by  Weir 
Mitchell.  Certain  medicines,  particularly  copaiba,  quinine,  belladonna,  mer- 
cury, ergot,  and  the  iodides  occasionally,  are  followed  by  a  petechial  rash. 
Purpura  may  follow  the  use  of  comparatively  small  doses  of  iodide  of  potas- 
sium. It  is  not  a  very  common  occurrence,  considering  the  great  frequency 
with  which  the  drug  is  employed.  A  fatal  event  may  be  caused  by  a  small 
.amount,  as  in  a  case  reported  by  Stephen  Mackenzie  of  a  child  which  died  after 
.a  dose  of  2^  grains.  Ah  erythema  may  precede  the  haemorrhage.  It  is  not 
.always  a  simple  purpura,  but  may  be  an  acute  febrile  eruption  of  great  inten- 
sity. In  September,  1894,  a  man  aged  forty-eight  was  admitted  under  my 
■eare  with  arterio-sclerosis  and  dropsy.  The  latter  yielded  rapidly  to  digitalis 
and  diuretin.  When  convalescent  he  was  ordered  iodide  of  potassium  in  10- 
.grain  doses  three  times  a  day,  and  took  in  fourteen  days  420  grains.  He  had 
high  fever,  coryza,  swelling  of  the  throat,  and  the  most  extensive  purpura 
over  the  whole  body.  I  saw  in  an  adult  an  extensive  purpura  of  the  skin  of  the 
legs  follow  the  taking  of  60  grains  of  the  drug  in  four  doses.  Under  this 
■division,  too,  comes  the  purpura  so  often  associated  with  jaundice. 

(c)  Cachectic. — Under  this  heading  are  best  described  the  instances  of 
purpura  which  occur  in  the  constitutional  disturbance  of  cancer,  tuberculosis, 
Hodgkin's  disease,  Bright's  disease,  scurvy,  and  in  the  debility  of  old  age.  In 
these  cases  the  spots  are  usually  confined  to  the  extremities.  They  may  be  very 
abundant  on  the  lower  limbs  and  about  the  wrists  and  hands.  This  constitutes, 
probably,  the  commonest  variety  of  the  disease,  and  many  examples  of  it  can 
'be  seen  in  the  wards  of  any  large  hospital. 

(d)  ISTeurotic. — One  variety  is  met  with  in  cases  of  organic  disease.  It 
is  the  so-called  myelopathic  purpura,  which  is  seen  occasionally  in  locomotor 
ataxia,  particularly  following  attacks  of  the  lightning  pains  and,  as  a  rule, 
involving  the  area  of  the  skin  in  which  the  pains  have  been  most  intense. 


744         DISEASES  OF  THE  BLOOD  AND  DUCTLESS  GLANDS. 

Cases  have  been  met  with  also  in  acute  myelitis  and  in  transverse  myelitis,, 
and  occasionally  in  severe  neuralgia.  Another  form  is  the  remarkable  hysteri- 
cal condition  in  which  stigmata,  or  bleeding  points,  appear  upon  the  skia. 

(e)  Mechaxical. — This  variety  is  most  frequently  seen  in  venous  stasis 
of  any  form,  as  in  the  paroxysms  of  whooping-cough  and  in  epilepsy  and 
about  tight  bandages. 

Arthritic. — This  form  is  characterized  by  involvement  of  the  joints.  It 
is  usually  known,  therefore,  as  rheumatic,  though  in  reality  the  evidence  upon 
which  this  view  is  based  is  not  conclusive.  Of  200  cases  of  purpura  analyzed 
by  Stephen  Mackenzie,  61  had  a  history  of  rheumatism.  For  the  present  it 
seems  more  satisfactory  to  use  the  designation  arthritic.  Three  groups  of 
cases  may  be  recognized : 

{a)  iPuEPUEA  Simplex. — A  mild  form,  often  known  as  purpura  simplex, 
seen  most  commonly  in  children,  in  whom,  with  or  without  articular  pain,  a 
crop  of  purpuric  spots  appears  upon  the  legs,  less  commonly  upon  the  trunk 
and  arms.  As  pointed  out  by  Graves,  this  form  is  not  infrequently  associated 
with  diarrhoea.  The  disease  is  seldom  severe.  There  may  be  loss  of  appetite, 
and  slight  angemia.  Fever  is  not,  as  a  rule,  present,  and  the  patients  get  well 
in  a  week  or  ten  days.  Usually  regarded  as  rheumatic,  and  certainly  asso- 
ciated, in  some  instances,  with  undoubted  rheumatic  manifestations,  yet  in  a 
majority  of  the  patients  the  arthritis  is  slighter  than  in  the  ordinary  rheuma- 
tism of  children,  and  no  other  manifestations  are  present. 

(h)  PuEPUEA  (Peliosis)  Eheumatica  {ScJwnlein's  Disease) . — This  re- 
markable affection  is  characterized  by  multiple  arthritis,  and  an  eruption 
which  varies  greatly  in  character,  sometimes  purpuric,  more  commonly  asso- 
ciated with  urticaria  or  with  erythema  exudativum.  The  disease  is  most 
common  in  males  between  the  ages  of  twenty  and  thirty.  It  not  infrequently 
sets  in  with  sore  throat,  a  fever  from  101°  to  103°,  and  articular  pains.  The 
rash,  which  makes  its  appearance  first  on  the  legs  or  about  the  affected  joints, 
may  be  a  simple  purpura  or  may  show  ordinary  urticarial  wheals.  In  other 
instances  there  are  nodular  infiltrations,  not  to  be  distinguished  from  erythema 
nodosum.  The  combination  of  wheals  and  purpura,  the  purpura  urticans,  is 
very  distinctive.  Much  more  rarely  vesication  is  met  with,  the  so-called 
pemphigoid  purpura.  The  amount  of  cedema  is  variable;  occasionally  it  is 
excessive.  In  one  case,  which  I  saw  in  Montreal  with  Molson,  the  chin  and 
lower  lip  were  enormously  swollen,  tense,  glazed,  and  deeply  ecch^-motic.  The 
eyelids  were  swollen  and  purpuric,  while  scattered  over  the  cheeks  and  about 
the  joints  were  numerous  spots  of  purpura  urticans.  These  are  the  cases  which 
have  been  described  as  felrile  purpuric  (xdema.  The  temperature  range,  in 
mild  cases,  is  not  high,  but  may  reach  102°  or  103°. 

The  urine  is  sometimes  reduced  in  amount  and  may  be  albuminous.  The 
joint  affections  are  usually  slight,  though  associated  with  much  pain,  par- 
ticularly as  the  rash  comes  out.  Eelapses  may  occur  and  the  disease  may 
return  at  the  same  time  for  several  years  in  succession. 

The  diagnosis  of  Schonlein's  disease  offers  no  difficulty.  The  association 
of  multiple  arthritis  wdth  purpura  and  urticaria  is  very  characteristic.  In  a 
case  which  I  saw  with  Musser  there  Aras  endo-pericarditis,  and  the  question 
at  first  arose  whether  the  patient  had  malignant  endocarditis  with  extensive 
cutaneous  infarcts. 


PURPURA.  745 

Schonlein's  peliosis  is  thought  by  most  writers  to  be  of  rheumatic  origin, 
and  certainly  many  of  the  cases  have  the  characters  of  ordinary  rheumatic 
fever,  plus  purpura.  By  many,  however,  it  is  regarded  as  a  special  affection^ 
of  which  the  arthritis  is  a  manifestation  analogous  to  that  which  occurs  in 
haemophilia  and  in  scurvy.  The  frequency  with  which  sore  throat  precedes 
the  attack,  and  the  occasional  occurrence  of  endocarditis  or  pericarditis,  are 
certainly  very  suggestive  of  true  rheumatism. 

The  cases  usually  do  well,  and  a  fatal  event  is  extremely  rare.  The  throat 
symptoms  may  persist  and  give  trouble.  In  two  instances  I  have  seen  necrosis 
and  sloughing  of  a  portion  of  the  uvula. 

(c)  Purpura,  Erythema,  and  Urticaria  with  Visceral  Lesions. — 
This  variety,  seen  chiefly  in  children,  is  characterized  by  (1)  relapses  or  recur- 
rences, often  extending  over  several  years;  (2)  cutaneous  lesions,  which  may 
be  simple  purpura,  purpura  urticans,  urticaria,  angio-neurotic  oedema,  and 
erythema  in  all  its  multiform  varieties;  in  successive  attacks  the  skin  lesions 
may  vary  greatly;  (3)  gastro-intestinal  crises — pain,  vomiting,  and  diarrhoea; 
(4)  joint  pains  or  swelling,  often  trifling;  (5)  haemorrhages  from  the  mucous 
membranes;  (6)  enlargement  of  the  spleen;  (7)  nephritis,  which  is  the  most 
serious  feature  and  the  most  frequent  cause  of  death.  The  cases  with  colic 
and  purpura  are  often  spoken  of  as  Henoch's  purpura,  but  the  skin  lesion  is 
very  variable.  The  whole  group  of  symptoms  is  really  a  manifestation  of  an  as 
yet  unknown  mischief,  which  at  one  time  attacking  the  skin  causes  any  of  the 
manifestations  of  the  erythema  group,  from  simple  purpura  to  angio-neurotic 
oedema,  attacking  the  intestines  or  stomach  causes  vomiting,  colic,  or  bleeding, 
or  attacking  the  kidneys  an  acute  and  sometimes  fatal  nephritis.  (For  a  study 
of  twenty-eight  cases  see  American  Journal  of  Medical  Sciences,  January, 
1904.) 

Purpura  Hsemorrhag^ica. — Under  this  heading  may  be  considered  the  cases 
of  very  severe  purpura  with  haemorrhages  from  the  mucous  membranes.  The 
affection,  known  as  the  morbus  maculosus  of  Werlhof,  is  most  commonly  met 
with  in  young  and  delicate  individuals,  particularly  in  girls;  but  cases  are 
described  in  which  the  disease  has  attacked  adults  in  full  vigor.  After  a 
few  days  of  weakness  and  debility,  purpuric  spots  appear  on  the  skin  and 
rapidly  increase  in  numbers  and  size.  Bleeding  from  the  mucous  surfaces  sets 
in,  and  the  epistaxis,  haematuria,  and  hsemoptysis  may  cause  profound  anaemia. 
Chart  XX  illustrates  the  rapidity  with  which  anaemia  is  produced  and  the 
gradual  recovery.  Death  may  take  place  from  loss  of  blood,  or  from  haemor- 
rhage into  the  brain.  Slight  fever  usually  accompanies  the  disease.  In  favor- 
able cases  the  affection  terminates  in  from  ten  days  to  two  weeks.  There  are 
instances  of  purpura  haemorrhagica  of  great  malignancy,  which  may  prove 
fatal  within  twenty-four  hours — purpura  fulminans.  This  form  is  most  com- 
monly met  with  in  children,  and  is  characterized  chiefly  by  cutaneous  haemor- 
rhages, and  death  may  occur  before  any  bleeding  takes  place  from  the  mucous 
membranes. 

In  the  diagnosis  of  purpura  haemorrhagica  it  is  important  to  exclude 
scurvy,  which  may  be  done  by  the  consideration  of  the  previous  health,  the 
cirqumstances  under  which  the  disease  occurs,  and  by  the  absence  of  swelling 
of  the  gums.  The  malignant  forms  of  the  fevers,  particularly  small-pox  and 
measles,  are  distinguished  by  the  prodromes  and  the  higher  temperature. 


746 


DISEASES  OF  THE  BLOOD  AND  DUCTLESS  GLANDS. 


Treatment. — In  symptomatic  purpura  attention  should  be  paid  to  the  con- 
ditions under  which  it  occurs,  and  measures  should  be  emploj^ed  to  increase 
the  strength  and  to  restore  a  normal  blood  condition.  Tonics,  good  food,  and 
fresh  air  meet  these  indications.     In  the  simple  purpura  of  children,  or  that 


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CORPU30LC3 


BLACK,_RED  CCSPUSCLE3.  RED,  HAEMAGLOBIN,  BLUE,   COLORLESS  CORPUSCLES. 

Chart  XX. — Illustrates  the  Rapidity  with  which  Anemia  is   Produced  in  Purpura 

HEMORRHAGICA  AND   THE   GRADUAL   RECOVERY. 


associated  with  slight  articular  trouble,  arsenic  in  full  doses  should  be  given. 
No  good  is  obtained  from  the  small  doses,  but  the  Fowler's  solution  should  be 
pushed  freely  until  physiological  effects  are  obtained.  In  peliosis  rheumatica 
the  sodium  salicylate  may  be  given,  but  with  discretion.  I  confess  not  to 
have  seen  any  special  control  of  the  hemorrhages  by  this  remedy. 

Aromatic  sulphuric  acid,  ergot,  turpentine,  acetate  of  lead,  or  tannic  and 
gallic  acids,  may  be  given,  and  in  some  instances  they  seem  to  check  the  bleed- 
ing. Oil  of  turpentine  is  perhaps  the  best  remedy,  in  10  or  15  minims  doses 
three  or  four  times  a  day.  Wright,  of  Xetley,  advises  the  use  of  calcium 
chloride  in  20-grain  doses  four  times  a  day  (for  three  or  four  days)  to 
increase  the  coagulability  of  the  blood.  In  bleeding  from  the  mouth,  gums, 
and  nose,  the  inhalation  of  carbon  dioxide,  irrigations  with  2-per-cent  gelatin 
solution,  and  adrenalin  should  be  tried.  The  last  remedy  has  often  acted 
promptly. 


HMMOPHILIA.  J  41 

H-'EMORRHAGIC  DISEASES  OF   THE  NeW-BORN. 

1.  Syphilis  Hsemorrhagica  Neonatorum. — The  child  may  be  born  healthy, 
or  there  may  be  signs  of  hemorrhage  at  birth.  Then  in  a  few  days  there 
are  extensive  cutaneous  extravasations  and  bleeding  from  the  mucous  sur- 
faces and  from  the  navel.  The  child  may  become  deeply  jaundiced.  The 
post  mortem  shows  numerous  extravasations  in  the  internal  organs  and  exten- 
sive syphilitic  changes  in  the  liver  and  other  organs. 

2.  Epidemic  Haemoglobinuria  {WinckeVs  Disease). — Hemoglobinuria  in 
the  new-born,  which  occasionally  occurs  in  epidemic  form  in  lying-in  insti- 
tutions, is  a  very  fatal  affection,  which  sets  in  usually  about  the  fourth  day 
after  birth.  The  child  becomes  jaundiced,  and  there  are  marked  gastro-intes- 
tinal  symptoms,  with  fever,  jaundice,  rapid  respiration,  and  sometimes  cyano- 
sis. The  urine  contains  albumin  and  blood-coloring  matter — methaemoglobin. 
The  disease  has  to  be  distinguished  from  the  simple  icterus  neonatorum,  with 
which  there  may  sometimes  be  blood  or  blood-coloring  matter  in  the  urine. 
The  post  mortem  shows  an  absence  of  any  septic  condition  of  the  umbilical 
vessels,  but  the  spleen  is  swollen,  and  there  are  punctiform  haemorrhages  in 
different  parts.  Some  cases  have  shown  in  a  marked  degree  acute  fatty  degen- 
eration of  the  internal  organs — the  so-called  Buhl's  disease. 

3.  Morbus  Maculosus  Neonatorum. — Apart  from  the  common  visceral 
haemorrhages,  the  result  of  injuries  at  birth,  bleeding  from  one  or  more  of 
the  surfaces  is  a  not  uncommon  event  in  the  new-born,  particularly  in  hos- 
pital practice.  Forty- five  cases  occurred  in  6,700  deliveries  (C.  W.  Townsend). 
The  bleeding  may  be  from  the  navel  alone,  but  more  commonly  it  is  general. 
Of  Townsend's  50  cases,  in  20  the  blood  came  from  the  bowels  (melcena  neo- 
natorum), in  14  from  the  stomach,  in  14  from  the  mouth,  in  13  from  the  nose, 
in  18  from  the  navel,  in  3  from  the  navel  alone.  The  bleeding  begins  within 
the  first  week,  but  in  rare  instances  is  delayed  to  the  second  or  third.  Thirty- 
one  of  the  cases  died  and  19  recovered.  The  disease  is  usually  of  brief  dura- 
tion, death  occurring  in  from  one  to  seven  days.  The  temperature  is  often 
elevated.  The  nature  of  the  disease  is  unknown.  As  a  rule,  nothing  abnor- 
mal is  found  post  mortem.  The  general  and  not  local  nature  of  the  affection, 
its  self-limited  character,  the  presence  of  fever,  and  the  greater  prevalence 
of  the  disease  in  hospitals,  suggest  an  infectious  origin  (Townsend).  The 
bleeding  may  be  associated  with  intense  hsematogenous  jaundice.  Not  every 
case  of  bleeding  from  the  stomach  or  bowels  belongs  in  this  category.  Ulcers 
of  the  oesophagus,  stomach,  and  duodenum  have  been  found  in  the  new-born 
dead  of  melcena  neonatorum.  The  child  may  draw  the  blood  from  the  breast 
and  subsequently  vomit  it.  In  the  treatment  the  external  warmth  must  be 
maintained,  and  in  feeble  infants  the  couveuse  may  be  used.  Camphor  is 
recommended,  ergotin  hypodermically,  and  the  suprarenal  extract. 

V.    HEMOPHILIA. 

Definition. — A  constitutional  fault,  hereditary  or  acquired,  characterized 
by  a  tendency  to  uncontrollable  bleeding,  either  spontaneous  or  from  slight 
wounds,  sometimes  associated  with  a  form  of  arthritis.  The  coagulation  time 
of  the  blood  is  usuall}''  much  retarded. 


748         DISEASES  OF  THE  BLOOD  AND  DUCTLESS  GLANDS. 

The  fact  that  fatal  haemorrhage  might  occur  from  slight^  trifling  wounds 
had  been  known  for  centuries.  Fordyce,  in  1784,  recognized  the  hereditary- 
nature,  and  early  in  the  last  century  described  the  American  bleeder  families. 
Buel,  Otto,  Hay,  Coates,  and  others  in  America  published  similar  reports.  The 
disease  is  considered  at  length  in  the  monographs  of  Legg  and  Grandidier,  and 
recently  by  Stempel. 

Etiology. — In  a  majority  of  cases  the  disposition  is  hereditary.  In  the 
Appleton- Swain  famih^,  of  Reading,  Mass.,  there  have  been  cases  for  nearly 
two  centuries;  and  F.  F.  Brown,  of  that  town,  teUs  me  that  instances  have 
already  occurred  in  the  seventh  generation.  Atavism  through  the  female  alone 
is  almost  the  rule,  and  the  daughters  of  a  bleeder,  though  healthy  and  free 
irom  any  tendency,  are  almost  certain  to  transmit  the  disposition  to  the  male 
offspring.  The  affection  is  much  more  common  in  males  than  in  females — 
11 :1,  Legg;  4 :1,  Stempel.  The  tendency  usually  appears  within  the  first  two 
years  of  life.  It  is  rare  for  manifestations  to  be  delayed  until  the  tenth  or 
twelfth  year.  Families  in  all  conditions  of  life  are  affected.  The  bleeder 
families  are  usually  large.  The  members  are  healthy-looking,  and  have  fine, 
soft  skins.  The  Anglo-German  races  are  chiefly  attacked;  of  209  cases  col- 
lected within  the  ten  years  1890-1900  by  Stempel,  96  were  German,  95  Eng- 
lish or  American,  only  16  French,  Hungarian,  or  Eussian.  Steiner  has  re- 
ported from  my  clinic  instances  occurring  in  a  negro  family. 

Morbid  Anatomy. — No  special  peculiarities  have  been  described.  In  some 
instances  changes  have  been  found  in  the  smaller  vessels ;  but  in  others  careful 
studies  have  been  negative.  An  unusual  thinness  of  the  vessels  has  been  noted. 
Haemorrhages  have  been  found  in  and  about  the  capsules  of  the  joints,  and  in 
a  few  iostances  inflammation  of  the  synovial  surfaces.  The  nature  of  the  dis- 
ease is  imknown.  An  increase  in  the  number  of  the  red  blood-corpuscles — ery- 
throcythsemia — with  a  peculiar  frailty  of  the  blood-vessels,  has  been  supposed. 
A  deficiency  of  the  leucocytes  and  a  diminution  of  the  blood-plates  have  been 
noted,  though  in  a  case  from  my  clinic,  studied  by  Steiner,  these  structures 
were  normal.  Wright  has  found  the  coagulation  time  much  retarded,  as  long 
as  twenty-three  and  forty-five  minutes. 

Symptoms. — Usually  hsemophilia  is  not  noted  in  the  child  until  a  trifling 
cut  is  followed  by  serious  or  uncontrollable  hgemorrhage,  or  spontaneous  bleed- 
ing occurs  and  presents  insuperable  difficulties  in  its  arrest.  The  symptoms 
may  be  grouped  under  three  divisions :  external  bleedings,  spontaneous  and 
traxmiatic;  interstitial  bleedings,  petechige  and  ecch}-moses;  and  the  joint  affec- 
tions. The  external  bleedings  may  be  spontaneous,  but  more  commonly  they 
follow  cuts  and  wounds.  In  334  cases  (Grandidier)  the  chief  bleedings  were 
epistaxis,  169;  from  the  mouth,  43;  stomach,  15;  bowels,  36;  urethra,  16; 
lungs,  17;  and  in  a  few  instances  bleeding  from  the  skin  of  the  head,  the 
tongue,  finger-tips,  tear-papilla,  eyelids,  external  ear,  vulva,  navel,  and 
scrotum. 

Traumatic  bleeding  may  result  from  blows,  cuts,  scratches,  etc.,  and  the 
blood  may  be  diffused  into  the  tissues  or  discharged  externally.  Trivial  opera- 
tions have  proved  fatal,  such  as  the  extraction  of  teeth,  circumcision,  or  vene- 
section. It  is  possible  that  there  may  be  local  defects  which  make  bleeding 
from  certain  parts  of  the  body  more  dangerous.  D.  Hayes  Agnew  mentioned 
to  me  the  case  of  a  bleeder  who  had  alwavs  bled  from  cuts  and  bruises  above 


HEMOPHILIA.  749 

the  neck,  never  from  those  below.  The  bleeding  is  a  capillary  oozing.  It  may 
last  for  hours,  or  even  many  days.  Epistaxis  may  prove  fatal  in  twenty-four 
hours.  In  the  slow  bleeding  from  the  mucous  surfaces  large  blood  tumors  may 
form  and  project  from  the  nose  or  mouth,  forming  remarkable-looking  struc- 
tures, and  showing  that  the  blood  has  the  power  of  coagulation.  The  inter- 
stitial haemorrhages  may  be  spontaneous,  or  may  result  from  injury.  Petechias 
or  large  extravasations — haematomata — may  occur,  particularly  after  blows. 

Joint  Affections. — The  knees  and  elbows  are  chiefly  involved,  but  the  small 
joints  may  be  attacked.  The  onset  is  usually  acute,  with  slight  fever  and 
swelling  and  pain,  and  sometimes  redness.  In  other  instances  there  is  haemor- 
rhagic  effusion  without  fever.  Konig  recognizes  three  stages:  first,  haemar^ 
throsis;  secondly,  an  inflammatory  process,  with  fever  and  spindle-formed 
swelling,  which  is  apt  to  be  mistaken  for  tuberculosis;  and,  lastly,  there  may 
be  extensive  organic  changes,  which  may  even  resemble  those  of  arthritis 
deformans.  There  are  cases  with  spontaneous  haemorrhages  into  muscles  and 
joints  without  (for  years  at  least)  external  bleedings. 

Abdominal  Symptoms. — Intestinal  crises,  similar  to  those  which  occur  in 
purpura,  may  be  present  and  are  of  great  importance,  as  the  diagnosis  of 
appendicitis  may  be  made.     I  have  seen  two  cases. 

Diagnosis. — In  the  diagnosis  of  the  condition  the  family  tendency  is  impor- 
tant. A  single  uncontrollable  haemorrhage  in  child  or  adult  is  not  to  be  ranked 
as  haemophilia;  but  it  is  only  when  a  person  shows  a  marked  tendency  to  mul- 
tiple haemorrhages,  spontaneous  or  traumatic,  which  tendency  is  not  transitory 
but  persists,  and  particularly  if  there  have  been  joint  affections,  that  we  may 
consider  the  condition  haemophilia.  Such  conditions  as  epistaxis,  recurring  for 
years — if  no  other  haemorrhage  occurs — or  recurring  haematuria  from  one  kid- 
ney, which  has  been  spoken  of  as  unilateral  renal  haemophilia,  have  no  associa- 
tion with  the  true  disease.  There  is  a  remarkable  form  of  hereditary  epistaxis 
with  multiple  cutaneous  naevi — telangiectases.  The  bleeding  comes  from  the 
dilated  spider  naevi  in  the  nose,  or  on  the  lips,  tongue,  or  cheeks  (/.  H.  H. 
Bulletin,  IdOl) .  Peliosis  rheumatica  is  an  affection  which  touches  haemophilia 
very  closely,  particularly  in  the  relation  of  the  joint  swellings.  It  may  also 
show  itself  in  several  members  of  a  family.  The  diagnosis  from  the  various 
forms  of  purpura  is  usually  easy. 

Prognosis. — The  patients  rarely  die  in  the  first  bleeding.  The  younger 
the  individual  the  worse  is  the  outlook,  though  children  rarely  die  in  the  first 
year.  Grandidier  states  that  of  152  boy  subjects,  81  died  before  the  termi- 
nation of  the  seventh  year.  The  longer  the  bleeder  survives  the  greater  the 
chance  of  his  outliving  the  tendency;  but  it  may  persist  to  old  age,  as  shown 
in  the  case  of  Oliver  Appleton,  the  first  reported  American  bleeder,  who  died 
at  an  advanced  age  of  haemorrhage  from  a  bed-sore  and  from  the  urethra. 
The  prognosis  is  graver  in  a  boy  than  in  a  girl.  In  the  latter  menstruation 
is  sometimes  early  and  excessive,  but  fortunately,  in  the  female  members  of 
haemophilic  families,  neither  this  function  nor  the  act  of  parturition  brings 
with  it  special  dangers. 

Treatment. — Members  of  a  bleeder's  family,  particularly  the  boys,  should 
be  guarded  from  injury,  and  operations  of  all  sorts  avoided.  The  daughters 
should  not  marry,  as  it  is  through  them  that  the  tendency  ■  is  propagated. 

Wh^n  an  injury  or  wound  has  occurred,  absolute  rest  and  compression 


750         DISEASES  OF  THE  BLOOD  AND  DUCTLESS  GLANDS. 

should  first  be  tried,  and  if  these  fail  the  styptics  may  be  used.  In  epistaxis 
ice,  tannic  and  gallic  acid  may  be  tried  before  resorting  to  plugging.  Internally 
ergot  seems  to  have  done  good  in  several  cases.  Legg  advises  the  perchloride 
of  iron  in  half-drachm  doses  every  two  hours  with  a  purge  or  sulphate  of  soda. 
For  the  epistaxis  the  inhalation  of  carbon  dioxide  through  the  nostrils  is 
recommended  by  A.  E.  Wright.  He  also  advises  a  solution  of  fibrin  ferment 
and  chloride  of  calcium  as  a  st}^tic.  Dried  suprarenal  gland,  1  part  to  10^ 
of  water,  freshly  prepared,  may  be  applied  to  the  part,  or  the  active  principle, 
epinephrin  or  adrenalin,  may  be  tried.  Gelatin  in  5-per-cent  solution  is  warmly 
recommended.  Venesection  has  been  tried  in  several  cases.  Transfusion  has 
been  employed,  but  without  success.  During  convalescence,  iron  and  arsenic 
should  be  freely  used. 

VI.    SCURVY    (Scorbutus). 

Definition. — A  constitutional  disease  characterized  by  great  debility,  with 
angemia,  a  spongy  condition  of  the  gums,  and  a  tendency  to  haemorrhages. 

Etiology. — The  disease  has  been  known  from  the  earliest  times,  and  has 
prevailed  particularly  in  armies  in  the  field  and  among  sailors  on  long  voy- 
ages.    It  has  been  well  called  "  the  calamity  of  sailors." 

From  the  early  part  of  the  last  century,  owing  largely  to  the  efforts  of 
Lind  and  to  a  knowledge  of  the  conditions  upon  which  the  disease  depends,, 
scurvy  has  gradually  disappeared  from  the  naval  service.  In  the  mercantile 
marine,  cases  still  occasionally  occur,  owing  to  the  lack  of  proper  and  suitable 
food. 

In  parts  of  Eussia  scurvy  is  endemic,  at  certain  seasons  reaching  epidemic 
proportions;  and  the  leading  authorities  upon  the  disorder,  now  in  that  coun- 
try, are  almost  unanimous,  according  to  Hoffmann,  in  regarding  it  as  infec- 
tious. 

In  the  United  States  scurvy  has  become  a  very  rare  disease.  To  the  hos- 
pitals in  the  seaport  towns  sailors  are  now  and  then  admitted  with  it.  In. 
large  almshouses  outbreaks  occasionally  occur.  A  very  great  increase  of  for- 
eign population  of  a  low  grade  has  in  certain  districts  made  the  disease  not 
at  all  uncommon.  In  the  mining  districts  of  Pennsylvania  the  Hungarian, 
Bohemian,  and  Italian  settlers  are  not  infrequently  attacked.  McGrew  has 
recently  reported  43  cases  in  Chicago,  limited  entirely  to  Poles.  He  ascer- 
tained that  in  a  large  proportion  of  the  cases  the  diet  was  composed  of  bread 
strong  coffee,  and  meat.  Occasionally  one  meets  with  scurvy  among  quite 
well-to-do  people.  One  of  the  most  characteristic  cases  I  have  ever  seen  was 
in  a  woman  with  chronic  dyspepsia,  who  had  lived  for  many  months  chiefly 
on  tea  and  bread.  Some  years  ago  ■  scurvy  was  not  infrequent  in  the  large 
lumbering  camps  in  the  Ottawa  Valley,  In  Great  Britain  and  Ireland  it  has 
become  very  rare;  only  302  cases  were  admitted  to  the  Seaman's  Hospital  in 
the  twenty-two  years  ending  1896  (Johnson  Smith).  Judging  from  the  Ee- 
port  of  the  American  Pediatric  Society,  we  must  infer  that  infantile  scurvy  is- 
on  the  increase  in  the  United  States. 

The  precise  cause  is  unknown;  there  are  three  theories  of  the  disease: 

(a)  That  it  is  the  result  of  an  absence  of  those  ingredients  in  the  food 
which  are  supplied  by  fresh  vegetables.    What  these  constituents  are  has  not 


SCURVY.  751 

yet  been  definite!}'  determined.  Garrod  holds  that  the  defect  is  the  absence 
of  the  potassic  salts.  Others  believe  that  the  essential  factor  is  the  absence 
of  the  organic  salts  present  in  fruits  and  vegetables.  Ealfe  believed  that  the 
absence  from  the  food  of  the  malates,  citrates,  and  lactates  reduces  the  alka- 
linity of  the  blood;  and  Wright  has  brought  forward  evidence  which  suggests 
that  it  may  be  an  acid  intoxication. 

(&)  That  it  is  due  to  toxic  materials  in  the  foods — some  unknown  organic 
poison  the  product  of  decomposition.  That  it  is  not  due  to  an  absence  of 
fresh  vegetables  or  the  salts  of  fruits  and  vegetables  seems  to  have  been  settled 
by  Nansen  and  his  comrades,  who,  living  for  months  under  the  most  unfavor- 
able hygienic  surroundings,  but  eating  fresh  bear's  meat  and  bear's  blood, 
escaped  scurvy.  Hoist  and  Frolich  in  their  recent  work  oppose  this  toxic  view, 
and  maintain  that  the  disease  is  due  to  the  lack  in  the  food  of  nutrient  con- 
stituents which  so  far  have  not  been  identified. 

(c)  In  opposition  to  these  chemical  views  it  is  urged  that  the  disease 
depends  upon  a  specific  (as  yet  unknown)  micro-organism. 

Other  factors  play  an  important  part  in  the  disease,  particularly  physical 
and  moral  influences — overcrowding,  dwelling  in  cold,  damp  quarters,  and 
prolonged  fatigue  under  depressing  influences,  as  during  the  retreat  of  an 
army.  Among  prisoners,  mental  depression  plays  an  important  role.  It  is 
stated  that  epidemics  of  the  disease  have  broken  out  in  the  French  convict- 
ships  en  route  to  New  Caledonia  even  when  the  diet  was  amply  sufficient. 
Nostalgia  is  sometimes  an  important  element.  It  is  an  interesting  fact 
that  prolonged  starvation  in  itself  does  not  necessarily  cause  scurvy.  Not 
one  of  the  professional  fasters  of  late  years  has  displayed  any  scorbutic  symp- 
tom. The  disease  attacks  all  ages,  but  the  old  are  more  susceptible  to  it. 
Sex  has  no  special  influence,  but  during  the  siege  of  Paris  it  was  noted  that  the 
males  attacked  were  greatly  in  excess  of  the  females. 

Morbid  Anatomy. — The  anatomical  changes  are  marked,  though  by  no 
means  specific,  and  are  chiefly  those  associated  with  haemorrhage.  The  blood 
is  dark  and  fluid.  The  microscopical  alterations  are  those  of  a  severe  ansemia, 
without  leucocytosis.  The  bacteriological  examination  has  not  yielded  any- 
thing very  positive.  Practically  there  are  no  changes  in  the  blood,  either  ana- 
tomical or  chemical,  which  can  be  regarded  as  peculiar  to  the  disease.  The 
skin  shows  the  ecchymoses  evident  during  life.  There  are  haemorrhages  into 
the  muscles,  and  occasionally  about  or  even  into  the  joints.  Haemorrhages 
occur  in  the  internal  organs,  particularly  on  the  serous  membranes  and  in  the 
kidneys  and  bladder.  The  gums  are  swollen  and  sometimes  ulcerated,  so  that 
in  advanced  cases  the  teeth  are  loose  and  have  even  fallen  out.  Ulcers  are 
occasionally  met  with  in  the  ileum  and  colon.  Haemorrhages  into  the  mucous 
membranes  are  extremely  common.  The  spleen  is  enlarged  and  soft.  Paren- 
chymatous changes  are  constant  in  the  liver,  kidneys,  and  heart. 

Symptoms. — The  disease  is  insidious  in  its  onset.  Early  symptoms  are 
loss  in  weight,  progressive  weakness,  and  pallor.  Very  soon  the  gums  are 
noticed  to  be  swollen  and  spongy,  to  bleed  easily,  and  in  extreme  cases  to  pre- 
sent a  fungous  appearance.  These  changes,  regarded  as  characteristic,  are 
sometimes  absent.  The  teeth  may  become  loose  and  even  fall  out.  Actual 
necrosis  of  the  jaw  is  not  common.  The  breath  is  excessively  foul.  The 
tongue  is  swollen,  but  may  be  red  and  not  much  furred.    The  salivary  glands 


752         DISEASES  OF  THE  BLOOD  AND  DUCTLESS  GLANDS. 

are  occasionally  enlarged.  Haemorrhages  beneath  the  mucous  membranes  of 
the  mouth  are  common.  The  skin  becomes  dry  and  rough,  and  ecchymoses 
soon  appear,  first  on  the  legs  and  then  on  the  arms  and  trunk,  and  particularly 
into  and  about  the  hair-follicles.  They  are  petechial,  but  may  become  larger, 
and  when  subcutaneous  may  cause  distinct  swellings.  In  severe  cases,  par- 
ticularly in  the  legs,  there  may  be  effusion  between  the  periosteum  and  the 
bone,  forming  irregular  nodes,  which  may  break  down  and  form  foul-looking 
sores.  The  slightest  bruise  or  injur}^  causes  hgemorrhages  into  the  injured 
part.  (Edema  about  the  ankles  is  common.  The  "  scurvy  sclerosis,"  seen 
oftenest  in  the  legs,  is  a  remarkable  infiltration  of  the  subcutaneous  tissues  and 
muscles,  forming  a  brawny  induration,  the  skin  over  which  may  be  blood- 
stained. Haemorrhages  from  the  mucous  membranes  are  less  constant  symp- 
toms ;  epistaxis_is,  however,  frequent.  Hgemoptysis  and  hsematemesis  are 
uncommon.  Hsematuria  and  bleeding  from  the  bowels  may  be  present  in 
very  severe  cases. 

Palpitation  of  the  heart  and  feebleness  and  irregularity  of  the  impulse 
are  prominent  symptoms.  A  hsemic  murmur  can  usually  be  heard  at  the 
base.  Hsemorrhagic  infarction  of  the  lungs  and  spleen  has  been  described. 
Respiratory  symptoms  are  not  common.  The  appetite  is  impaired,  and  owing 
to  the  soreness  of  the  gums  the  patient  is  unable  to  chew  the  food.  Constipa- 
tion is  more  frequent  than  diarrhoea.  Pain,  tenderness,  or  swelling  in  the 
joints  were  present  in  13  of  McG-rew's  42  cases.  The  urine  is  often  albu- 
minous. The  changes  in  its  composition  are  not  constant ;  the  specific  gravity 
is  high;  the  color  is  deeper.  The  statements  with  reference  to  the  inorganic 
constituents  are  contradictory.  Some  authorities  have  found  the  phosphates 
and  potassium  salts  to  be  deficient :  others  hold  that  they  are  increased. 

There  are  mental  depression,  indifference,  in  some  cases  headache,  and 
in  the  later  stages  delirium.  Cases  of  convulsions,  of  hemiplegia,  and  of 
meningeal  haemorrhage  have  been  described.  Eemarkable  ocular  symptoms  are 
occasionally  met  with,  such  as  night-blindness  or  day-blindness. 

In  advanced  cases  necrosis  of  the  bones  may  occur,  and  in  young  persons 
even  separation  of  the  epiphyses.  There  are  instances  in  which  the  cartilages 
have  separated  from  the  sternum.  The  callus  of  a  recently  repaired  fracture 
has  been  known  to  undergo  destruction.  Fever  is  not  present,  except  in  the 
later  stages,  or  when  secondary  inflammations  in  the  internal  organs  appear. 
The  temperature  may,  indeed,  be  sometimes  below  normal.  Acute  arthritis 
is  an  occasional  complication. 

Diagnosis. — No  difficulty  is  met  in  the  recognition  of  scurv}'"  when  a  num- 
ber of  persons  are  affected  together.  In  isolated  cases,  however,  the  disease 
is  distinguished  with  difficulty  from  certain  forms  of  purpura.  The  associa^ 
tion  with  manifest  insufficiency  in  diet,  and  the  rapid  amelioration  with  suit- 
able food,  are  points  by  which  the  diagnosis  can  be  readily  settled. 

Prognosis. — The  outlook  is  good,  unless  the  disease  is  far  advanced  and  the 
conditions  persist  which  lead  to  its  occurrence.  The  mortalit}^  now  is  rarely 
great.  Death  results  from  gradual  heart-failure,  occasionally  from  sudden 
syncope.  Meningeal  haemorrhage,  extravasation  into  the  serous  cavities,  entero- 
colitis, and  other  intercurrent  affections  may  prove  fatal. 

Prophylaxis. — The  regulations  of  the  Board  of  Trade  require  that  a  suffi- 
cient supply  of  antiscorbutic  articles  of  diet  be  taken  on  each  ship ;  so  that 


SCURVY.  753 

now,  except  as  the  result  of  accident,  the  occurrence  of  scurvy  is  rare  in 
sailors. 

Treatment. — The  juice  of  two  or  three  lemons  daily  and  a  diet  of  plenty 
of  meat  and  fresh  vegetables  suffice  to  cure  all  cases  of  scurvy,  unless  far 
advanced.  When  the  stomach  is  much  disordered,  small  quantities  of  scraped 
meat  and  milk  should  be  given  at  short  intervals,  and  the  lemon-juice  in  grad- 
ually increasing  quantities.  A  bitter  tonic,  or  a  steel  and  bark  mixture,  may 
be  given.  As  the  patient  gains  in  strength,  the  diet  may  be  more  liberal,  and 
he  may  eat  freely  of  potatoes,  cabbage,  water-cresses,  and  lettuce.  The  stoma- 
titis is  the  symptom  which  causes  the  greatest  distress.  The  permanganate 
of  potash  or  dilute  carbolic  acid  forms  the  best  mouth-wash.  Pencilling  the 
swollen  gums  with  a  tolerably  strong  solution  of  nitrate  of  silver  is  very  useful. 
The  solution  is  better  than  the  solid  stick,  as  it  reaches  to  the  crevices  between 
the  granulations.  The  constipation  which  is  so  common  is  best  treated  with 
large  enemata.  For  other  conditions,  such  as  haemorrhages  and  ulcerations, 
suitable  measures  must  be  employed. 

Infantile  Scurvy  {Barlow's  Disease). 

As  in  adults,  scurvy  may  occur  in  children  in  consequence  of  imperfect 
food  supply. 

W.  B.  Cheadle  and  Gee,  in  London,  have  described  in  very  young  children 
a  cachexia  associated  with  haemorrhage.  Cheadle  regarded  the  cases  as  scurvy 
ingrafted  on  a  rickety  stock.  Gee  called  his  cases  periosteal  cachexia.  Cases 
had  previously  been  regarded  as  acute  rickets. 

A  few  years  later  Barlow  made  an  exhaustive  study  of  the  condition  with 
careful  anatomical  observations.  The  affection  is  now  recognized  as  infantile 
scurvy,  and  is  called  Barlow's  disease.  The  American  Paediatric  Society  has 
collected  (1898)  in  the  United  States  379  cases.  Of  these,  the  hygienic  sur- 
roundings were  good  in  303.  A  majority  of  the  patients  were  under  twelve 
months.  The  proprietary  foods,  particularly  malted  milk  and  condensed  milk, 
seem  to  be  the  most  important  factors  in  producing  the  disease.  There  are 
instances  in  which  it  has  developed  in  breast-fed  infants,  and  in  others  fed 
on^  the  carefully  prepared  milk  of  the  Walker-Gordon  laboratories. 

The  following  is  a  general  clinical  summary,  taken  from  Barlow's  de- 
scription : 

"  So  long  as  it  is  left  alone  the  child  is  tolerably  quiet;  the  lower  limbs 
are  kept  drawn  up  and  still ;  but  when  placed  in  its  bath  or  otherwise  moved 
there  is  continuous  crying,  and  it  soon  becomes  clear  that  the  pain  is  con- 
nected with  the  lower  limbs.  At  this  period  the  upper  limbs  may  be  touched 
with  impunity,  but  any  attempt  to  move  the  legs  or  thighs  gives  rise  to 
screams.  Next,  some  obscure  swelling  may  be  detected,  first  on  one  lower 
limb,  then  on  the  other,  though  it  is  not  absolutely  symmetrical.  .  .  .  The 
swelling  is  ill-defined,  but  is  suggestive  of  thickening  round  the  shafts  of  the 
bones,  beginning  above  the  epiphyseal  junctions.  Gradually  the  bulk  of  the 
limbs  affected  becomes  visibly  increased.  .  .  .  The  position  of  the  limbs  be- 
comes somewhat  different  from  what  it  was  at  the  outset.  Instead  of  being 
flexed  they  lie  everted  and  immobile,  in  a  state  of  pseudo-paralysis.  .  .  . 
About  this  time,  if  not  before,  great  weakness  of  the  back  becomes  manifest. 
49 


754         DISEASES  OF  THE  BLOOD  AND  DUCTLESS  GLANDS. 

A  little  swelling  of  one  or  both  scapulas  may  aj^pear,  and  the  upper  limbs 
may  show  changes.  These  are  rarely  so  considerable  as  the  alterations  in 
the  lower  limbs.  There  may  be  swelling  above  the  wrists,  extending  for  a  short 
distance  up  the  forearm,  and  some  swelling  in  the  neighborhood  of  the  epi- 
physes of  the  humerus.  There  is  symmetry  of  lesions,  but  it  is  not  absolute; 
and  the  limb  affection  is  generally  consecutive,  though  the  involvement  of  one 
limb  follows  very  close  upon  another.  The  joints  are  free.  In  severe  cases 
another  symptom  may  now  be  found — ^namely,  crepitus  in  the  regions  adjacent 
to  the  junctions  of  the  shafts  with  the  epiphyses.  The  upper  and  lower  ex- 
tremities of  the  femur,  and  the  upper  extremity  of  the  tibia,  are  the  common 
sites  of  such  fractures;  but  the  upper  end  of  the  humerus  may  also  be  so 
affected.  ...  A  very  startling  appearance  may  be  observed  at  this  period 
in  the  front  of  the  chest.  The  sternum,  with  the  adjacent  costal  cartilages 
and  a  small  portion  of  the  contiguous  ribs,  seems  to  have  sunk  bodily  back, 
en  hloc,  as  though  it  had  been  subjected  to  some  violence  which  had  fractured 
several  ribs  in  the  front  and  driven  them  back.  Occasionally  thickenings  of 
varying  extent  may  be  found  on  the  exterior  of  the  vault  of  the  skull,  or 
even  on  some  of  the  bones  of  the  face.  .  .  .  Here  also  must  be  mentioned  a 
remarkable  eye  phenomenon.  There  develops  a  rather  sudden  proptosis  of  one 
eyeball,  with  puffiness  and  very  slight  staining  of  the  upper  lid.  Within  a 
day  or  two  the  other  eye  presents  similar  appearances,  though  they  may  be  of 
less  severity.  The  ocular  conjunctiva  may  show  a  little  ecchymosis,  or  may 
be  quite  free.  With  respect  to  the  constitutional  symptoms  accompanying  the 
above  series  of  events  the  most  important  feature  is  the  profound  angemia 
which  is  developed.  .  .  .  The  anaemia  is  proportional  to  the  amount  of  limb 
involvement.  As  the  case  proceeds,  there  is  a  certain  earthy-colored  or  sallow 
tint,  which  is  noteworthy  in  severe  cases,  and  when  once  this  is  established 
bruise-like  echymoses  may  appear,  and  more  rarely  small  purpurge.  Emacia- 
tion is  not  a  marked  feature,  but  asthenia  is  extreme  and  suggestive  of  mus- 
cular failure.  The  temperature  is  very  erratic;  it, is  often  raised  for  a  day 
or  two,  when  successive  limbs  are  involved,  especially  during  the  tense  stage, 
but  is  rarely  above  101°  or  103°.  At  other  times  it  may  be  normal  or  sub- 
normal."   If  the  teeth  have  appeared  the  gums  may  be  spongy. 

In  young  children  with  difficulty  in  moving  the  lower  limbs,  or  in  whom 
paralysis  is  suspected,  the  condition  should  always  be  looked  for.  What  is 
known  sometimes  as  Parrot's  disease,  or  syphilitic  pseudo-paralysis,  may  be 
confounded  with  it.  In  it  the  loss  of  motion  is  more  or  less  sudden  in  the 
upper  or  lower  limbs,  or  in  both,  due  to  a  solution  of  continuity  and  separation 
of  the  cartilage  at  the  end  of  the  diaphysis.  There  are  usually  crepitation 
and  much  pain  on  movement. 

The  essential  lesion  is  a  subperiosteal  blood  extravasation,  which  causes  the 
thickening  and  tenderness  in  the  shafts  of  the  bones.  In  some  instances  there 
is  haemorrhage  in  the  intramuscular  tissue. 

The  prophylaxis  is  most  important.  The  various  proprietary  forms  of  con- 
densed milk  and  preserved  foods  for  infants  should  not  be  used.  The  fresh 
cow's  milk  should  be  substituted,  and  a  teaspoonful  of  meat-juice  or  gravy 
may  be  given  with  a  little  mashed  potato.  Orange-juice  or  lemon-juice 
should  be  given  three  or  four  times  a  day.  Eecovery  is  usually  prompt  and 
satisfactory. 


STATUES  LYMPHATICUS.     LYMPHATISM.  755 


VII.     STATUS    LYMPHATICUS.    LYMPHATISM. 

Definition. — A  rare  condition  met  with  chiefly  in  children  and  young  per- 
sons, in  which  the  lymphatic  glands  and  lymph  tissues  throughout  the  body, 
the  spleen,  the  thymus,  and  the  lymphoid  bone-marrow  are  in  a  state  of 
hyperplasia.  These  features  have  been  found  associated  with  rickets  and  with 
hypoplasia  of  the  heart  and  aorta. 

The  special  interest  lies  in  the  fact  that  these  pathological  conditions  have 
been  met  with  frequently  in  cases  of  sudden  death.  Paltauf  and  others  of  the 
Vienna  school,  who  have  written  extensively  on  the  subject,  believe  that  indi- 
viduals with  this  hyperplasia  have  lowered  powers  of  resistance,  and  are  par- 
ticularly liable  to  paralysis  of  the  heart. 

Anatomical  Condition. — (a)  Lymph-glands. — The  pharyngeal,  thoracic, 
and  abdominal  groups  are  most  frequently  affected.  The  cervical,  axillary, 
and  inguinal  are  less  commonly  involved,  but  these  glands  may  show  slight 
enlargement.  The  lymphatic  structures  of  the  alimentary  tract,  the  tissues 
of  the  tonsils,  the  adenoid  structures  in  the  upper  pharynx,  and  the  solitary 
and  agminated  follicles  of  the  small  and  large  intestines  are  usually  much  en- 
larged. The  hyperplasia  of  the  intestinal  lymphatic  structures  may  be  the 
most  remarkable,  the  individual  glands  standing  out  like  peas. 

(&)  Spleen. — Enlargement  of  this  organ  is  usually  moderate  in  degree. 
The  Malpighian  bodies  may  show  very  prominently,  and  when  ansemic  may 
look  like  large  tubercles.     The  organ  is  usually  soft  and  hyperffimic. 

(c)  The  THYMUS  is  enlarged,  and  may  measure  as  much  as  10  cm.  in 
length.  It  looks  swollen  and  soft,  and  on  section  may  exude  a  milky  white 
fluid. 

(d)  The  BONE-MAKROW  has  been  found  in  a  state  of  hyperplasia,  and  the 
yellow  marrow  of  the  long  bones  in  young  adults,  and  even  in  persons  between 
the  ages  of  twenty  and  thirty,  has  been  found  replaced  by  red  marrow.  Among 
other  associated  conditions  of  this  constitutio  lympliatica,  as  it  has  been  called, 
are  hypoplasia  of  the  heart  and  aorta  and  enlargement  of  the  thyroid  gland. 
In  a  large  number  of  the  cases  in  children  rickets  is  coincident. 

Diagnosis. — The  diagnosis  of  the  lymphatic  constitution  is  not  always  easy. 
Enlargement  of  the  superficial  glands,  with  hypertrophy  of  the  tonsils,  signs 
of  slight  swelling  of  the  thyroid,  dulness  over  the  sternum,  with  signs  of 
enlargement  of  the  mesenteric  glands,  are  among  the  most  important  fea- 
tures. Signs  of  hypoplasia  of  the  vascular  system  are  still  more  uncertain, 
though  Quincke  believes  that  in  such  instances  the  left  ventricle  is  dilated  and 
the  peripheral  arteries  may  be  much  smaller  than  normal.  The  subjects  have 
usually  a  pale  and  pasty  complexion,  and  are  fat  and  flabby. 

Sudden  Death  in  the  Status  Lymphaticus. — What  has  directed  the  atten- 
tion of  writers  more  particularly  to  this  condition  is  the  frequency  with  which 
it  has  been  found  in  cases  of  unexpected  death  from  very  trifling  and  inade- 
quate causes,  as  in  the  case  of  a  death  immediately  after  the  preventive  inocu- 
lation with  the  antitoxin  of  diphtheria,  and  during  anathesia  in  young  chil- 
dren for  trifling  operations,  as  for  adenoids  or  circumcision,  etc.  Hinkel, 
Blake,  and  others  have  studied  this  question  with  great  care.  Ether  and 
chloroform  seem  equally  dangerous  in  these  cases.     Cases  of  sudden  death  of 


756  DISEASES  OF   THE  BLOOD  AND  DUCTLESS   GLANDS. 

persons  in  the  water,  who  have  fallen  in  and,  though  immediately  recovered, 
were  dead,  or  who  have  died  suddenly  while  bathing,  are  referred  by  Paltauf 
to  this  condition.  And,  lastly,  there  is  a  large  group  of  cases  of  sudden  death 
in  children  without  recognizable  cause,  in  whom  post  mortem  the  thymus  has 
been  found  enlarged — the  so-called  "Thymus  Tod''  (see  under  Thymus 
Gland).  It  has  also  been  suggested  that  certain  of  the  sudden  deaths  during 
convalescence  from  the  infectious  fevers  are  to  be  referred  to  this  status  lym- 
phaticus.  Escherich  thinks  that  certain  measures  usually  harmless,  such  as 
hydrotherapy,  may  have  an  untoward  effect  in  children  in  this  condition  of 
lymphatism,  and  adds  that  tetany  and  lar3Tigismus  may  be  associated  with  it. 
Two  explanations  are  offered  of  the  sudden  death :  First,  that  it  is  due  to 
mechanical  pressure  of  the  enlarged  thjanus  on  the  trachea.  In  only  one  of 
Blumer's  nine  cases  was  there  evidence  of  this.  Secondl}^,  that  it  is  caused 
by  a  toxaemia,  an  overproduction  of  the  internal  secretion  of  the  thymus. 
Blumer  has  extended  this  view,  and  suggests  that  it  is  a  lymphotoxaemia. 

VIII.     DISEASES    OF    THE    SUPRARENAL    BODIES. 

1.  Addison's  Disease. 

Definition. — A  constitutional  affection  characterized  by  asthenia,  muscular 
and  vascular,  irritability  of  the  stomach,  and  pigmentation  of  the  skin,  symp- 
toms due,  in  all  probability,  to  loss  of  the  internal  secretion  of  the  adrenal 
glands.     Tuberculosis  of  the  adrenals  is  the  common  anatomical  change. 

The  recognition  of  the  disease  is  due  to  Addison,  of  Guy's  Hospital,  whose 
monograph  on  The  Constitutional  and  Local  Effects  of  Disease  of  the  Supra- 
renal Capsules  was  published  in  1855. 

Etiology. — Males  are  more  frequently  attacked  than  females.  In  Green- 
how's  analysis  of  183  cases  119  were  males  and  64  females.  A  majority  of 
the  cases  occur  between  the  twentieth  and  the  fortieth  year.  A  congenital 
case  has  been  described  in  which  the  skin  had  a  yellow-gray  tint.  The  child 
lived  for  eight  weeks,  and  post  mortem  the  adrenals  were  found  to  be  large 
and  cystic.  Injury  such  as  a  blow  upon  the  abdomen  or  back,  and  caries  of  the 
spine,  have  in  many  cases  preceded  the  attack.  The  disease  is  rare  in  America; 
only  17  cases  came  under  my  observation. 

Morbid  Anatomy  and  Pathology. — There  is  rarely  emaciation  or  angemia. 
Eolleston  thus  summarizes  the  condition  of  the  suprarenal  bodies  in  Addison's 
disease : 

"  1.  The  fibro-caseous  lesion  due  to  tuberculosis — far  the  commonest  con- 
dition found.  2.  Simple  atrophy.  3.  Chronic  interstitial  inflammation  lead- 
ing to  atrophy.  4.  Malignant  disease  invading  the  capsules,  including  Addi- 
son's case  of  malignant  nodule  compressing  the  suprarenal  vein.  5.  Blood 
extravasated  into  the  suprarenal  bodies.  6.  No  lesion  of  the  suprarenal  bodies 
themselves,  but  pressure  or  inflammation  involving  the  semilunar  ganglia. 

"  The  first  is  the  only  common  cause  of  Addison's  disease.  The  others, 
with  the  exception  of  simple  atrophy,  may  be  considered  as  very  rare." 

The  nerve-cells  of  the  semilunar  ganglia  have  been  found  degenerated  and 
deeply  pigmented,  and  the  nerves  sclerotic.  The  ganglia  are  not  uncommonly 
entangled  in  the  cicatricial  tissue  about  the  adrenals.  The  spleen  has  occa- 
sionally been  found  enlarged ;  a  persistent  enlarged  thymus  has  been  found. 


DISEASES  OF  THE  SUPRARENAL  BODIES.  757 

The  two  chief  theories  which  have  heen  advanced  to  explain  the  disease  are : 
(a)  That  it  depended  upon  the  loss  of  function  of  the  adrenals.  This  was  the 
view  of  Addison.  The  balance  of  experimental  evidence  is  in  favor  of  the  view 
that  the  adrenals  are  functional  glands,  which  furnish  an  internal  secretion 
essential  to  the  normal  metabolism,  Schafer  and  Oliver  have  shown  that  the 
human  adrenals  contain  a  very  powerful  extract,  which  is  not  to  be  obtained 
in  eases  of  Addison's  disease;  they  have  also  studied  the  toxic  effects  on  ani- 
mals of  the  extracts  of  the  glands.  In  the  cases  in  which  the  adrenals  have 
been  found  involved  without  the  symptoms  of  Addison's  disease,  accessory 
glands  may  have  been  present ;  while  in  the  rare  cases  in  which  the  symptoms 
of  the  disease  have  been  present  with  healthy  adrenals  the  semilunar  ganglia 
and  adjacent  tissues  have  been  involved  in  dense  adhesions,  which  may  have 
interfered  readily  with  the  vessels  or  lymphatics  of  the  glands.  On  this  view 
Addison's  disease  is  due  to  an  inadequate  supply  of  the  adrenal  secretion,  just 
as  myxoedema  is  caused  by  loss  of  function  of  the  thyroid  gland.  "  Whether 
the  deficiency  in  this  internal  secretion  leads  to  a  toxic  condition  of  the  blood 
or  to  a  general  atony  and  apathy  is  a  question  which  must  remain  open  "  (Eol- 
leston).  (&)  That  it  is  an  affection  of  the  abdominal  sympathetic  system, 
induced  most  commonly  by  disease  of  the  adrenals,  but  also  by  other  chronic 
disorders  which  involve  the  solar  plexus  and  its  ganglia.  According  to  this 
view,  it  is  an  affection  of  the  nervous  system,  and  the  pigmentation  has  its 
origin  in  changes  induced  through  the  trophic  nerves.  The  pronounced  debil- 
ity is  the  outcome  of  disturbed  tissue  metabolism,  and  the  circulatory,  respira- 
tory, and  digestive  symptoms  are  due  to  implication  of  the  pneumogastric 
nerves.  The  changes  found  in  the  abdominal  sympathetic  are  held  to  support 
this  view,  and  its  advocates  urge  the  occurrence  of  pigmentation  of  the  skin 
in  tuberculosis  of  the  peritonasum,  cancer  of  the  pancreas,  or  aneurism  of  the 
abdominal  aorta.  Bramwell  thinks  that  the  symptoms  may  be  in  part  due  to 
irritation  of  the  sympathetic  and  in  part  to  adrenal  inadequacy. 

Symptoms. — In  the  words  of  Addison,  the  characteristic  symptoms  are 
"  anaemia,  general  languor  or  debility,  remarkable  feebleness  of  the  heart's 
action,  irritability  of  the  stomach,  and  a  peculiar  change  of  color  in  the 
skin," 

The  onset  is,  as  a  rule,  insidious.  The  feelings  of  weakness,  as  a  rule, 
precede  the  pigmentation.  In  other  instances  the  gastro-intestinal  symptoms, 
the  weakness,  and  the  pigmentation  come  on  together.  There  are  a  few  cases 
in  the  literature  in  which  the  whole  process  has  been  acute,  following  a  shock 
or  some  special  depression.    There  are  three  important  symptoms : 

(1)  PiGMENTATioisr  OF  THE  Skin. — TMs,  as  a  rule,  first  attracts  the  atten- 
tion of  the  patient's  friends.  The  grade  of  coloration  ranges  from  a  light 
yellow  to  a  deep  brown,  or  even  black.  In  typical  cases  it  is  diffuse,  but  always 
deeper  on  the  exposed  parts  and  in  the  regions  where  the  normal  pigmentation 
is  more  intense,  as  the  areolae  of  the  nipples  and  about  the  genitals ;  also  wher- 
ever the  skin  is  compressed  or  irritated,  as  by  the  waistband.  At  first  it  may 
be  confined  to  the  face  and  hands.  Occasionally  it  is  absent.  Patches  show- 
ing atrophy  of  pigment,  leucoderma,  may  occur.  The  pigmentation  is  found 
on  the  mucous  membranes  of  the  mouth,  conjunctivae,  and  vagina.  Pig- 
mentation of  the  mucous  membrane  is  not  distinctive.  It  has  been  found 
in  chronic  stomach  troubles,  etc.  (Fr.  Schultze),  and  is  common  in  the  negro. 


758         DISEASES  OF  THE  BLOOD  AND  DUCTLESS  GLANDS. 

A  patchy  pigmentation  of  the  serous  membranes  has  often  been  found.  Over 
the  diffusely  pigmented  skin  there  may  be  little  mole-like  spots  of  deeper  pig- 
mentation, and  upon  the  trunk,  particularly  on  the  lower  abdomen,  they  may 
be  "  ribbed  "  like  the  sand  on  the  seashore. 

(2)  Gasteo-intestinal  Symptoms. — The  disease  may  set  in  with  attacks 
of  nausea  and  vomiting,  spontaneous  in  character.  Toward  the  close  there 
may  be  pain  with  retraction  of  the  abdomen,  and  even  features  suggestive  of 
peritonitis  (Ebstein).  A  marked  anorexia  may  be  present.  The  gastric  symp- 
toms are  variable  throughout  the  course ;  occasionally  they  are  absent.  Attacks 
of  diarrhoea  are  frequent  and  come  on  without  obvious  cause. 

(3)  Asthenia,  the  most  characteristic  feature  of  the  disease,  may  be 
manifested  early  as  a  feeling  of  inability  to  carry  on  the  ordinary  occupation, 
or  the  patient  may  complain  constantly  of  feeling  tired.  The  weakness  is 
specially  marked  in  the  muscular  and  cardio-vascular  systems.  There  may  be 
an  extreme  degree  of  muscular  prostration  in  an  individual  apparently  well 
nourished,  whose  muscles  feel  firm  and  hard.  The  cardio-vascular  asthenia 
is  manifest  in  a  feeble,  irregular  action  of  the  heart,  which  may  come  on  in 
paroxysms,  in  attacks  of  vertigo,  or  of  syncope,  in  one  of  which  the  disease 
may  prove  fatal.  The  blood-pressure  is  low,  falling  to  70  or  80  mm.  of  Hg. 
Headache  is  a  frequent  symptom ;  convulsions  occasionally  occur.  Pain  in  the 
back  may  be  an  early  and  important  symptom. 

Anaemia,  a  symptom  specially  referred  to  by  Addison,  is  not  common.  In 
a  majority  of  the  patients  the  blood-count  is  normal.  McMunn  has  described 
an  increase  in  the  urinary  pigments,  and  a  pigment  has  been  isolated  of  very 
much  the  same  character  as  the  melanin  of  the  skin. 

The  mode  of  termination  is  either  by  syncope,  which  may  occur  even  early 
in  the  disease,  by  gradual  progressive  asthenia,  or  by  the  development  of  tuber- 
culous lesions.  In  two  cases  I  have  known  a  noisy  delirium  with  urgent 
dyspnoea  to  precede  the  fatal  event. 

Diagnosis. — Pigmentation  of  the  skin  is  not  confined  to  Addison's  disease. 
The  following  are  the  conditions  which  may  give  rise  to  an  increase  in  the 
pigment : 

(1)  Abdominal  growths — tubercle,  cancer,  or  lymphoma.  In  tuberculosis 
of  the  peritonseum  pigmentation  is  not  uncommon.'^ 

(3)  Pregnancy,  in  which  the  discoloration  is  usually  limited  to  the  face, 
the  so-called  masque  des  femmes  enceintes.  Uterine  disease  is  a  common  cause 
of  a  patchy  melasma.  v 

(3)  Hcemocliromatosis,  associated  with  hypertrophic  cirrhosis,  pigmenta- 
tion of  the  skin,  and  diabetes.  More  commonly  in  overworked  persons  of  con- 
stipated habit  and  with  sluggish  livers  there  is  a  patchy  staining  about  the 
face  and  forehead.  ^ 

(4)  The  vagabond's  discoloration,  caused  by  the  irritation  of  lice  and 
dirt,  which  may  reach  a  very  high  grade,  and  has  sometimes  been  mistaken 
for  Addison's  disease.  y 

(5)  In  rare  instances  there  is  deep  discoloration  of  the  skin  in  melanotic 
cancer,  so  deep  and  general  that  it  has  been  confounded  with  melasma  supra- 
renale. J 

(6)  In  certain  cases  of  exophthalmic  goitre  abnormal  pigmentation  occurs, 
as  noted  by  Drummond  and  others. 


DISEASES  OF  THE  SUPRARENAL  BODIES.  759 

(7)  In  a  few  rare  instances  the  pigmentation  in  scleroderma  may  be 
general  and  deep, 

(8)  In  the  face  there  may  be  an  extraordinary  degree  of  pigmentation  due 
to  innumerable  small  black  comedones.  If  not  seen  in  a  very  good  light, 
the  face  may  suggest  argyria.  Pigmentation  of  an  advanced  grade  may  occur 
in  chronic  ulcer  of  the  stomach  and  in  dilatation  of  the  organ. 

(9)  Argyria  could  scarcely  be  mistaken,  and  yet  I  was  consulted  in  a  case 
in  which  the  diagnosis  of  Addison's  disease  had  been  made  by  several  good 
observers. 

(10)  Arsenic  when  taken  for  many  months  may  cause  a  most  intense  pig- 
mentation of  the  skin. 

(11)  With  arterio-sclerosis  and  chronic  heart-disease  there  may  be  marked 
melanoderma. 

(12)  In  pernicious  angemia  the  pigmentation  may  be  extreme,  most  com- 
monly due  to  the  prolonged  administration  of  arsenic. 

(13)  There  is  a  form  of  deep  pigmentation,  usually  in  women,  which  per- 
sists for  years  without  change  and  without  any  special  impairment  of  health. 
I  have  met  with  two  cases;  in  one  the  pigmentation  was  a  little  more  leaden 
than  is  usual  in  Addison's  disease;  in  both  the  condition  had  lasted  some 
years. 

In  any  case  of  unusual  pigmentation  these  various  conditions  must  be 
sought  for;  the  diagnosis  of  Addison's  disease  is  scarcely  justifiable  without 
the  asthenia.  In  many  instances  it  is  difficult  early  in  the  disease  to  arrive 
at  a  definite  conclusion.  The  occurrence  of  fainting  fits,  of  nausea,  and  gas- 
tric irritability  are  important  indications.  As  the  lesion  of  the  capsules  is 
almost  always  tuberculous,  in  doubtful  cases  the  tuberculin  test  may  be  used. 
In  two  of  my  cases,  robust,  healthy  men  with  pigmentation  and  gastric  symp- 
toms, the  reaction  was  obtained. 

Prognosis. — The  disease  is  usually  fatal.  The  cases  in  which  the  bronzing 
is  slight  or  does  not  occur  run  a  more  rapid  course.  There  are  occasionally 
acute  cases  which,  with  great  weakness,  vomiting,  and  diarrhcea,  prove  fatal 
in  a  few  weeks.  In  a  few  cases  the  disease  is  much  prolonged,  even  to  six  or 
ten  years.  In  rare  instances  recovery  has  taken  place,  and  periods  of  improve- 
ment, lasting  many  months,  may  occur. 

Treatment. — When  there  is  profound  asthenia  the  patient  should  be  con- 
fined to  bed,  as  fatal  syncope  may  at  any  time  occur.  In  three  of  my  cases 
death  was  sudden.  Arsenic  and  strychnia  are  useful  tonics.  For  the  diar- 
rhoea large  doses  of  bismuth  should  be  given ;  for  the  irritability  of  the  stom- 
ach, creasote,  hydrocyanic  acid,  ice,  and  champagne.  The  diet  should  be 
light  and  nutritious.    Many  patients  thrive  best  oh  a  strict  milk  diet. 

Treatment  hy  Suprarenal  Extract. — E.  W.  Adams  has  analyzed  97  cases. 
In  7  the  condition  grew  worse,  in  3  cases  of  transplantation  death  was  attrib- 
uted to  the  treatment.  In  43  there  was  no  effect  noticed.  In  31  there  was 
temporary  improvement;  in  16  the  relief  seemed  permanent.  In  two  of  our 
cases  there  was  marked  improvement;  in  one  all  the  severe  symptoms  disap- 
peared, and  the  patient  died  of  an  acute  infection,  which  apparently  had  noth- 
ing to  do  with  the  disease.  The  adrenals  were  found  sclerotic.  The  gland 
may  be  given  raw  or  partially  cooked  or  in  a  glycerin  extract.  Tabloids  of  the 
dried  extract  are  given,  one  grain  of  which  corresponds  to  fifteen  of  the  gland. 


760         DISEASES  OF  THE  BLOOD  AND  DUCTLESS  GLANDS. 

Three  of  the  tabloids  may  be  given  daily.     Operation  has  been  suggested,  but 
has  not  been  carried  out  on  any  undoubted  case. 

2.  Other  Diseases  of  the  Suprarenal  Capsules. 

Adrenalitis,  Acute  Hcemorrhagic. — The  lesion  resembles  that  of  acute  pan- 
creatitis, hfemorrhage  and  necrosis  in  varying  proportions.  The  clinical  picture 
is  very  complex.  The  onset  is  sudden  with  pain  and  vomiting,  profound 
prostration  and  death  in  a  few  days.  In  other  cases  convulsions  occur,  or 
there  may  be  a  profound  myasthenia,  acute  or  subacute.  Sudden  death  has 
occurred.  In  children  the  disease  may  be  associated  with  purpura,  cutaneous 
and  visceral.  The  symptoms  are  believed  to  be  due  to  acute  or  subacute 
adrenal  insufficiency.  The  diagnosis  is  not  often  made  during  life.  The 
white  line,  the  anaemic  vascular  skin  reflex,  described  by  Sergent  as  of  diag- 
nostic value,  is  too  common  to  be  of  much  import. 

Hypertrophy. — In  chronic  nephritis  and  arterio-sclerosis  adenoma  or  dif- 
fuse hyperplasia  of  the  glands  has  been  found,  which  some  have  attributed  to 
hyperadrenalism — an  overactivity  of  the  antitoxic  and  angiotonic  functions 
of  the  gland.  In  children  tumor  or  hypertrophy  has  been  found  associated 
with  remarkable  precocity  and  development  of  the  sexual  organs. 

Tumors. — Primary  growths  are  rare,  secondary  are  not  uncommon.  The 
former  are  usually  mistaken  for  kidney  tumors.  There  is  a  special  type  of 
malignant  growth  in  children  characterized  by  rapid  growth,  diffuse  infiltra- 
tion of  the  liver,  and  great  distention  of  the  abdomen  without  ascites  or  jaun- 
dice (Pepper  tertius)  ;  and  Eobert  Hutchison  has  described  a  remarkable 
syndrome  in  children  of  adrenal  tumor,  exophthalmos  and  cranial  tumors. 

IX.     DISEASES    OF   THE    SPLEEN. 

The  acute  swelling  in  fever,  and  the  chronic  enlargement  of  the  organ  in 
paludism,  leuksemia,  cirrhosis  of  the  liver,  and  heart-disease  have  been  fully 
described,  but  there  remain  several  conditions  to  which  brief  reference  may 
be  made. 

1.  Movable  Spleen. 

Movable  or  wandering  spleen  is  seen  most  frequently  in  women  the  sub- 
jects of  enter optosis.  It  may  be  present  without  signs  of  displacement  of 
other  organs.  It  may  be  found  accidentally  in  individuals  who  present  no 
symptoms  whatever.  In  other  cases  there  are  dragging,  uneasy  feelings  in  the 
back  and  side.  All  grades  are  met  with,  from  a  spleen  that  can  be  felt  com- 
pletely below  the  margin  of  the  ribs  to  a  condition  in  which  the  tumor-mass 
impinges  upon  the  pelvis;  indeed,  the  organ  has  been  found  in  an  inguinal 
hernia !  In  the  large  majority  of  all  cases  the  spleen  is  enlarged.  Sometimes 
it  appears  that  the  enlargement  has  caused  relaxation  of  the  ligaments;  in 
other  instances  the  relaxation  seems  congenital,  as  movable  spleens  have  been 
found  in  different  members  of  the  same  family.  Possibly  traumatism  may 
account  for  some  of  the  cases.  Apart  from  the  dragging,  uneasy  sensations 
and  the  worry  in  nervous  patients,  wandering  spleen  causes  very  few  serious 
symptoms.  Torsion  of  the  pedicle  may  produce  a  very  alarming  and  serious 
condition,  leading  to  great  swelling  of  the  organ,  high  fever,  or  even  to 


DISEASES  OF  THE  SPLEEN.  761 

necrosis.  A  young  woman  was  admitted  to  my  colleague  Kelly's  ward  with 
a  tumor  supposed  to  be  ovarian,  but  which  proved  to  be  a  wandering,  moder- 
ately enlarged  spleen.  She  was  transferred  to  the  medical  ward,  where  she 
had  suddenly  very  great  pain  in  the  abdomen,  a  large  swelling  in  the  left  flank, 
and  much  tenderness.  Halsted  operated  and  found  an  enormously  enlarged 
spleen  in  a  condition  of  necrosis,  adherent  to  the  adjacent  parts  and  to  the 
abdominal  wall.  He  laid  it  open  freely,  and  large  necrotic  masses  of  spleen 
tissue  discharged  for  some  time.     She  made  a  good  recovery. 

The  diagnosis  of  a  wandering  spleen  is  usually  easy  unless  the  organ  be- 
comes fixed  and  is  deformed  by  adhesions  and  perisplenitis.  The  shape  of  the 
organ  and  the  sharp  margin  with  the  notches  are  the  points  to  be  specially 
noted. 

The  treatment  of  the  condition  is  important.  Occasionally  the  organ  may 
be  kept  in  position  by  a  properly  adapted  belt  and  a  pad  under  the  left  costal 
margin.  Eemoval  of  the  displaced  organ  has  been  advised  and  carried  out  in 
many  cases,  and  nowadays  it  is  not  a  very  serious  operation.  It  is,  however, 
as  a  rule  unnecessary.  In  2  cases  of  enlarged  spleen  under  my  care,  with  great 
mobility,  causing  much  discomfort  and  uneasiness,  Halsted  completely  relieved 
the  condition  by  replacing  the  spleen,  packing  it  in  position  with  gauze,  and 
allowing  firm  adhesions  to  take  place.  Both  these  patients  were  seen  more 
than  eighteen  months  after  the  operation  and  the  organ  had  remained  in 
position. 

2.   EUPTURE   OF   THE    SpLEEN". 

This  is  of  interest  in  connection  with  the  spontaneous  rupture  in  cases  of 
acute  enlargement  during  typhoid  fever  or  malaria,  which  is  very  rare.  Eup- 
ture  of  a  malarial  spleen  may  follow  a  blow,  or  a  fall,  or  an  exploratory  punc- 
ture. In  India  and  in  Mauritius  rupture  of  the  spleen  is  stated  to  be  very 
common.  Fatal  haemorrhage  may  follow  puncture  of  a  swollen  spleen  with  a 
hypodermic  needle.  Occasionally  the  rupture  results  from  the  breaking  of  an 
infarct  or  of  an  abscess.  The  symptoms  are  those  of  haemorrhage  into  the 
peritonasum,  and  the  condition  demands  immediate  laparotomy. 

3.  Infaect  and  Abscess  of  the  Spleen. 

Emboli  in  the  splenic  arteries  causing  infarcts  may  be  either  infective  or 
simple.  They  are  seen  most  frequently  in  ulcerative  endocarditis  and  in  septic 
conditions.  Infarcts  may  also  follow  the  formation  of  thrombi  in  the  branches 
of  the  splenic  artery  in  cases  of  fever.  They  are  not  very  infrequent  in 
typhoid.  In  a  few  instances  the  infarcts  have  followed  thrombosis  in  the 
splenic  veins.  They  are  chiefly  of  pathological  interest.  The  infarct  of  the 
spleen  may  be  suspected  in  cases  of  septicasmia  or  pyemia  when  there  is  pain 
in  the  splenic  region,  tenderness  on  pressure,  and  slight  swelling  of  the  organ ; 
on  several  occasions  I  have  heard  a  well-marked  peritoneal  friction  rub.  Occa- 
sionally in  the  infective  infarcts  large  abscesses  are  formed,  and  in  rare 
instances  the  whole  organ  may  be  converted  into  a  sac  of  pus. 

Tumors  of  the  spleen^  hydatid  and  other  cysts  of  the  organ,  and  gummata 
are  rare  conditions  of  anatomical  interest.  In  Hodgkin's  disease  the  organ 
may  be  enlarged  and  smooth,  or  irregular  from  the  presence  of  nodular  tumors. 
50 


762  DISEASES  OF  THE  BLOOD  AND  DUCTLESS  GLANDS. 


4.  Splenomegaly,  Splenic  Anemia,  Banti's  Disease, 

Angemia  may  be  associated  with  many  conditions  in  which  the  spleen  is 
enlarged — in  leukaemia,  in  pernicious  anaemia,  in  Hodgkiij!s_  disea^,  in  cir- 
rhosis of  the  liver,  particularly  of  the  hypertrophic  type,  and  in  the  syjhilitic 
^orm,  and  in  chronic  malaria.  But  apart  from  all  these,  and  apart  from  the 
forms  of  tropical  splenomegaly  already  considered,  are  the  conditions  which 
have  been  grouped  under  the  names  primitive  splenomegaly,  splenic  angemia, 
and  Banti's  disease.  Though  the  clinical  picture  may  be  very  similar,  it  seems 
impossible  to  classify  them  all  as  one  disease.  The  following  groups  of  cases 
may  be  described: 

1.  Banti's  disease,  with  its  three  stages:  (a)  simple  splenomegaly,  which_ 
may  persist  for  years,  without  anaemia  or  with  perhaps  only  a  low  color  index; 
(&)  severe  anemia  of  a  secondary  type  with  pigmentation  of  the  skin  and  a_ 
marked  tendency  to  hasmatemesis ;  (c)  finally  jaundice  supervenes  and  ascites. 
The  chronicity,  the  great  enlargement  of  the  spleen,  and  the  secondary  anaemia 
are  the  most  striking  features.  In  most  cases  a  chronic  hyperplasia  of  the 
organ  has  been  found;  in  a  few  an  extraordinary  endothelial  hyperplasia, 
which  Gaucher  described  as  a  chronic  endothelioma.  In  a  small  number  of 
cases.  Dock,  Deve,  and  others  have  reported  a  remarkable  sclerosis  of  the  por- 
tal vessels,  with  thromboses  and  obliteration;  but  whether  this  is  primary  or 
secondary  has  not  yet  been  determined.  The  cause  of  the  disease  is  unknown. 
It  may  be  a  chronic  infective  process,  the  chief  seat  of  which  is  in  the  spleen, 
where  the  poisons  cause  the  endothelial  proliferation.  That  the  spleen  itself 
is  at  fault  appears  probable  from  the  prompt  relief  which  follows  removal  of 
the  organ.  In  three  of  five  cases  which  I  have  seen,  permanent  recovery  has 
followed  splenectomy. 

2.  There  are  two  family  forms  of  splenomegaly;  in  one  the  children 
attacked  present  marked  constitutional  disturbances — dwarfing  of  stature, 
clubbing  of  the  fingers,  infantilism,  pigmentation  of  the  skin,  and  sometimes 
enlargement  of  the  liver.  This  is  the  variety  described  by  Collier,  Bovaid, 
Brill,  and  Frederick  Taylor.  In  the  other,  the  Minkowski  type,  the  spleno- 
megaly is  associated  with  a  congenital  jaundice,  but  the  health  of  the  patient 
is  not  disturbed.  Though  jaundice  is  present,  there  is  no  bile  coloring  matter 
in  the  urine — an  acholuric  icterus. 

In  Banti's  disease  removal  of  the  spleen  offers  the  best  chance  of  perma- 
nent relief.  Armstrong's  recent  statistics  give  72  per  cent  of  recoveries. 
Arsenic  and  the  X-rays  appear  to  have  very  little  influence. 

5.  Splenomegalic  Polycythemia  with  Cyanosis   (Vaquez's  Disease). 

A  condition  in  which  with  an  enlarged  spleen  and  cyanosis  there  is  an 
extraordinary  increase  of  the  red  blood-corpuscles,  up  to  9-13  millions  per 
c.mm.  Headache,  giddiness,  and  constipation  are  the  common  symptoms.  The 
patients  may  present  a  curious  brick-red  color,  or  when  it  is  cold  an  extreme 
degree  of  cyanosis.  It  is  a  chronic  affection,  lasting  many  years.  In  the 
few  post-mortems  which  have  been  performed  the  bone-marrow  has  been  found 
in  a  state  of  extreme  hyperplasia,  and  it  has  been  suggested  that  the  disease 
is  the  red-blood  counterpart  of  leuksemia — an  erythrocythsemia  or  erythraemia. 


DISEASES  OF   THE  THYROID  GLAND.  763 

In  the  Quarterly  Journal  of  Medicine,  October,  1908,  and  January,  1909, 
Dr.  Parkes  Weber  gives  a  full  critical  digest  of  the  subject,  which  is  one 
of  great  clinical  and  pathological  interest.  Polyglobulism  without  splenic 
enlargement  occurs  in  many  other  conditions,  particularly  in  congenital  heart- 
disease  and  after  residence  at  high  altitudes.  With  primary  tuberculosis  of 
the  spleen  there  has  also  been  associated  polyglobulism  and  cyanosis.-  But 
apart  from  all  these  conditions  there  is  probably  a  well-defined  disease  of 
unknown  etiology  with  the  above-mentioned  characters. 

X.    DISEASES    OF    THE    THYROID    GLAND. 

1.  Congestion. 

At  puberty,  in  girls,  often  at  the  onset  of  menstruation,  the  gland  enlarges ; 
in  certain  women  the  neck  becomes  fuller  at  each  menstruation,  and  it  was 
an  old  idea  that  the  gland  enlarged  at  or  after  defloration.  The  slight  enlarge- 
ment at  puberty  may  persist  for  months  and  cause  uneasiness,  but  as  a  rule 
it  disappears  completely.  I  do  not  remember  a  single  instance  in  which  the 
goitre  has  remained,  though  of  course  such  a  possibility  has  to  be  considered. 
From  mechanical  causes,  as  tight  collars,  repeated  crying,  or  prolonged  use  of 
the  voice,  the  gland  may  swell  for  a  short  time. 

• 

2.  Acute  Thyeoiditis. 

Earely  primary,  it  is  almost  always  a  complication  of  one  of  the  acute 
infections,  typhoid  fever,  scarlet  fever,  diphtheria,  pneumonia,  rheumatic  fever, 
or  mumps.  The  whole  gland  may  be  involved,  or  only  one  lobe.  There  is 
swelling,  pain  on  pressure,  and  very  soon  redness  over  the  affected  part.  It 
may  resolve  or  go  on  to  suppuration.  The  entire  gland  may  be  destroyed  and 
myxoedema  follow,  as  in  a  case  reported  by  Shields.  Basedow's  disease  has  fol- 
lowed the  acute  thyroiditis  of  typhoid  fever. 

3.  Goitre. 

Definition. — Hypertrophy  of  the  thyroid  gland,  occurring  sporadically  or 
endemically. 

Sporadic  goitre  is  not  uncommon,  and  is  confined  almost  exclusively  to 
women.  In  girls  at  puberty  slight  enlargement  of  the  gland  is  very  common, 
and  it  may  persist  for  a  year  or  longer ;  in  rare  instances  the  enlargement  per- 
sists. 

The  following  varieties  may  be  distinguished:  (a)  Parenchymatous,  in 
which  the  enlargement  is  general  and  the  follicles,  usually  newly  formed, 
contain  a  gelatinous  colloid  material,  (h)  Vascular,  in  which  the  en- 
largement is  chiefly  due  to  dilatation  of  the  blood-vessels  without  the 
new  formation  of  glandular  tissue,  (c)  Cystic  goitre,  in  which  the  en- 
larged gland  is  occupied  by  large  cysts,  the  walls  of  which  often  undergo  cal- 
cification. 

Endemic  goitre  is  rare  in  the  United  States  and  Canada.  The  endemic 
centres  referred  to  in  Barton's  monograph  (1819)  and  in  Hirsch's  Geograph- 
ical Pathology  no  longer  exist.  It  is  most  prevalent  about  the  eastern  end  of 
Lake  Ontario  and  in  Michigan  (Dock),  and  in  parts  of  the  province  of  Que- 


764          DISEASES  OF  THE  BLOOD  AND  DUCTLESS  GLANDS. 

bee ;  and  of  late  5^ears  there  appears  to  have  been  an  increase  in  the  cases. 
In  Great  Britain  it  is  still  met  with  in  a  few  localities,  as  in  Derbyshire — ^the 
Derbyshire  neck;  and  it  is  very  common  in  the  upper  Thames  valle}^.  In 
Switzerland  and  parts  of  France  and  Italy  it  is  very  prevalent,  occurring 
alone  or  in  association  with  cretinism.  In  parts  of  Central  Asia  there  are 
towns,  such  as  Khokand  in  Turkestan,  in  which  a  large  proportion  of  the 
population  have  goitre  or  cretinism.  Eussian  troops  stationed  there  may  have 
goitres  within  a  few  months. 

In  schools  and  garrisons  there  have  been  remarkable  otitbreaks  of  acute 
goitre  in  epidemic  form,  lasting  a  few  months,  and  disappearing,  in  schools, 
after  the  holidays.  In  one  instance  161  boys  among  350,  and  245  girls  among 
381,  were  attacked  (Guillaume). 

Symptoms. — The  enlargement  may  be  uniform  or  affect  only  one  lobe, 
or  the  isthmus  alone.  When  small,  a  goitre  causes  no  inconvenience.  When 
large,  it  may  compress  the  trachea,  causing  dyspnoea,  or  may  pass  iDcneath  the 
sternum  and  compress  the  veins.  These,  however,  are  exceptional  circum- 
stances, and  in  a  large  proportion  of  all  cases  no  serious  symptoms  are  noted. 
The  affection  usually  comes  under  the  care  of  the  surgeon.  Sudden  death 
occasionally  occurs  in  large  bronchoceles.  In  some  instances  it  may  be  difficult 
to  determine  the  cause,  and  it  has  been  thought  to  be  associated  with  pressure 
on  the  vagi.  I  have  reported  an  instance  in  which  it  resulted  from  hgemor- 
rhage  into  the  gland  and  into  the  adjacent  tissues.  The  blood  passed  into  the 
cellular  tissues  of  the  neck  and  under  the  sternum,  covering  the  aorta  and 
pericardium.  In  regions  in  which  goitre  prevails  the  drinking-water  should 
be  boiled.  Change  of  locality  is  sometimes  followed  by  cure.  The  medicinal 
treatment  is  very  unsatisfactory.  Iodine  and  various  counterirritants  exter- 
nally, iodide  of  potash,  ergot,  and  many  other  drugs  are  recommended  by 
writers.  The  thyroid  extract  has  been  used  with  success  in  a  few  cases.  If 
the  organ  progressively  enlarges  and  causes  great  disfigurement  or  inconven- 
ience, operation  should  be  advised. 

4.  Tumors  of  the  Thyroid. 

These  are  very  varied,  (a)  Adenomata,  either  simple  or  malignant. 
The  latter  may  form  extensive  metastases.  A  case  is  reported  by  Hayward 
in  which  growths  resembling  thyroid  tissue  occurred  in  the  lungs  and 
various  bones  of  the  body,  (h)  Cancer,  of  which  several  forms  have  been 
described,  (c)  Sarcoma.  All  of  these  have  a  surgical  rather  than  a  medical 
interest. 

Aberrant  and  Accessory  Thyroids. — Anywhere  from  the  root  of  the  tongue 
to  the  arch  of  the  aorta  small  fragments  of  thyroidal  tissue  have  been  found. 
In  the  mediastinum  they  may  form  large  tumors,  and  in  the  pleura  an  acces- 
sory cystic  thyroid  may  fill  the  upper  half  of  one  pleural  cavity  or  even  the 
entire  side  (F.  A.  Packard).  The  Ungual  thyroid  is  not  uncommon,  vary- 
ing in  size  from  a  hemp  seed  to  a  pea,  usually  free  in  the  deep  muscles 
of  the  tongue,  or  attached  to  the  hyoid  bone.  When  enlarged  the  lingual 
goitre  may  form  a  tumor  of  considerable  size.  The  true  thyroid  has  been 
absent,  and  removal  of  the  lingual  goitre  has  been  followed  by  myxoedema 
(Storrs). 


DISEASES  OF  THE  THYROID  GLAND.  765 

5.  Exophthalmic  Goitre. 
(Graves's,  Basedow's,  or  Parry's  Disease.) 

Definition. — A  disease  characterized  by  exophthalmos,  enlargement  of  the 
thyroid,  and  functional  disturbance  of  the  vascular  system.  It  is  very  possibly 
caused  by  disturbed  function  of  the  thyroid  gland  (hyperthyroidism). 

Historical  Note. — In  the  posthumous  writings  of  Caleb  Hillier  Parry 
(1835)  is  a  description  of  8  cases  of  Enlargement  of  the  Thyroid  Gland  in 
Connection  with  Enlargement  or  Palpitation  of  the  Heart.  In  the  first  case, 
seen  in  1786,  he  also  described  the  exophthalmos:  '"'The  eyes  were  protruded 
from  their  sockets,  and  the  countenance  exhibited  an  appearance  of  agitation 
and  distress,  especially  in  any  muscular  movement."  The  Italians  claim  that 
Flajani  described  the  disease  in  1800.  I  have  not  been  able  to  see  his  original 
account,  but  Moebius  states  that  it  is  meagre  and  inaccurate,  and  bears  no 
comparison  with  that  of  Parry.  If  the  name  of  any  physician  is  to  be  asso- 
ciated with  the  disease,  undoubtedly  it  should  be  that  of  the  distinguished  old 
Bath  physician.    Graves  described  the  disease  in  1835  and  Basedow  in  1840. 

Etiology. — The  disease  is  more  frequent  in  women  than  in  men.  Of  200 
cases  tabulated  by  Eshner,  there  were  161  females.  The  age  of  onset  is  usually 
from  the  twentieth  to  the  thirtieth  year.  It  is  sometimes  seen  in  several  mem- 
bers of  the  same  family.  Worry,  fright,  and  depressing  emotions  precede  the 
development  of  the  disease  in  a  number  of  cases. 

The  disease  is  regarded  by  some  as  a  pure  neurosis,  in  favor  of  which  is 
urged  the  onset  after  a  profound  emotion,  the  absence  of  lesions,  and  the 
cure  which  has  followed  in  a  few  cases  after  operations  upon  the  nose.  Others 
believe  that  it  is  caused  by  a  central  lesion  in  the  medulla  oblongata.  In 
support  of  this  there  is  a  certain  amount  of  experimental  evidence,  and  in 
a  few  autopsies  changes  have  been  found  in  the  medulla.  Of  late  years  the 
view  has  been  urged,  particularly  by  Moebius  and  by  Greenfield,  that  exoph- 
thalmic goitre  is  primarily  a  disease  of  the  thyroid  gland  (hyperthyrea) ,  in 
antithesis  to  myxcedema  (athyrea).  The  clinical  contrast  between  these  two 
diseases  is  most  suggestive — the  increased  excitability  of  the  nervous  system, 
the  flushed,  moist  skin,  the  vascular  erythism  in  the  one;  the  dull  apathy, 
the  low  temperature,  slow  pulse,  and  dry  skin  of  the  other.  The  changes  in 
the  gland  in  exophthalmic  goitre  are,  as  shown  by  Greenfield,  those  of  an  organ 
in  active  evolution — viz.,  increased  proliferation,  with  the  production  of  newly 
formed  tubular  spaces  and  absorption  of  the  colloid  material  which  is  replaced 
by  a  more  mucinous  fluid  (Bradshaw  Lecture,  1893).  The  thyroid  extract 
given  in  excess  produces  symptoms  not  unlike  those  of  Parry's  disease — tachy- 
cardia, tremor,  headache,  sweating,  and  prostration.  Beclere  has  recently 
reported  a  case  in  which  exopthalmos  developed  after  an  overdose.  Use  of 
the  thj^roid  extract  usually  aggravates  the  symptoms  of  exophthalmic  goitre. 
The  most  successful  line  of  treatment  has  been  that  directed  to  diminish  the 
bulk  of  the  goitre.  These  are  some  of  the  considerations  which  favor  the  view 
that  the  symptoms  are  due  to  disturbed  function  of  the  thyroid  gland,  prob- 
ably to  hypersecretion  of  certain  materials,  which  induce  a  sort  of  chronic 
intoxication.  Myxcedema  may  develop  in  the  late  stages,  and  there  are  tran- 
sient oedema  and  in  a  few  eases  scleroderma,  which  indicate  that  the  nutrition 


766         DISEASES  OF  THE  BLOOD  AND  DUCTLESS  GLANDS. 

of  the  skin  is  involved.  Persistence  of  the  thymns  is  almost  the  rule  (Hector 
Mackenzie),  but  its  significance  is  unknown. 

Symptoms. — Acute  and  chronic  forms  may  be  recognized.  In  the  acute 
form  the  disease  may  arise  with  great  rajDidity.  In  a  patient  of  J.  H.  Lloyd's, 
of  Philadelphia,  a  woman,  aged  thirty-nine,  who  had  been  considered  perfectly 
healthy,  but  whose  friends  had  noticed  that  for  some  time  her  eyes  looked 
rather  large,  was  suddenly  seized  with  intense  vomiting  and  diarrhoea,  rapid 
action  of  the  heart,  and  great  throbbing  of  the  arteries.  The  eyes  were  promi- 
nent and  staring  and  the  thyroid  gland  was  found  much  enlarged  and  soft. 
The  gastro-intestinal  symptoms  continued,  the  pulse  became  more  rapid,  the 
vomiting  was  incessant,  and  the  patient  died  on  the  third  day  of  the  illness. 
Only  the  abdominal  and  thoracic  organs  could  be  examined  and  no  changes 
were  found.  Two  rapidly  fatal  cases  occurred  at  the  Philadelphia  Hospital, 
one  of  which,  under  F.  P.  Henry's  care,  had  marked  cerebral  symptoms.  The 
acute  cases  are  not  always  associated  with  delirium.  In  a  case  reported  by 
Sutcliff  death  occurred  within  three  months  from  the  onset  of  the  s}anptoms, 
owing  to  repeated  and  uncontrollable  vomiting.  More  frequently  the  onset  is 
gradual  and  the  disease  is  chronic.  There  are  four  characteristic  symptoms 
of  the  disease — exophthalmos,  tachycardia,  enlargement  of  the  thyroid,  and 
tremor. 

Tachtcaedia. — Eapid  heart  action  is  only  one  of  a  series  of  remarkable 
vascular  phenomena  in  the  disease.  The  pulse-rate  at  first  may  be  not  more 
than  95  or  100,  but  when  the  disease  is  established  it  may  be  from  1-10  to 
160,  or  even  higher.  Irregularity  is  not  common,  except  toward  the  close.  In 
a  Avell-developed  case  the  visible  area  of  cardiac  pulsation  is  much  increased, 
the  action  is  heaving  and  forcible,  and  the  shock  of  the  heart-sounds  is  well 
felt.  The  large  arteries  at  the  root  of  the  neck  throb  forcibly.  There  is 
visible  pulsation  in  the  peripheral  arteries.  The  capillary  pulse  is  readily 
seen,  and  there  are  few  diseases  in  which  one  may  see  at  times  with  greater 
distinctness  the  venous  pulse  in  the  veins  of  the  hand.  The  throbbing  pulsa- 
tion of  the  arteries  may  be  felt  even  in  the  finger  tips.  Vascular  erythema  is 
common — the  face  and  neck  are  flushed  and  there  may  be  a  wide-spread  ery- 
thema of  the  body  and  limbs.  On  auscultation  murmurs  are  usually  heard 
over  the  heart,  a  loud  apex  systolic  and  loud  bruits  at  the  base  and  over  the 
manubrium.  The  sounds  of  the  heart  may  be  very  intense.  In  rare  instances 
they  may  be  heard  at  some  distance  from  the  patient;  according  to  Graves, 
as  far  as  four  feet.  Attacks  of  acute  dilatation  of  the  heart  may  occur  with 
dyspnoea,  cough,  and  a  frothy  bloody  expectoration. 

Exophthalmos^  which  may  be  unilateral,  usually  follows  the  vascular  dis- 
turbance. It  is  readily  recognized  by  the  protrusion  of  the  balls,  and  partly  by 
the  fact  that  the  lids  do  not  completely  cover  the  sclerotics,  so  that  a  rim  of 
white  is  seen  above  and  below  the  cornea.  The  protrusion  may  become  very 
great  and  the  eye  may  even  be  dislocated  from  the  socket,  or  both  eyes  may  be 
destroyed  by  panophthalmitis,  a  condition  present  in  one  of  Basedow's  cases. 
The  vision  is  normal.  Graefe  noted  that  when  the  eyeball  is  moved  downward 
the  upper  lid  does  not  follow  it  as  in  health.  This  is  known  as  Graefe's  sign. 
The  palpebral  aperture  is  wider  than  in  health,  owing  to  spasm  or  retraction  of 
the  upper  lid  (Stellwag's  sign).  The  patient  winks  less  frequently  than  in 
health.     Moebius  has  called  attention  to  the  lack  of  convergence  of  the  two 


DISEASES  OF  THE  THYROID  GLAND.  '        767 

eyes.  Changes  in  the  pupils  and  in  the  optic  nerves  are  rare.  Pulsation  of  the 
retinal  arteries  is  common. 

Enlargement  of  the  thyroid  commonly  occurs  with  the  exophthalmos. 
It  may  be  general  or  in  only  one  lobe,  and  is  rarely  so  large  as  in  ordinary 
goitre.  The  vessels  are  usually  much  dilated,  and  the  whole  gland  may  be 
seen  to  pulsate.  A  thrill  may  be  felt  on  palpation  and  on  auscultation  a  loud 
systolic  murmur,  or  more  commonly  a  bruit  de  diable.  A  double  murmur  is 
common  and  is  pathognomonic  (Guttmann). 

Tremor  is  the  fourth  cardinal  symptom,  and  was  really  first  described  by 
Basedow.  It  is  involuntary,  fine,  about  eight  to  the  second.  It  is  of  great 
importance  in  the  diagnosis  of  the  early  cases. 

Among  other  symptoms  are  anaemia,  emaciation,  and  slight  fever.  At- 
tacks of  vomiting  and  diarrhoea  may  occur.  The  latter  may  be  very  severe 
and  distressing,  recurring  at  intervals.  The  greatest  complaint  is  of  the  forci- 
ble throbbing  in  the  arteries,  often  accompanied  with  unpleasant  flushes  of 
heat  and  profuse  perspirations. 

Erythematous  flushing  is  common.  Pruritus  may  be  a  severe  and  per- 
sistent symptom.  Multiple  telangiectases  have  been  described.  Solid,  infil- 
trated oedema  is  not  uncommon.  It  may  be  transitory,  A  remarkable  myx- 
cedematous  state  may  supervene.  Pigmentary  changes  are  very  common.  They 
may  be  patchy  or  generalized.  Hydrocystoma  may  occur,  and  the  coexistence 
of  scleroderma  and  Graves's  disease  has  been  frequently  noticed.  Irritability 
of  temper,  change  in  disposition,  and  great  mental  depression  have  been  de- 
scribed. An  important  complication  is  acute  mania,  in  which  the  patient  may 
die  in  a  few  days.  Weakness  of  the  muscles  is  not  uncommon,  particularly  a 
feeling  of  "  giving  way  "  of  the  legs.  If  the  patient  holds  the  head  down  and 
is  asked  to  look  up  without  raising  the  head,  the  forehead  remains  smooth  and 
is  not  wrinkled,  as  in  a  normal  individual  (Joffroy).  A  feature  of  interest 
noted  by  Charcot  is  the  great  diminution  in  the  electrical  resistance,  which 
may  be  due  to  the  saturation  of  the  skin  with  moisture  owing  to  the  vaso-motor 
dilatation  (Hirt).  Bryson  has  noted  the  fact  that  the  chest  expansion  may  be 
greatly  diminished.  The  emaciation  may  be  extreme.  Glycosuria  and  albu- 
minuria are  not  infrequent  complications.     True  diabetes  may  occur. 

The  course  of  the  disease  is  usually  chronic,  lasting  several  years.  After 
persisting  for  six  months  or  a  year  the  symptoms  may  disappear.  There  are 
remarkable  instances  in  which  the  symptoms  have  come  on  with  great  inten- 
sity, following  fright,  and  have  disappeared  again  in  a  few  days.  A  certain 
proportion  of  the  cases  get  well,  but  when  the  disease  is  well  advanced  recov- 
ery is  rare. 

Diagnosis. — Few  diseases  are  so  easily  recognized.  The  difficulty  is  with 
the  partially  developed  forms,  formes  frustes,  which  are  not  uncommon.  The 
nervous  state,  the  tremor,  and  tachycardia  may  be  the  only  features,  or  there 
may  be  slight  swelling  of  the  thyroid  with  tremor  alone.  The  greatest  diffi- 
culty arises  in  the  cases  of  hysterical  tremor  with  rapid  heart  action. 

Treatment. — (a)  The  disease  is  serious  enough  to  warrant  strong  measures 
systematically  carried  out ;  much  valuable  time  is  lost  in  trying  various  rem- 
edies. The  patient  should  be  in  bed,  at  absolute  rest,  and  see  very  few  persons. 
To  quiet  the  heart's  action  the  ice-bag  may  be  continuously  applied  through 
the  day,  and  veratrum  viride,  aconite,  or  strophanthus  given  in  full  doses. 


768       '  DISEASES  OF  THE  BLOOD  AND  DUCTLESS  GLANDS.      ' 

Ergot,  belladonna,  phosphate  of  soda,  small  doses  of  opium,  and  many  other 
remedies  are  recommended,  and  in  some  instances  I  have  seen  benefit  from 
the  belladonna  and  the  phosphate  of  soda.     Electricity  may  be  helpful. 

(&)  Serum  Therapy. — Two  methods  are  employed:  feeding  with  the  milk 
of  dethyroidized  goats,  introduced  by  Lanz,  which  is  obtainable  as  a  substance 
called  rodagen.  Good  results  have  been  reported  by  Mackenzie  and  others. 
Beebe,  on  the  other  hand,  uses  the  serum  of  animals  into  which  human  thyroid 
extract  has  been  injected.  Excellent  results  have  been  obtained,  but  the 
method  has  the  danger  associated  with  the  use  of  foreign  sera. 

(c)  Surgical  Treatment. — Eemoval  of  part  of  the  thyroid  gland  offers 
the  best  hope  of  permanent  cure.  It  is  remarkable  with  what  rapidity  all  the 
symptoms  may  disappear  after  partial  thyroidectomy.  A  second  operation 
may  be  necessary  in  severe  cases.  The  results  obtained  by  the  brothers  Mayo 
and  by  Kocher  give  a  remarkable  percentage  of  recoveries.  The  operation 
under  cocaine  may  be  done  with  safety  when  the  condition  of  the  heart  and 
the  extreme  tachycardia  do  not  contraindicate  it.  Tying  of  the  arteries  and 
exothyropexia  are  also  recommended.  Excision  of  the  superior  cervical  ganglia 
of  the  sympathetic  has  one  beneficial  result,  viz.,  the  production  of  slight 
ptosis,  which  obviates  the  staring  character  of  the  exophthalmos. 

Marked  benefit  has  followed  the  use  of  the  X-rays  in  a  few  cases. 

6,  Myx(edema  (Atkyrea). 

Definition. — A  constitutional  affection,  due  to  the  loss  of  function  of  the 
thyroid  gland.  The  disease,  which  was  described  by  Sir  William  Gull  as  a 
cretinoid  change,  and  later  by  Ord,  is  characterized  clinically  by  a  myxoedema- 
tous  condition  of  the  subcutaneous  tissues  and  mental  failure,  and  anatom- 
ically by  atrophy  of  the  thyroid  gland. 

Clinical  Forms. — Three  groups  of  cases  may  be  recognized — cretinism, 
myxoedema  proper,  and  operative  myxcedema.  To  Felix  Semon  is  due  the 
credit  of  recognizing  that  these  were  one  and  the  same  condition  and  all  due 
to  loss  of  function  of  the  thyroid. 

Cketixism. — This  remarkable  impairment  of  nutrition  follows  absence  or 
loss  of  function  of  the  thyroid  gland,  either  congenital  or  appearing  at  any 
time  before  puberty.  There  is  remarkable  retardation  of  development,  reten- 
tion of  the  infantile  state,  and  an  extraordinary  disproportion  between  the 
different  parts  of  the  body.  Two  forms  are  recognized,  the  sporadic  and  the 
endemic.  In  the  sporadic  form  the  gland  may  be  congenitally  absent,  it  may 
be  atrophied  after  one  of  the  specific  fevers,  or  the  condition  may  develop 
with  goitre.  Since  we  have  learned  to  recognize  the  disease  it  is  surprising 
how  many  cases  have  been  reported.  In  Great  Britain  the  disease  is  not 
uncommon,  and  many  cases  have  been  reported. 

The  condition  is  rarely  recognized  before  the  infant  is  six  or  seven 
months  old.  Then  it  is  noticed  that  the  child  does  not  grow  so  rapidly  and 
is  not  bright  mentally.  The  tongue  looks  large  and  hangs  out  of  the  mouth. 
The  hair  may  be  thin  and  the  skin  very  dry.  Usually  by  the  end  of  the 
first  year  and  during  the  second  year  the  signs  become  very  marked.  The 
face  is  large,  looks  bloated,  the  eyelids  are  puffy  and  swollen;  the  alse  nasi 
are  thick,  the  nose  looks  depressed  and  flat.     Dentition  is  delayed,  and  the 


DISEASES  OF  THE  THYROID  GLAND.  769 

teeth  which  appear  decay  early.  The  abdomen  is  swollen,  the  legs  are  thick 
and  short,  and  the  hands  and  feet  are  undeveloped  and  pudgy.  The  face  is 
pale  and  sometimes  has  a  waxy,  sallow  tint.  The  fontanelles  remain  open; 
there  is  much  muscular  weakness,  and  the  child  can  not  support  itself.  In  the 
supraclavicular  regions  there  are  large  pads  of  fat.  The  child  does  not  develop 
mentally ;  there  are  various  grades  of  idiocy  and  imbecility. 

A  very  interesting  form  is  that  in  which,  after  the  child  has  thriven  and 
developed  until  its  fourth  or  fifth  year,  or  even  later,  the  symptoms  begin 
after  a  fever,  in  consequence  of  an  atrophy  of  the  gland.  Parker  suggests  for 
this  variety  the  name  juvenile  myxoedema. 

Endemic  cretinism  occurs  under  local  conditions,  as  yet  unknown,  in  asso- 
ciation with  goitre.  It  is  met  with  chiefly  in  Switzerland  and  parts  of  Italy 
and  France. 

The  diagnosis  is  very  easy  after  one  has  seen  a  case  or  good  illustrations. 
Infants  a  year  or  so  old  sometimes  become  flabby,  lose  their  vivacity,  or  show 
a  protuberant  abdomen  and  lax  skin  with  slight  cretinoid  appearance.  These 
milder  forms,  as  they  have  been  termed,  are  probably  due  to  transient  func- 
tional disturbance  in  the  gland.  There  is  rarely  any  difficulty  in  recognizing 
the  different  other  types  of  idiocy.  The  condition  known  as  foetal  rickets, 
achondroplasia^  or  chondrodystrophia  fcetalis,  is  more  likely  to  be  mistaken 
for  cretinism.  The  children  which  survive  birth  grow  up  as  a  remarkable 
form  of  dwarfs,  characterized  by  shortness  of  the  limbs  ( micro melia)  and 
enormous  enlargement  of  the  articulations,  due  to  hyperplasia  of  the  carti- 
laginous ends  of  the  bones.  Infantilism — the  condition  characterized  by  a 
preservation  in  the  adult  of  the  exterior  form  of  infancy  with  the  non-appear- 
ance of  the  secondary  sexual  chargtcters — could  scarcely  be  mistaken  for 
cretinism. 

Myxcedema  of  Adults  (Gull's  Disease). — In  this,  women  are  very  much 
more  frequently  affected  than  men — in  a  ratio  of  6  to  1.  The  disease  may 
affect  several  members  of  a  family,  and  it  may  be  transmitted  through  the 
mother.  In  some  instances  there  has  been  first  the  appearance  of  exophthalmic 
goitre.  Though  occurring  most  commonly  in  women,  it  seems  to  have  no 
special  relation  to  the  catamenia  or  to  pregnancy ;  the  symptoms  of  myxoedema 
may  disappear  during  pregnancy  or  may  develop  post  partum.  Myxoedema 
and  exophthalmic  goitre  may  occur  in  sisters.  It  is  not  so  common  in  Amer- 
ica as  in  England.  In  sixteen  years  I  saw  only  10  cases  in  Baltimore,  7  of 
which  were  in  the  hospital.  C.  P.  Howard  has  collected  100  American  cases, 
of  which  86  were  in  women.  The  symptoms  of  this  form,  as  given  by  Ord, 
are  marked  increase  in  the  general  bulk  of  the  body,  a  firm,  inelastic  swell- 
ing of  the  skin,  which  does  not  pit  on  pressure;  dryness  and  roughness, 
which  tend,  with  the  swelling,  to  obliterate  in  the  face  the  lines  of  ex- 
pression; imperfect  nutrition  of  the  hair;  local  tumefaction  of  the  skin  and 
subcutaneous  tissues,  particularly  in  the  supraclavicular  region.  The  phys- 
iognomy is  altered  in  a  remarkable  way:  the  features  are  coarse  and  broad, 
the  lips  thick,  the  nostrils  broad  and  thick,  and  the  mouth  is  enlarged. 
Over  the  cheeks,  sometimes  the  nose,  there  is  a  reddish  patch.  There  is  a 
striking  slowness  of  thought  and  of  movement.  The  memory  becomes  de- 
fective, the  patients  grow  irritable  and  suspicious,  and  there  may  be  head- 
ache.    In  some  instances  there  are  delusions  and  hallucinations,  leading  to 


770  DISEASES  OF  THE  BLOOD  AND  DUCTLESS  GLANDS. 

a  final  condition  of  dementia.  The  gait  is  heavy  and  slow.  The  tempera- 
ture may-  be  below  normal.  The  functions  of  the  heart,  lungs,  and  abdom- 
inal organs  are  normal.  Haemorrhage  sometimes  occurs.  Albuminuria  is 
sometimes  present,  more  rarely  glycosuria.  Death  is  usually  due  to  some 
intercurrent  disease,  most  frequently  tuberciilosis  (Greenfield).  The  thyroid 
gland  is  diminished  in  size  and  may  become  completely  atrophied  and  con- 
verted into  a  fibrous  mass.  The  subcutaneous  fat  is  abundant,  and  in  one 
or  two  instances  a  great  increase  in  the  mucin  has  been  found.  The  larynx 
is  also  involved. 

The  course  of  the  disease  is  slow  but  progressive,  and  extends  over  ten  or 
fifteen  years.  A  condition  of  acute  and  temporary  myxoedema  may  develop  in 
connection  with  enlargement  of  the  thyroid  in  young  persons.  Myxoedema 
may  follow  exophthalmic  goitre.  In  other  instances  the  symptoms  of  the  two 
diseases  have  been  combined.  I  have  reported  a  case  in  which  a  young  man 
became  bloated  and  increased  in  weight  enormously  during  three  months,  then 
had  tachycardia  with,  tremor  and  active  delirium,  and  died  within  six  months 
of  the  onset  of  the  symptoms. 

Operative  Mtxcedema  ;  Cachexia  Strumipeiva. — Horsley,  in  a  series  of 
interesting  experiments,  showed  that  complete  removal  of  the  thyroid  in  mon- 
keys was  followed  by  the  production  of  a  condition  similar  to  that  of  myx- 
oedema and  often  associated  with  spasms  or  tetanoid  contractures,  and  followed 
by  apathy  and  coma.  When  the  monkeys  were  kept  warm  myxoedema  was 
averted,  and,  instead  of  an  acute  myxoedema,  the  animals  had  a  condition 
which  closely  resembled  cretinism.  An  identical  condition  may  follow  extirpa- 
tion of  the  thyroid  in  man.  Kocher,  of  Bern,  found  that  after  complete  extir- 
pation a  cachectic  condition  followed  in  many  cases,  the  symptoms  of  which 
are  practically  identical  with  those  of  myxoedema.  The  disease  follows  only 
a  certain  number  of  total  and  a  much  smaller  proportion  of  partial  removals 
of  the  thyroid  gland.  Of  408  cases,  in  69  the  operative  myxoedema  occurred. 
It  has  been  thought  that  if  a  small  fragment  of  the  thyroid  remains,  or  if 
there  are  accessory  glands,  which  in  animals  are  very  common,  these  symptoms 
do  not  develop.  It  is  possible  that,  in  men,  in  the  cases  of  complete  removal, 
the  accessory  fragments  subserve  the  function  of  the  gland.  Operative  myx- 
oedema is  very  rare  in  America.  A  few  years  ago  I  was  able  to  find  only  two 
cases,  one  of  which,  McOraw's,  referred  to  in  previous  editions  of  this  work,  has 
since  been  cured. 

The  diagnosis  of  myxoedema  is  easy,  as  a  rule.  The  general  aspect  of  the 
patient — ^the  subcutaneous  swelling  and  the  pallor — suggests  Bright's  disease, 
which  may  be  strengthened  by  the  discovery  of  tube-casts  and  of  albumin  in 
the  urine;  but  the  solid  character  of  the  swelling,  the  exceeding  dryness  of 
the  skin,  the  yellowish-white  color,  the  low  temperature,  the  loss  of  hair,  and 
the  dull,  listless  mental  state  should  suffice  to  differentiate  the  two  conditions. 
In  dubious  cases  not  too  much  stress  should  be  laid  upon  the  supraclavicular 
swellings.  There  may  be  marked  fibro-fatty  enlargements  in  this  situation  in 
healthy  persons,  the  supraclavicular  pseudo-lipomata  of  Verneuil. 

Treatment. — The  patients  suffer  in  cold  and  improve  greatly  in  warm 
weather.  They  should  therefore  be  kept  at  an  even  temperature,  and  should, 
if  possible,  move  to  a  warm  climate  during  the  winter  months.  Eepeated  warm 
baths  with  shampooing  are  useful.     Our   art  has  made  no  more  brilliant 


DISEASES  OF  THE   THYMUS  GLAND.  771 

advance  than  in  the  cure  of  these  disorders  due  to  disturbed  function  of  the 
thyroid  gland.  That  we  can  to-day  rescue  children  otherwise  doomed  to  help- 
less idiocy — that  we  can  restore  to  life  the  hopeless  victims  of  myxoedema — 
is  a  triumph  of  experimental  medicine  for  which  we  are  indebted  very  largely 
to  Victor  Horsley  and  to  his  pupil  Murray.  Transplantation  of  the  gland  was 
first  tried ;  then  Murray  used  an  extract  subcutaneously.  Hector  Mackenzie  in 
London  and  Howitz  in  Copenhagen  introduced  the  method  of  feeding.  We 
now  know  that  the  gland,  taken  either  fresh,  or  as  the  watery  or  glycerin  ex- 
tract, or  dried  and  powdered,  is  equally  efficacious  in  a  majority  of  all  the  cases 
of  myxoedema  in  infants  or  adults.  Many  preparations  are  now  on  the  mar- 
ket, but  it  makes  little  difference  how  the  gland  is  administered.  The  dried 
powdered  gland  and  the  glycerin  extract  are  most  convenient.  It  is  well  to 
begin  with  the  powdered  gland,  1  grain  three  times  a  day,  of  the  Parke-Davis 
preparation,  or  one  of  the  Burroughs  and  Welcome  tablets.  The  dose  may  be 
increased  gradually  until  the  patient  takes  10  or  15  grains  in  the  day.  In 
many  cases  there  are  no  unpleasant  symptoms;  in  others  there  are  irritation 
of  the  skin,  restlessness,  rapid  pulse,  and  delirium;  in  rare  instances  tonic 
spasms,  the  condition  to  which  the  term  thyroidism  is  applied.  The  results, 
as  a  rule,  are  most  astounding — unparalleled  by  anything  in  the  whole  range 
of  curative  measures.  Within  six  weeks  a  poor,  feeble-minded,  toad-like  cari- 
cature of  humanity  may  be  restored  to  mental  and  bodily  health.  Loss  of 
weight  is  one  of  the  first  and  most  striking  effects ;  one  of  my  patients  lost  over 
30  pounds  within  six  weeks.  The  skin  becomes  moist,  the  urine  is  increased, 
the  perspiration  returns,  the  temperature  rises,  the  pulse-rate  quickens,  and  the 
mental  torpor  lessens.  Ill  effects  are  rare.  Two  or  three  cases  with  old  heart 
lesions  have  died  during  or  after  the  treatment;  in  one  instance  a  temporary 
condition  of  Graves'  disease  was  induced. 

The  treatment,  as  Murray  suggests,  must  be  carried  out  in  two  stages — 
one,  early,  in  which  full  doses  are  given  until  the  cure  is  effected ;  the  other, 
the  permanent  use  of  small  doses  sufficient  to  preserve  the  normal  metabolism. 
In  the  cases  of  cretinism  it  seems  to  be  necessary  to  keep  up  the  treatment 
indefinitely.  I  have  seen  several  instances  of  remarkable  relapse  follow  the 
cessation  of  the  use  of  the  extract. 

XI.     DISEASES    OF    THE    THYMUS    GLAND. 

The  functions  of  this  gland  are  unknown.  It  is  a  suggestive  fact  that  Bau- 
mann  found  in  it  minute  quantities  of  a  compound  containing  iodine.  It  has 
been  thought  that  its  internal  secretion  has  an  infiuence  in  combating  infective 
agents.  Friedleben's  estimate  of  the  weight  of  the  organ  at  birth — 13 
grammes — is  stated  by  Dudgeon  to  be  too  high.  He  puts  it  at  7.10  grammes. 
The  largest  in  his  series  occurred  in  a  child  aged  five  months,  47  grammes. 
At  the  ninth  month  the  gland  weighs  20  grammes,  and  at  the  second  year 
25  to  30. 

The  organ,  after  reaching  its  largest  size  about  the  end  of  the  second  year, 
gradually  wastes,  until  at  the  time  of  puberty  it  is  a  mere  fatty  remnant, 
in  which,  however,  there  are  "  traces  of  its  original  structure  in  the  form  of 
small  masses  of  thymus  corpuscles,  and  even  of  concentric  corpuscles " 
(Quain).     A  complete  consideration  of  the  affections  of  this  gland  is  to  be 


772         DISEASES  OF  THE  BLOOD  AND  DUCTLESS  GLANDS. 

found  in  Friedleben's  remarkable  monograph,  Die  Physiologie  der  Thymus- 
driise,  1858.    The  following  are  the  most  important  conditions: 

I.  Persistence  of  the  organ  after  the  fifteenth  year,  met  with  occasionally, 
but  under  circumstances  so  varied  that  a  satisfactory  explanation  can  not  be 
offered.  The  existence  of  the  gland  may  be  determined  by  the  presence  of 
an  area  of  dulness  along  the  left  sternal  border. 

II.  Hypertrophy  of  the  Thymus. — The  size  of  the  gland  varies  widely,  so 
that  it  is  difficult  to  define  exactly  the  limits  between  persistence  and  enlarge- 
ment. The  condition  is  of  interest  from  three  standpoints:  (a)  The  supposed 
occurrence  of  thymic  asthma,  due  to  pressure  from  the  enlarged  gland.  A 
number  of  observers  have  attributed  the  symptoms  of  laryngismus  stridulus 
to  pressure  exerted  by  the  enlarged  thymus.  Many  German  writers  consider 
thymic  asthma  identical  with  the  laryngismus  stridulus  of  English  authors, 
who,  as  a  rule,  have  laid  no  stress  whatever  on  the  association.  There  can  be, 
I  think,  no  question  that  the  ordinary  laryngismus  seen  in  rickety  children  is  a 
convulsive  affection  and  is  not  the  result  of  compression.  But  a  very  greatly 
enlarged  thymus  may  seriously  hamper  the  structures  within  the  thorax. 
Jacobi,  in  his  monograph  on  the  gland,  states  that  in  an  infant  of  eight  months 
the  distance  between  the  manubrium  sterni  and  the  vertebral  column  is  2.3 
cm.,  a  space  which  he  thinks  might  be  completely  filled  by  an  enlarged  and 
congested  thjaiius.  Siegel's  case  also  points  to  the  possibility  of  this  com- 
pression. A  boy  aged  two  and  a  half  years  had  had  for  two  weeks  cough 
and  bronchial  rales  with  dyspnoea,  which  was  more  or  less  constant  with  noc- 
turnal exacerbations.  Laryngismus  stridulus  was  diagnosed.  Tracheotomy 
was  performed  shortly  after  admission  without  relief,  but  when  subsequently 
the  anterior  mediastinum  was  opened  from  above  by  extending  the  incision 
from  the  tracheotomy  wound,  a  piece  of  the  thymus  as  large  as  a  hazel-nut 
appeared  with  each  inspiration.  The  gland  was  drawn  up  with  forceps  and 
fastened  by  three  stitches  to  the  fascia  over  the  sternum.  The  child  rested 
quietly  after  the  operation,  had  no  dyspnoea,  and  made  a  complete  recovery 
(Berl.  klin.  Woch.,  1896,  No.  40).  From  a  child  aged  two  months  (dyspnoeic 
from  the  eighth  day)  Konig  removed  a  portion  of  the  thymus,  leaving  the 
substernal  part.  These  are  cases  that  go  far  to  disprove  Friedleben's  dictum — 
es  gieht  l-ein  Asthma  thymicum.  Warthin  has  considered  the  whole  question 
very  thoroughly  in  his  exhaustive  article  on  the  Thymus  in  my  "  System  of 
Medicine,"  Vol.  IV. 

(h)  Thymus  Enlargement  and  Sudden  Death. — In  considering  the  ques- 
tion of  the  so-called  lymphatic  constitution,  with  which  an  enlarged  th5Tiius 
is  usually  associated,  we  have  spoken  of  the  occurrence  of  sudden  death.  Two 
groups  of  cases  are  met  with  in  the  literature :  First,  such  instances  as  those 
described  by  Grawitz,  Jacobi,  and  others,  in  which  young  infants  have  been 
either  found  dead  in  bed  or  have  been  attacked  suddenly  with  dyspnoea,  have 
become  cyanotic  and  died  in  a  few  minutes.  In  such  cases  the  thymus  has 
been  found  greatly  enlarged,  and  death  has  been  thought  to  be  directly  due 
either  to  pressure  on  the  air-passages,  pressure  on  the  pneumogastric  (causing 
spasm  of  the  glottis),  or  pressure  on  the  great  vessels.  To  the  second  group 
belong  the  cases  in  adults  which  have  been  described  of  late  by  ISTordmann, 
Paltauf,  Ohlmacher,  and  others,  in  which  the  sudden  death  has  occurred  under 
such  conditions  as  anaesthesia  or  while  bathing.    In  a  number  of  these  cases 


INFANTILISM.  773 

not  only  has  the  thymus  been  found  enlarged,  but  the  spleen  and  lymphatic 
tissues  generally.  The  question  is  one  of  considerable  medico-legal  interest, 
and  has  been  spoken  of  under  Lymphatism. 

Eolleston  reports  a  case  of  sudden  death  after  signs  of  cardiac  failure  last- 
ing for  only  twenty  minutes,  in  which  there  was  hyperplasia  of  a  persistent 
thymus.    The  gland  with  the  trachea  weighed  11  ounces. 

(c)  Atrophy  of  the  Thymus. — The  condition  may  be  primary,  found  acci- 
dentally in  a  child  without  any  other  pathological  changes  except  a  wasting 
or  marasmus.  To  this  association  Ruhrah  has  called  special  attention.  The 
secondary  atrophy  is  common  in  tuberculosis  and  other  chronic  maladies. 

(d)  Thymus  Gland  and  Exophthalmic  Goitre. — That  there  is  some  asso- 
ciation between  these  conditions  is  urged  on  two  grounds :  First,  the  per- 
sistence of  the  gland  in  Graves'  disease.  W.  W.  Ord  and  Hector  Mackenzie 
state  that  it  has  been  found  enlarged  in  all  the  cases  examined  at  St.  Thomas's 
Hospital.  Hektoen  concludes  from  a  very  thorough  study  of  the  question 
that  the  coexistence  is  more  than  accidental.  Secondly,  the  good  results  which 
are  stated  to  follow  the  feeding  of  the  thymus  gland  in  Graves'  disease  are  held 
to  bear  out  the  idea  that  the  enlargement  during  life  is  compensatory.  The 
general  conclusion,  however,  reached  by  Hector  Mackenzie  and  by  Kinnicutt 
is  that  the  thymus  feeding  has  at  best  only  slight  influence  upon  Graves' 
disease. 

It  is  interesting  to  note  in  connection  with  the  question  of  enlarged 
thymus  and  sudden  death  that  two  of  Hale  White's  cases  of  exophthalmic 
goitre  died  suddenly,  and  autopsy  showed  no  reasonable  cause  of  death. 

Among  other  conditions  with  which  enlarged  thymus  has  been  associated 
may  be  mentioned  epilepsy  (Ohlmacher). 

III.  Other  Morbid  Conditions  of  the  Thymus. — Hcemorrhages  are  not  un- 
common, and  are  found  particularly  in  children  who  have  died  of  asphyxia. 

Tumors  of  the  gland,  particularly  sarcoma  and  lympho-sarcoma,  have  been 
frequently  described.  Many  mediastinal  tumors  originate  in  the  remnants  of 
the  thymus.  Dermoid  tumors  and  cysts  have  also  been  met  with.  Tubercu- 
losis of  the  gland,  chiefly  in  the  form  of  miliary  nodules,  is  well  described  in 
Jacobi's  monograph.  There  is  a  well-authenticated  case  in  which  it  was  pri- 
mary.   Focal  necroses  in  diphtheria  have  also  been  described  by  Jacobi. 

Abscess  oe  the  Thymus. — The  condition  described  by  Dubois,  in  which 
there  were  fissure-like  cavities  filled  with  a  purulent  fluid,  and  supposed  to  be 
present  chiefly  in  the  subjects  of  congenital  syphilis,  is  stated  by  Chiari  to  be 
a  post-mortem  softening,  which  opinion  Dudgeon's  observations  confirm.  In 
one  case  Jacobi  found  a  small  gumma. 

XII.     INFANTILISM. 

Associated  with  loss  or  perversion  of  the  internal  secretions  there  is  a 
remarkable  condition  known  as  infantilism,  characterized  by  the  persistence  of 
the  physical  features  of  childhood  after  the  period  of  puberty  has  passed. 
There  is  an  arrest  of  development  of  the  sexual  organs  and  an  absence  of 
the  secondary  sexual  characteristics — namely,  the  changes  in  the  figure,  as  seen 
in  the  adult,  the  presence  of  the  facial,  pubic,  and  axillary  hair,  and  the  laryn- 
geal enlargement  with  the  corresponding  changes  in  the  voice.    There  is  usu- 


774         DISEASES  OF   THE  BLOOD  AND  DUCTLESS  GLANDS. 

ally  a  corresponding  failure  in  tlie  mental  development,  so  that  the  individual 
remains  a  child  in  mind  as  well  as  in  body.  Various  types  have  been  de- 
scribed.    The  following  are  the  most  important : 

1.  Myxoedematous  Infantilism. — This  has  already  been  described  under 
cretinism.  Here  there  is  no  question  that  the  thyroid  inadequacy  is  respon- 
sible for  the  condition. 

2.  The  Lorain  Type  of  Infantilism. — "  In  this  variety,  the  figure  is  so 
small  that,  at  first  sight,  it  looks  like  that  of  a  child.  When  the  patient  is 
stripped,  however,  his  outlines  are  seen  to  be  those  of  an  adult  and  not  those 
of  childhood.  The  head  is  proportionately  small  and  the  trunk  well-formed; 
for  the  shoulders  are  broad  compared  to  the  hips,  and  the  bony  prominences 
and  the  muscles  stand  out  distinctly.  We  have  before  us  a  miniature  man  (or 
woman,  as  the  case  may  be),  and  not  one  who  has  retained  the  characteristics 
of  childhood  beyond  the  proper  time.  There  is  indeed  no  growth  of  facial, 
pubic,  or  axillary  hair,  yet  the  genital  organs,  although  small,  are  well  shaped 
and  quite  large  enough  for  the  size  of  the  body.  The  intelligence  in  both 
sexes  is  generally  normal.^'  ( Jolm  Thomson.)  By  far  the  most  potent  cause 
in  producing  this  form  is  hereditary  syphilis.  Alcoholism  in  the  parents  and 
consanguinity  are  also  mentioned.  The  various  causes  leading  to  malnutrition 
play  an  important  part — insufficient  food,  chronic  poisoning  by  tobacco,  lead, 
and  mercury.  Defective  arterial  development  is  suggested  by  some  writers  as 
an  important  factor. 

B3Tom  Bramwell  has  described  a  condition  of  retarded  development  asso- 
ciated with  chronic  diarrhoea,  which  he  has  called  pancreatic  infantilism.  One 
patient  gained  remarkably  in  two  years  under  the  use  of  the  pancreatic  extract, 
and  it  is  suggested  that  pancreatic  internal  secretion  was  defective. 

3.  Ateliosis:  Progeria. — Under  these  terms,  signifying  continuous  youth 
and  premature  old  age,  Hastings  Gilford  has  described  interesting  types  of 
dwarfs.  There  are  two  varieties  of  ateliosis;  the  asexual,  an  infantilism  with- 
out any  connection  with  cretinism,  sj^philis,  or  congenital  heart  disease.  It 
is  often  more  a  delay  than  an  arrest  of  development.  The  sexual  form  is  the 
"  Tom  Thumb  "  variety  of  dwarf.  There  is  a  similar  delay  in  development 
until  puberty,  when  the  sexual  organs  mature  and  the  body  becomes  set  or 
stereotyped  as  a  miniature  man  or  woman. 

Progeria  is  a  remarkable  condition  in  which,  with  infantilism,  as  shown  in 
stature  and  proportion,  there  is  premature  decay,  as  shown  in  the  facial  appear- 
ance, attitude,  loss  of  hair,  muscular  and  fatty  emaciation,  and  post  mortem 
extensive  atheroma  of  arteries  and  degenerative  (senile)  changes  in  the  viscera. 


SECTION    IX. 
DISEASES   OF  THE   OIEOULATORY   SYSTEM. 


A.    DISEASES   OE  THE  PERICARDIUM. 

I.     PERICARDITIS. 

Peeicarditis  is  the  result  of  infective  processes,  primary  or  secondary,  or 
arises  by  extension  of  inflammation  from  contiguous  organs. 

Etiology. — Primary,  so-called  idiopathic,  inflammation  is  rare ;  but  it  has 
been  met  with  in  children  without  any  evidence  of  rheumatism  or  of  any  local 
or  general  disease.    Certain  of  these  cases  are  tuberculous. 

Pericarditis  from  injury  usually  comes  under  the  care  of  the  surgeon  in 
connection  with  the  primary  wound.  The  trauma  may  be  from  within,  due 
to  the  passage  of  a  foreign  body — a  needle,  a  pin,  or  a  bone — through  the 
oesophagus — a  variety  exceedingly  common  in  cows  and  horses. 

Secondary:  (a)  Most  frequently  in  connection  with  rheumatism.  The 
percentage  given  by  different  authors  ranges  from  thirty  to  seventy.  In  our 
330  cases  of  rheumatic  fever  (Johns  Hopkins  Hospital)  pericarditis  occurred 
in  twenty — practically  6  per  cent.  The  articular  trouble  may  be  slight  or, 
indeed,  the  disease  may  be  associated  with  acute  tonsillitis  in  rheumatic  sub- 
jects. Certain  of  the  so-called  idiopathic  cases  have  their  origin  in  an  acute 
tonsillitis.  The  pericarditis  may  precede  the  arthritis,  (h)  In  septic  pro- 
cesses; in  the  acute  necrosis  of  bone  and  in  puerperal  fever  it  is  not  uncom- 
mon, (c)  In  tuberculosis,  in  which  the  disease  may  be  primary  or  part  of  a 
general  involvement  of  the  serous  sacs  or  associated  with  extensive  pulmonary 
disease,  (d)  In  the  fevers.  Not  infrequent  after  scarlatina;  it  is  rare  in 
measles,  small-pox,  typhoid  fever,  and  diphtheria.  In  pneumonia  it  is  not 
uncommon,  occurring  in  31  among  665  in  my  clinic  (J.  A.  Chatard).  Post 
mortem  there  were  184  cases  with  39  instances  of  pericarditis.  It  is  most 
frequent  in  double  pneumonia,  and  in  our  series  with  disease  of  the  right  side, 
if  only  one  lung  was  involved.  Pericarditis  sometimes  complicates  chorea;  it 
was  present  in  19  of  73  autopsies  which  I  collected;  in  only  8  of  these  was 
arthritis  present,  (e)  Terminal  pericarditis.  In  gout,  in  chronic  Bright's 
disease — pericardite  hrightique  of  the  French — ^in  arterio-sclerosis,  in  scurvy, 
in  diabetes,  and  in  chronic  illness  of  all  sorts  a  latent  pericarditis  is  common 
and  is  usually  overlooked. 

(/)  By  Extension. — In  pleuro-pneumonia  it  forms  a  serious  complication, 
and  was  present  in  5  cases  of  100  post  mortems  (Montreal  General  Hospital). 
It  is  most   often  met  with  in  the  pleuro-pneumonia   of  children   and  of 

775 


776  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

alcoholics.  With,  simple  pleurisy  it  is  rare.  In  ulcerative  endocarditis,  puru- 
lent m3-ocarditis,  and  in  aneurism  of  the  aorta  pericarditis  is  occasionally 
found.  It  may  also  follow  extension  of  the  disease  from  the  mediastinal 
glands,  the  ribs,  sternum,  vertebras,  and  even  from  the  abdominal  viscera.  The 
ordinary  pus  cocci,  the  pneumococcus,  and  the  tubercle  bacillus  are  the  chief 
organisms  met  with  in  acute  pericarditis. 

Pericarditis  occurs  at  all  ages.  Cases  have  been  reported  in  the  foetus. 
In  the  new-born  it  may  result  from  septic  infection  through  the  navel. 
Throughout  childhood  the  incidence  of  rheumatism  and  scarlet  fever  makes 
it  a  frequent  affection,  whereas  late  in  life  it  is  most  often  associated  with 
tuberculosis,  Bright's  disease,  and  gout.  Males  are  somewhat  more  frequently 
attacked  than  females.  Climatic  and  seasonal  influences  have  been  mentioned 
by  some  writers.  The  so-called  epidemics  of  pericarditis  have  been  outbreaks 
of  pneumonia  with  this  as  a  frequent  complication. 

Of  100  consecutive  cases  at  the  Boston  City  Hospital,  in  54  the  exudate 
was  dry,  in  41  serous,  in  4  haemorrhagic,  and  in  5  purulent.  Thirty-four  cases 
showed  signs  of  old  valvular  disease;  rheumatism  was  a  factor  in  51;  pneu- 
monia in  18;  and  in  7  chronic  nephritis.     Of  the  100  cases  43  died  (Sears). 

Acute  Fibeinous  Peeicarditis. 

This,  the  most  common  and  benign  form,  is  distinguished  by  the  small 
amount  of  exudate  which  coats  the  surface  in  a  thin  layer. 

It  may  be  partial  or  general.  In  the  mildest  grades  the  membrane  looks 
lustreless  and  roughened,  due  to  the  presence  of  a  thin  fibrinous  sheeting, 
which  can  be  lifted  with  the  knife,  showing  beneath  an  injected  or  ecchymotic 
serosa.  As  the  fibrinous  sheeting  increases  in  thickness  the  constant  move- 
ment of  the  adjacent  surfaces  gives  to  it  sometimes  a  ridge-like,  at  others  a 
honeycombed  appearance.  With  more  abundant  fibrinous  exudation  the  mem- 
branes present  an  appearance  resembling  buttered  surfaces  which  have  been 
drawn  apart.  The  fibrin  is  in  long  shreds,  and  the  heart  presents  a  curiously 
shaggy  appearance — the  so-called  hairy  heart  of  old  writers — cor  villosum. 

In  mild  grades  the  subjacent  muscle  looks  normal,  but  in  the  more  pro- 
longed and  severe  eases  there  is  myocarditis,  and  for  2  or  3  mm.  beneath  the 
visceral  layer  the  muscle  presents  a  pale,  turbid  appearance.  Many  of  these 
acute  cases  are  tuberculous  and  the  granulations  are  easily  overlooked  in  a 
superficial  examination. 

There  is  usually  a  slight  amount  of  fluid  entangled  in  the  meshes  of  fibrin, 
but  there  may  be  very  thick  exudate  without  much  serous  effusion. 

Symptoms. — Simple  plastic  pericarditis,  like  simple  endocarditis,  presents 
as  a  rule  no  symptoms,  and  unless  sought  for  there  are  no  objective  signs,  and 
this  is  the  reason  why  it  is  so  often  overlooked,  and  why  in  hospitals  the  dis- 
ease is  relatively  more  common  in  the  post-mortem  room  than  in  the  wards. 

Pain  is  a  variable  s}Tiiptom,  not  usually  intense,  and  in  this  form  rarely 
excited  by  pressure.  It  is  more  marked  in  the  early  stage,  and  may  be 
referred  either  to  the  pra^cordia  or  to  the  region  of  the  xiphoid  cartilage. 
Instances  are  recorded  of  pain  of  an  aggravated  and  most  distressing  char- 
acter resembling  angina.  Fever  is  usually  present,  but  it  is  not  always  easy 
to  say  how  much  depends  upon  the  primary  disease,  and  how  much  upon  the 


DISEASES  OF   THE  PERICARDIUM.  777 

pericarditis.  It  is  as  a  rule  not  high,  rarely  exceeding  103.5°.  In  rheumatic 
cases  hyperpyrexia  has  been  observed. 

Physical  Signs. — Inspection  is  negative;  palpation  may  reveal  the  pres- 
ence of  a  distinct  fremitus  caused  by  the  rubbing  of  the  roughened  pericardial 
surfaces.  This  is  usually  best  marked  over  the  right  ventricle.  It  is  not 
always  to  be  felt,  even  when  the  friction  sound  on  auscultation  is  loud  and 
clear.  Auscultation:  The  friction  sound,  due  to  the  movement  of  the  peri- 
cardial surfaces  upon  each  other,  is  one  of  the  most  distinctive  of  physical 
signs.  It  is  double,  corresponding  to  the  systole  and  diastole;  but  the  syn- 
chronism with  the  heart-sounds  is  not  accurate,  and  the  to-and-fro  murmur 
usually  outlasts  the  time  occupied  by  the  first  and  second  sound.  In  rare 
instances  the  friction  is  single ;  more  frequently  it  appears  to  be  triple  in  char- 
acter— a  sort  of  canter  rhythm.  The  sounds  have  a  peculiar  rubbing,  grating 
quality,  characteristic  when  once  recognized,  and  rarely  simulated  by  endo- 
cardial murmurs.  Sometimes  instead  of  grating  there  is  a  creaking  quality — 
the  bruit  de  cuir  neuf — the  new-leather  murmur  of  the  French.  The  peri- 
cardial friction  appears  superficial,  very  close  to  the  ear,  and  is  usually  inten- 
sified by  pressure  with  the  stethoscope.  It  is  best  heard  over  the  right  ven- 
tricle, the  part  of  the  heart  which  is  most  closely  in  contact  with  the  front 
of  the  chest — that  is,  in  the  fourth  and  fifth  interspaces  and  adjacent  portions 
of  the  sternum.  There  are  instances  in  which  the  friction  is  most  marked  at 
the  base,  over  the  aorta,  and  at  the  superior  reflection  of  the  pericardium. 
Occasionally  it  is  best  heard  at  the  apex.  It  may  be  limited  and  heard  over  a 
very  narrow  area,  or  it  may  be  transmitted  up  and  down  the  sternum.  There 
are,  however,  no  definite  lines  of  transmission  as  in  the  endocardial  murmur. 
An  important  point  is  the  variability  of  the  sounds,  both  in  position  and 
quality;  they  may  be  heard  at  one  visit  and  not  at  another.  The  maximum 
of  intensity  will  be  found  to  vary  with  position.  Friction  may  be  present 
with  a  thin,  almost  imperceptible,  layer  of  exudate;  on  the  other  hand  it  may 
not  be  present  with  a  thick,  buttery  layer.  The  rub  may  be  entirely  obscured 
by  the  loud  bronchial  rales  in  pneumonia,  in  which  disease  pericarditis  is  not 
recognized  clinically  in  more  than  half  the  cases,  only  13  in  31  cases  in  my 
series.  i 

Diagnosis. — There  is  rarely  any  difficulty  in  determining  the  presence  of 
a  dry  pericarditis,  for  the  friction  sounds  are  distinctive.  The  double  murmur 
of  aortic  incompetency  may  simulate  closely  the  to-and-fro  pericardial  rub. 
I  recall  several  instances  in  which  this  mistake  was  made.  The  constant  char- 
acter of  the  aortic  murmur,  the  direction  of  transmission,  the  phenomena  in 
the  arteries,  and  the  associated  conditions  of  the  disease  should  be  sufficient  to 
prevent  this  error. 

I  have  never  known  an  instance  in  which  pericarditis  was  mistaken  for 
acute  endocarditis,  though  writers  refer  to  such,  and  give  the  differential  diag- 
nosis in  the  two  affections  which  so  often  occur  together  in  children.  The 
only  possible  mistake  could  be  made  in  those  rare  instances  of  single  soft, 
systolic,  pericardial  friction. 

Pleuro-pericardial  friction  is  very  common,  and  may  be  associated  with 
endo-pericarditis,  particularly  in  cases  of  pleuro-pneumonia.  It  is  frequent, 
too,  in  tuberculosis.  It  is  best  heard  over  the  left  border  of  the  heart,  and  is 
much  affected  by  the  respiratory  movement.     Holding  the  breath  or  taking 


778  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

a  deep  inspiration  may  annihilate  it.  The  rhytlim  is  not  the  simple  to-and- 
fro  diastolic  and  systolic,  but  the  respiratory  rhythm  is  superadded,  usually 
intensifying  the  murmur  during  expiration  and  lessening  it  on  inspiration. 
In  tuberculosis  of  the  lungs  there  are  instances  in  which,  with  the  friction, 
a  loud  systolic  click  is  heard,  due  to  the  compression  of  a  thin  layer  of  lung 
and  the  expulsion  of  a  bubble  of  air  from  a  small  softening  focus  or  from  a 
bronchus. 

And,  lastly,  it  is  not  very  uncommon,  in  the  region  of  the  apex  beat, 
to  hear  a  series  of  fine  crepitant  sounds,  systolic  in  time,  often  very  dis- 
tinct, suggestive  of  pericardial  adhesions,  but  heard  too  frequently  for  this 
cause. 

Course  and  Termination. — Simple  fibrinous  pericarditis  never  kills,  but 
it  occurs  so  often  in  connection  with  serious  affections  that  we  have  frequent 
opportunities  to  see  all  stages  of  its  progress.  In  the  majority  of  cases  the 
inflammation  subsides  and  the  thin  fibrinous  laminse  gradually  become  con- 
verted into  connective  tissue,  which  unites  the  pericardial  leaves  firmly  to- 
gether. A  very  thin  layer  may  "  clear  "  without  leaving  adhesions.  In  other 
instances  the  inflammation  progresses,  with  increase  of  the  exudation,  and  the 
condition  is  changed  from  a  "  dry  "  to  a  '^  moist "  pericarditis,  or  the  peri- 
carditis with  effusion. 

In  a  few  instances — probably  always  tuberculous — the  simple  plastic  peri- 
carditis becomes  chronic,  and  great  thickening  of  both  visceral  and  parietal 
layers  is  gradually  induced. 

Pericarditis  with  Effusion. 

Commonly  a  direct  sequence  of  the  dry  or  plastic  pericarditis,  of  which 
it  is  sometimes  called  the  second  stage,  this  form  is  found  most  frequently  in 
association  with  acute  rheumatism,  tuberculosis,  and  septicaemia,  and  sets  in 
usually  with  the  s3rmptoms  above  described,  namely,  prsecordial  pain,  with 
slight  fever  or  a  distinct  chill. 

In  children  the  disease  may,  like  pleurisy,  come  on  without  local  symp- 
toms, and,  after  a  week  or  two  of  failing  health,  slight  fever,  shortness  of 
breath,  and  increasing  pallor,  the  physician  may  find,  to  his  astonishment, 
signs  of  most  extensive  pericardial  effusion.  These  latent  cases  are  often 
tuberculous.  W.  Ewart  has  called  special  attention  to  latent  and  ephemeral 
pericardial  effusions,  which  he  thinks  are  often  of  short  duration  and  of 
moderate  size,  with  an  absence  of  the  painful  features  of  pericarditis.  The 
effusion  may  be  sero-fibrinous,  hsemorrhagic,  or  purulent.  The  amount  varies 
from  200  or  300  ec.  to  2  litres.  In  the  cases  of  sero-fibrinous  exudation  the 
pericardial  membranes  are  covered  with  thick,  creamy  fibrin,  which  may  be 
in  ridges  or  honeycombed,  or  may  present  long,  villous  extensions.  The 
parietal  layer  may  be  several  millimetres  in  thickness  and  may  form  a  firm, 
leathery  membrane.  The  hgemorrhagic  exudation  is  usually  associated  with 
tuberculous,  or  with  cancerous  pericarditis,  or  with  the  disease  in  the  aged. 
The  lymph  is  less  abundant,  but  both  surfaces  are  injected  and  often  show 
numerous  htemorrhages.  Thick,  curdy  masses  of  lymph  are  usually  found  in 
the  dependent  part  of  the  sac.  In  the  purulent  effusion  the  fluid  has  a  creamy 
consistency,  particularly  in  tuberculosis.  In  many  cases  the  effusion  is  really 
sero-purulent,  a  thin,  turbid  exudation  containing  flocculi  of  fibrin. 


DISEASES  OF   THE  PERICARDIUM.  779 

The  pericardial  layers  are  greatly  thickened  and  covered  with  fibrin.  When 
tlie  fluid  is  pus,  they  present  a  grayish,  rough,  granular  surface.  Sometimes 
there  are  distinct  erosions  on  the  visceral  membrane.  The  heart  muscle  in 
these  cases  becomes  involved  to  a  greater  or  less  extent,  and  on  section,  the 
tissue,  for  a  depth  of  from  2  to  3  mm.,  is  pale  and  turbid,  and  shows  evi- 
dence of  fatty  and  granular  change.  Endocarditis  coexists  frequently,  but 
rarely  results  from  the  extension  of  the  inflammation  through  the  wall  of 
the  heart. 

Symptoms. — Even  with  copious  effusion  the  onset  and  course  may  be  so 
insidious  that  no  suspicion  of  the  true  nature  of  the  disease  is  aroused. 

As  in  the  simple  pericarditis,  pain  may  be  present,  either  sharp  and  stab- 
bing or  as  a  sense  of  distress  and  discomfort  in  the  cardiac  region.  It  is  more 
frequent  with  effusion  than  in  the  plastic  form.  Pressure  at  the  lower  end  of 
the  sternum  usually  aggravates  it.  Dyspnoea  is  a  common  and  important 
symptom,  one  which,  perhaps,  more  than  any  other,  excites  suspicion  of  grave 
disorder  and  leads  to  careful  examination  of  heart  and  lungs.  The  patient  is 
restless,  lies  upon  the  left  side  or,  as  the  effusion  increases,  sits  up  in  bed. 
Associated  with  the  dyspnoea  is  in  many  cases  a  peculiarly  dusky,  anxious 
countenance.  The  pulse  is  rapid,  small,  sometimes  irregular,  and  may  present 
the  characters  known  as  pulsus  paradoxus,  in  which  during  each  inspiration 
the  pulse-beat  becomes  very  weak  or  is  lost.  These  symptoms  are  due,  in  great 
part,  to  the  direct  mechanical  effect  of  the  fluid  within  the  pericardium  which 
embarrasses  the  heart's  action.  Other  pressure  effects  are  distention  of  the 
veins  of  the  neck,  dysphagia,  which  may  be  a  marked  symptom,  and  irritative 
cough  from  compression  of  the  trachea.  Aphonia  is  not  uncommon,  owing 
to  compression  or  irritation  of  the  recurrent  laryngeal  as  it  winds  round  the 
aorta.  Another  important  pressure  effect  is  exercised  upon  the  left  lung.  In 
massive  effusion  the  pericardial  sac  occupies  such  a  large  portion  of  the  antero- 
lateral region  of  the  left  side  that  the  condition  has  frequently  been  mistaken 
for  pleurisy.  Even  in  moderate  grades  the  left  lung  is  somewhat  compressed, 
an  additional  element  in  the  production  of  the  dyspnoea. 

Great  restlessness,  insomnia,  and  in  the  later  stages  low  delirium  and  coma 
are  symptoms  in  the  more  severe  cases.  Delirium  and  marked  cerebral  symp- 
toms are  associated  with  the  hyperpyrexia  of  rheumatic  cases,  but  apart  from 
the  ordinary  delirium  there  may  be  peculiar  mental  symptoms.  The  patient 
may  become  melancholic  and  show  suicidal  tendencies.  In  other  cases  the 
condition  resembles  closely  delirium  tremens.  Sibson,  who  has  specially  de- 
scribed this  condition,  states  that  the  majority  of  such  cases  recover.  Chorea 
may  also  occur,  as  was  pointed  out  by  Bright.  Epilepsy  is  a  rare  complication 
which  has  occurred  during  paracentesis. 

Physical  Signs. — Inspection. — In  children  the  prsecordia  bulges  and 
with  copious  exudation  the  antero-lateral  region  of  the  left  chest  becomes 
enlarged.  A  wavy  impulse  may  be  seen  in  the  third  and  fourth  interspaces,  or 
there  may  be  no  impulse  visible.  The  intercostal  spaces  bulge  somewhat  and 
there  may  be  marked  oedema  of  the  wall.  The  epigastrium  may  be  more 
prominent.  Perforation  externally  through  a  space  is  very  rare.  Owing  to 
the  compression  of  the  lung,  the  expansion  of  the  left  side  is  greatly  dimin- 
ished. The  diaphragm  and  left  lobe  of  the  liver  may  be  pushed  down  and  may 
produce  a  distinct  prominence  in  the  epigastric  region. 


780  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

Palpation. — A  gradual  diminution  and  final  obliteration  of  the  cardiac 
shock  is  a  striking  feature  in  progressive  effusion.  The  j)osition  of  the  apex 
beat  is  not  constant.  In  large  effusions  it  is  usually  not  felt.  In  children  as 
the  fluid  collects  the  pulsation  may  be  best  seen  in  the  fourth  space,  but  this 
may  not  be  the  apex  itself.  Ewart  maintains  that  the  position  of  the  apex 
beat  is  unaltered,  or  even  depressed.  The  pericardial  friction  may  lessen  with 
the  effusion,  though  it  often  persists  at  the  base  when  no  longer  palpable  over 
the  right  ventricle,  or  may  be  felt  in  the  erect  and  not  in  the  recumbent  pos- 
ture.   Fluctuation  can  rarely,  if  ever,  be  detected. 

Percussion  gives  most  important  indications.  The  gradual  distention  of 
the  pericardial  sac  pushes  aside  the  margins  of  the  lungs  so  that  a  large  area 
comes  in  contact  with  the  chest  wall  and  gives  a  greatly  increased  percussion 
dulness.  The  form  of  this  dulness  is  irregularly  pear-shaped;  the  base  or 
broad  surface  directed  downward  and  the  stem  or  apex  directed  ujDward  toward 
the  manubrium.  A  valuable  sign,  to  which  Eotch  called  attention,  is  the 
absence  of  resonance  in  the  fifth  right  intercostal  space — the  cardio-hepatic 
angle.  In  the  left  infrascapular  area  there  may  be  a  patch  of  diminished  reso- 
nance or  even  flatness  (Ewart). 

Auscultation. — The  friction  sound  heard  in  the  early  stages  may  dis- 
appear when  the  effusion  is  copious,  but  often  persists  at  the  base  or  at  the 
limited  area  of  the  apex.  It  may  be  audible  in  the  erect  and  not  in  the  recum- 
bent posture.  With  the  absorption  of  the  fluid  the  friction  returns.  One  of 
the  most  important  signs  is  the  gradual  weakening  of  the  heart-sounds,  which 
with  the  increase  in  the  effusion  may  become  so  muffled  and  indistinct  as  to 
be  scarcely  audible.  The  heart's  action  is  usually  increased  and  the  rhythm 
disturbed.  Occasionally  a  systolic  endocardial  murmur  is  heard.  Early  and 
persistent  accentuation  of  the  pulmonary  second  sound  may  be  present 
(Warthin). 

Important  accessory  signs  in  large  effusion  are  due  to  pressure  on  the  left 
lung.  The  antero-lateral  margin  of  the  lower  lobe  is  pushed  aside  and  in 
some  instances  compressed,  so  that  percussion  in  the  axillary  region,  in  and 
just  below  the  transverse  nipple  line,  gives  a  modified  percussion  note,  usually 
a  flat  tympany.  Variations  in  the  position  of  the  patient  may  change  mate- 
rially this  modified  percussion  area,  over  which  on  auscultation  there  is  either 
feeble  or  tubular  breathing. 

Course. — Cases  vary  extremely  in  the  rapidity  with  which  the  effusion 
takes  place.  In  every  instance,  when  a  pericardial  friction  murmur  has  been 
detected,  the  practitioner  should  first  outline  with  care — ^using  the  aniline  pen- 
cil or  nitrate  of  silver — the  upper  and  lateral  limits  of  cardiac  dulness,  secondly 
mark  the  position  of  the  apex  beat,  and  thirdly  note  the  intensity  of  the  heart- 
sounds.  In  many  instances  the  exudation  is  slight  in  amount,  reaches  a 
maximum  within  forty-eight  hours,  and  then  gradually  subsides.  In  other 
instances  the  accumulation  is  more  gradual  and  progressive,  increasing  for 
several  weeks.  To  such  cases  the  term  chronic  has  been  applied.  The  rapidity 
with  which  a  sero-fibrinous  effusion  may  be  absorbed  is  surprising.  The  possi- 
bility of  the  absorption  of  a  purulent  exudate  is  shown  by  the  cases  in  which 
the  pericardium  contains  semi-solid  grayish  masses  in  all  stages  of  calcifica- 
tion. With  sero-fibrinous  effusion,  if  moderate  in  amount,  recovery  is  the 
rule,  with  inevitable  union,  however,  of  the  pericardial  layers.    In  some  of  the 


•  DISEASES  OF  THE  PERICARDIUM.  781 

septic  cases  there  is  a  raj)id  formation  of  pus  and  a  fatal  result  may  follow  in 
three  or  four  days.  More  commonly,  when  death  occurs  with  large  effusion,  it 
it  not  until  the  second  or  third  week  and  takes  place  by  gradual  asthenia. 

Prognosis. — In  the  sero-fibrinous  effusions  the  outlook  is  good,  and  a  large 
majority  of  all  the  rheumatic  cases  recover.  The  purulent  effusions  are,  of 
course,  more  dangerous ;  the  septic  cases  are  usually  fatal,  and  recovery  is  rare 
in  the  slow,  insidious  tuberculous  forms. 

Diagnosis. — Probably  no  serious  disease  is  so  frequently  overlooked  by  the 
practitioner.  Post-mortem  experience  shows  how  often  pericarditis  is  not 
recognized,  or  goes  on  to  resolution  and  adhesion  without  attracting  notice. 
In  a  case  of  rheumatism,  watched  from  the  outset,  with  the  attention  directed 
daily  to  the  heart,  it  is  one  of  the  simplest  of  diseases  to  diagnose;  but.  when 
one  is  called  to  a  case  for  the  first  time  and  finds  perhaps  an  increased  area 
of  prtecordial  dulness,  it  is  often  very  hard  to  determine  with  certainty  whether 
or  not  effusion  is  present. 

The  difficulty  usually  lies  in  distinguishing  between  dilatation  of  the  heart 
and  pericardial  effusion.  Although  the  differential  signs  are  simple  enough 
on  paper,  it  is  notoriously  difficult  in  certain  cases,  particularly  in  stout  per- 
sons, to  say  which  of  the  conditions  exists.  The  points  which  deserve  atten- 
tion are: 

(a)  The  character  of  the  impulse,  which  in  dilatation,  particularly  in 
thin-chested  people,  is  commonly  visible  and  wavy. 

(h)  The  shock  of  the  cardiac  sounds  is  more  distinctly  palpable  in  dila- 
tation. 

(c)  The  area  of  dulness  in  dilatation  rarely  has  a  triangular  form;  nor 
does  it,  except  in  cases  of  mitral  stenosis,  reach  so  high  along  the  left  sternal 
margin  or  so  low  in  the  fifth  and  sixth  interspaces  without  visible  or  palpable 
impulse.  An  upper  limit  of  dulness  shifting  with  change  of  position  speaks 
strongly  for  effusion. 

(d)  In  dilatation  the  heart-sounds  are  clearer,  often  sharp,  valvular,  or 
fcBtal  in  character;  gallop  rhythm  is  common,  whereas  in  effusion  the  sounds 
are  distant  and  muffled. 

(e)  Earely  in  dilatation  is  the  distention  sufficient  to  compress  the  lung 
and  produce  the  tympanitic  note  in  the  axillary  region. 

The  number  of  excellent  observers  who  have  acknowledged  that  they  have 
failed  sometimes  to  discriminate  between  these  two  conditions,  and  who  have 
indeed  performed  paracentesis  cordis  instead  of  paracentesis  pericardii^  is  per- 
haps the  best  comment  on  the  difficulties. 

Massive  (1^  to  2  litre)  exudations  have  been  confounded  with  a  pleural 
effusion.  On  more  than  one  occasion  the  pericardium  has  been  tapped  under 
the  impression  that  the  exudate  was  pleuritic.  The  flat  tympany  in  the  infra- 
scapular  region,  the  absence  of  well-defined  movable  dulness,  and  the  feeble, 
muffled  sounds  are  indicative  points.  Followed  from  day  to  day  there  is  rarely 
much  difficulty,  but  it  is  different  when  a  patient  seen  for  the  first  time  pre- 
sents a  large  area  of  dulness  in  the  antero-lateral  region  of  the  left  chest,  and 
there  is  no  to-and-fro  pericardial  friction  murmur.  Many  of  the  cases  have 
been  regarded  as  encapsulated  pleural  effusions. 

A  special  difficulty  exists  in  recognizing  the  large  exudate  in  pneumonia. 
The  effusion  may  be  very  much  larger  than  the  signs  indicate,  and  the  involve- 


782  DISEASES  OF   THE  CIRCULATORY  SYSTEM. 

ment  of  the  adjacent  lung  and  pleura  is  confusing.  In  at  least  tkree  cases 
in  our  series  we  should  have  tapped  the  sac ;  post  mortem  the  effusion  was  more 
than  a  litre. 

The  nature  of  the  fluid  can  not  positively  be  determined  without  aspira- 
tion; but  a  fairly  accurate  opinion  can  be  formed  from  the  nature  of  the 
primary  disease  and  the  general  condition  of  the  patient.  In  rheumatic  cases 
the  exudation  is  usually  sero-fibrinous ;  in  septic  and  tuberculous  cases  it  is 
often  purulent  from  the  outset;  in  senile^  nephritic,  and  tuberculous  cases  the 
exudate  may  be  hfemorrhagic. 

Treatment. — The  patient  should  have  absolute  quiet,  mentally  and  bodily, 
so  as  to  reduce  to  a  minimum  the  heart's  action.  Drugs  given  for  this  pur- 
pose, such  as  aconite  or  digitalis,  are  of  doubtful  utility.  Local  bloodletting 
by  cupping  or  leeches  is  certainly  advantageous  in  robust  subjects,  particularly 
in  the  cases  of  extension  in  pleuro-pneumonia.  The  ice-bag  is  of  great  value. 
It  may  be  applied  to  the  prscordia  at  first  for  an  hour  or  more  at  a  time, 
and  then  continuously.  It  reduces  the  frequency  of  the  heart's  action  and' 
seems  to  retard  the  progress  of  an  effusion.  Blisters  are  not  indicated  in  the 
early  stage. 

When  effusion  is  present,  the  following  measures  to  promote  absorption 
may  be  adopted:  Blisters  to  the  prsecordia,  a  practice  not  so  much  in  vogue 
now  as  formerly.  It  is  surprising,  however,  in  some  instances,  how  quickly 
an  effusion  will  subside  on  their  application.  Purges  and  iodide  of  potassium 
are  of  doubtful  utility.  The  diet  should  be  light,  dry,  and  nutritious.  The 
action  of  the  kidneys  may  be  promoted  by  the  infusion  of  digitalis  and  potas- 
sium acetate. 

With  an  effusion,  so  soon  as  signs  of  serious  impairment  of  the  heart  occur, 
as  indicated  by  dyspnoea,  small  rapid  pulse,  dusky,  anxious  countenance, 
paracentesis,  or  incision  of  the  pericardium,  should  be  performed.  With  the 
sero-fibrinous  exudate,  such  as  commonly  occurs  after  rheumatism,  aspiration 
is  sufficient;  but  when  the  exudate  is  purulent,  the  pericardium  should  be 
freel}'  incised  and  freely  drained.  The  puncture  may  be  made  in  the  fourth 
or  fifth  interspace,  in  or  outside  the  nipple  line.  In  large  effusions  the  peri- 
cardium can  be  readily  reached  without  danger  by  thrusting  the  needle  upward 
and  backward  close  to  the  costal  margin  in  the  left  costo-xiphoid  angle.  The 
results  of  paracentesis  of  the  pericardium  have  so  far  not  been  satisfactory. 
With  an  earlier  operation  in  many  instances  and  a  more  radical  one  in  others 
— incision  and  free  drainage,  not  aspiration,  when  the  fluid  is  purulent — 
the  percentage  of  recoveries  will  be  greatly  increased.  Eepeated  tapping  may 
be  needed.  One  case  of  tuberculous  effusion,  tapped  three  times,  recovered 
completely  and  was  alive  three  years  afterward. 

Cheoxic  Adhesive  Peeicaeditis   {Adherent  Pericardium). 

The  remote  prognosis  in  pericarditis  is  very  variable.  A  large  majority  of 
these  cases  get  well  and  have  no  further  trouble,  but  in  young  persons  serious 
results  sometimes  follow  adhesions  and  thickening  of  the  layers.  As  Sequira 
has  pointed  out.  the  danger  is  here  directly  in  proportion  to  the  amount  of  dila- 
tation and  weakening  of  the  pericardium  in  consequence  of  the  inflammation. 
The  loss  of  the  firm  support  afforded  to  the  heart  by  the  rigid  fibrous  bag 


DISEASES  OF  THE  PERICARDIUM.  783 

in  which  it  is  enclosed,  is  the  important  factor.  Tliere  are  two  groups  of 
cases  of  adherent  pericardium : 

(a)  Simple  adhesion  of  the  peri-  and  epicardial  layers,  a  common  sequence 
of  pericarditis,  met  with  post  mortem  as  an  accidental  lesion.  It  is  not 
necessarily  associated  with  disturbance  in  the  function  of  the  heart,  which  in 
a  large  proportion  of  the  cases  is  neither  dilated  nor  hypertrophied. 

(&)  Adherent  pericardium  with  chronic  mediastinitis  and  union  of  the 
outer  layer  of  the  pericardium  to  the  pleura  and  to  the  chest  walls.  This 
constitutes  one  of  the  most  serious  forms  of  cardiac  disease,  particularly  in 
early  life,  and  may  lead  to  an  extreme  grade  of  hypertrophy  and  dilatation  of 
the  heart.  The  peritoneum  may  be  involved  with  perihepatitis,  cirrhosis,  and 
ascites  (Pick's  disease). 

Symptoms. — The  symptoms  of  adherent  pericardium  are  those  of  hyper- 
trophy and  dilatation  of  the  heart,  and  later  of  cardiac  insufficiency.  G.  D. 
Head  in  a  careful  study  of  59  cases  divides  them  into  a  small  silent  group 
with  no  symptoms,  a  larger  group  with  all  the  features  of  cardiac  disease,  and 
a  third  group,  comprising  11  cases  in  his  series  in  which  the  features  were 
hepatic. 

Diagnosis. — The  following  are  important  points  in  the  diagnosis:  Inspec- 
tion.— A  majority  of  the  signs  of  value  come  under  this  heading,  (a)  The 
prgecordia  is  prominent  and  there  may  be  marked  asymmetry,  owing  to  the  enor- 
mous enlargement  of  the  heart.  ( & )  The  extent  of  the  cardiac  impulse  is  greatly 
increased,  and  may  sometimes  be  seen  from  the  third  to  the  sixth  interspaces, 
and  in  extreme  cases  from  the  right  parasternal  line  to  outside  the  left  nipple, 
(c)  The  character  of  the  cardiac  impulse.  It  is  undulatory,  wavy,  and  in 
the  apex  region  there  is  marked  systolic  retraction,  (d)  Diaphragm  phe- 
nomena. J.  F.  H.  Broadbent  has  called  attention  to  a  very  valuable  sign  in 
adherent  pericardium.  When  the  heart  is  adherent  over  a  large  area  of  the  dia- 
phragm there  is  with  each  pulsation  a  systolic  tug,  which  may  be  communicated 
through  the  diaphragm  to  the  points  of  its  attachment  on  the  wall,  causing  a 
visible  retraction.  This  has  long  been  recognized  in  the  region  of  the  seventh 
or  eighth  rib  in  the  left  parasternal  line,  but  Dr.  Broadbent  called  attention 
to  the  fact  that  it  was  frequently  best  seen  on  the  left  side  behind,  between 
the  eleventh  and  twelfth  ribs.  This  is  a  very  valuable  and  quite  common  sign, 
and  may  sometimes  be  very  localized.  One  difficulty  is  that,  as  A.  W.  Tallant 
has  pointed  out,  it  may  occur  in  thin-chested  persons  with  great  hypertrophy 
of  the  heart.  Sir  William  Broadbent  calls  attention  also  to  the  fact  that  owing 
to  the  attachment  of  the  heart  to  the  central  tendon  of  the  diaphragm  this 
part  does  not  descend  with  inspiration,  during  which  act  there  is  not  the  visible 
movement  in  the  epigastrium,  (e)  Diastolic  collapse  of  the  cervical  veins,  the 
so-called  Friedreich's  sign.     This  is  not  of  much  moment. 

Palpation. — The  apex  beat  is  fixed,  and  turning  the  patient  on  the  left  side 
does  not  alter  its  position.  This  I  have  found,  however,  somewhat  uncertain. 
On  placing  the  hand  over  the  heart  there  is  felt  a  diastolic  shock  or  reboimd, 
which  some  have  regarded  as  the  most  reliable  of  all  signs  of  adherent  peri- 
cardium. 

Percussion. — The  area  of  cardiac  dulness  is  usually  much  increased.  In 
a  majorit}^  of  instances  there  are  adhesions  between  the  pleura  and  the  peri- 
cardium, and  the  limit  of  cardiac  dulness  above  and  to  the  left  may  be  fixed 


784  DISEASES  OF   THE  CIRCULATORY  SYSTEM. 

and  is  uninfluenced  l\y  deep  inspiration.  This,  too,  is  an  uncertain  sign,  inas- 
much as  there  may  be  close  adhesions  between  the  pleura  and  the  pericardium 
and  between  the  pleura  and  the  chest  wall,  which  at  the  same  time  allow  a 
very  considerable  degree  of  mobility  to  the  edge  of  the  lung. 

Auscultation. — The  phenomena  are  variable  and  uncertain.  In  the  cases 
in  children  with  a  history  of  rheumatism,  endocarditis  has  usually  been  pres- 
ent. Even  in  the  absence  of  chronic  endocarditis,  when  the  dilatation  reaches 
a  certain  grade  there  are  murmurs  of  relative  insufficiency,  which,  as  in  one 
ease  I  have  recorded,  may  be  present  not  only  at  the  mitral  but  also  at  the  tri- 
cuspid and  pulmonary  orifices.  Theodore  Fisher  has  called  attention  to  the 
fact  that  there  may  be  a  well-marked  presystolic  murmur  in  connection  with 
adherent  pericardium.  Occasionally  the  layers  of  the  pericardium  are  united 
in  places  by  strong  fibrous  bands,  5-7  mm.  long  by  3-5  mm.  wide.  In  one 
such  case  Drasche  heard  a  remarkable  whirring,  systolic  murmur  with  a  twang- 
ing quality. 

The  pulsus  paradoxus,  in  which  during  inspiration  the  pulse- wave  is  small 
and  feeble,  is  sometimes  present,  but  it  is  not  a  diagnostic  sign  of  either  simple 
pericardial  adhesion  or  of  the  cicatricial  mediastino-pericarditis. 

Chronic  adhesive  pericarditis  and  mediastinitis  may  be  associated  with 
proliferative  peritonitis,  perihepatitis,  and  perisplenitis — the  polyserositis,  sim- 
ple or  tuberculous — in  which  condition  ascites  may  recur  for  months,  or  even 
for  years. 

Cardiohjsis.  Brauer's  operation,  has  been  proposed  for  this  condition  and 
has  been  helpful  in  a  few  cases.  Four  or  five  centimetres  of  the  fourth,  fifth, 
and  sixth  left  ribs  with  a  couple  of  centimetres  of  the  corresponding  cartilages 
are  resected,  by  wMch  means  the  heart's  action  is  less  embarrassed.  It  is  a 
justifiable  procedure  in  selected  cases — in,  for  example,  a  child  with  a  very 
large,  tumultuously  acting  heart,  with  much  bulging  of  the  chest. 

II.     OTHER   AFFECTIONS    OF    THE    PERICARDIUM. 

(1)  Hydropericardium.— The  pericardial  sac  contains  post  mortem  a  few 
cubic  centimetres  of  clear,  citron-colored  fluid.  In  connection  with  general 
dropsy,  due  to  kidney  or  heart  disease,  more  commonly  the  former,  the 
effusion  may  be  excessive,  adding  to  the  embarrassment  of  the  heart  and  the 
lungs,  particularly  when  the  pleural  cavities  are  the  seat  of  similar  transuda- 
tion. There  are  rare  instances  in  which  effusion  into  the  pericardium  occurs 
after  scarlet  fever  with  few,  if  any,  other  dropsical  symptoms.  Hydropericar- 
dium is  frequently  overlooked. 

In  rare  cases  the  serum  has  a  milkj'  character — chylopericardimn. 

(2)  Hsemopericardiuin. — This  condition  is  met  with  in  aneurism  of  the 
first  part  of  the  aorta,  of  the  cardiac  wall,  or  of  the  coronary  arteries,  and  in 
rupture  and  wounds  of  the  heart.  Death  usually  follows  before  there  is  time 
for  the  production  of  symptoms  other  than  those  of  rapid  heart-failure  due  to 
compression.  In  rupture  of  the  heart  the  patient  may  live  for  many  hours  or 
even  days  with  symptoms  of  progressive  heart-failure,  dyspnoea,  and  the 
physical  signs  of  effusion. 

In  the  pericarditis  of  tuberculosis,  of  cancer,  of  Bright's  disease,  and  of 
old  people,  the  inflammatory  exudate  is  often  blood-stained. 


DISEASES  OF  THE  HEART.  785 

(3)  Pneumopericardium. — This  is  an  excessively  rare  condition,  of  which 
Walter  James  was  able  to  collect  in  1903  only  38  cases.  I  have  met  with  but 
one  instance,  from  rupture  of  a  cancer  of  the  stomach.  Perforation  of  the  sac 
occurred  in  all  but  5,  in  which  the  gas  bacillus  was  the  possible  cause,  as  in 
Nicholl's  case  at  the  Royal  Victoria  Hospital,  Montreal,  this  organism  was  iso- 
lated. Seven  cases  were  due  to  perforation  of  the  oesophagus  and  eight  to  pene- 
trating wounds  from  without.  •  The  physical  signs  are  most  characteristic. 
A  tympany  replaces  the  normal  pericardial  flatness.  On  auscultation  there  is 
a  splashing,  gurgling,  churning  sound,  called  by  the  French  hruit  de  moulin. 
This  was  described  in  19  of  the  cases  collected  by  James.  Of  the  38  cases,  26 
died. 

(4)  Calciied  Pericardium. — This  remarkable  condition  may  follow  peri- 
carditis, particularly  the  suppurative  and  tuberculous  forms;  occasionally  it 
extends  from  the  calcified  valves.  It  may  be  partial  or  complete.  Of  59  cases 
collected  by  A.  E.  Jones,  in  38  there  were  no  cardiac  symptoms.  Adherent 
pericardium  was  diagnosed  in  one  case.  Jones's  careful  study  shows  that  the 
condition  is  usually  latent  and  unrecognized. 


B.    DISEASES  OF  THE  HEABT. 

I.     ENDOCARDITIS. 

Inflammation  of  the  lining  membrane  of  the  heart  is  usually  confined  to 
the  valves,  so  that  the  term  is  practically  synonymous  with  valvular  endo- 
carditis. It  occurs  in  two  forms — acute,  characterized  by  the  presence  of 
vegetations  with  loss  of  continuity  or  of  substance  in  the  valve  tissues ;  chronic, 
a  slow  sclerotic  change,  resulting  in  thickening,  puckering,  and  deformity. 

Acute  Endocarditis. 

This  occurs  in  rare  instances  as  a  primary,  independent  affection;  but 
in  the  great  majority  of  cases  it  is  an  accident  in  various  infective  processes, 
so  that  in  reality  the  disease  does  not  constitute  an  etiological  entity. 

For  convenience  of  description  we  speak  of  a  simple  or  benign,  and  a 
malignant,  ulcerative,  or  infective  endocarditis,  between  which,  however,  there 
is  no  essential  anatomical  difference,  as  all  gradations  can  be  traced,  and  they 
represent  but  different  degrees  of  intensity  of  the  same  process. 

Etiology. — Simple  Endocaeditis  does  not  constitute  a  disease  of  itself, 
but  is  invariably  found  with  some  other  affection.  In  330  cases  of  rheumatic 
fever  at  the  Johns  Hopkins  Hospital  there  were  110  cases  of  endocarditis. 
Bouillaud  first  emphasized  the  frequency  of  the  association  of  simple  endo- 
carditis with  rheumatic  fever.  Before  him,  however,  the  association  had  been 
noticed.  Possibly  it  is  nothing  in  the  disease  itself,  but  simply  an  altered 
state  of  the  fluid  media — a  reduction  perhaps  of  the  lethal  influences  which 
they  normally  exert — permitting  the  invasion  of  the  blood  by  certain  micro- 
organisms. Tonsillitis,  which  in  some  forms  is  regarded  as  a  rheumatic  affec- 
tion, may  be  complicated  with  endocarditis.  Of  the  specific  diseases  of  child- 
hood it  is  not  uncommon  in  scarlet  fever,  while  it  is  rare  in  measles  and 
51 


786  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

cliieken-pnx.  In  diphtheria  simple  endocarditis  is  rare.  In  small-pox  it  is  not 
common.     In  tyj^hoid  fever  it  occurred  six  times  among  1.500  cases. 

In  pneumonia  both  simple  and  malignant  endocarditis  are  common.  In 
100  autopsies  in  this  disease  made  at  the  Montreal  General  Hospital  there  were 
5  instances  of  the  former.  Among  61  cases  of  endocarditis  studied  bacterio- 
logically  in  Welch's  laboratory,  pneumococci  were  found  in  21  (Marshall). 
Of  517  fatal  cases  of  acute  endocarditis,  115  were  in  connection  with  pneu- 
monia— 22.3  per  cent  (E.  F.  Wells).  Acute  endocarditis  is  by  no  means  rare 
in  phthisis.    I  found  it  in  12  cases  in  216  post  mortems. 

In  chorea  simple  warty  vegetations  are  found  on  the  valves  in  a  large 
majority  of  all  fatal  cases,  in  62  of  73  cases  collected  by  me.  There  is  no 
disease  in  which,  post  mortem,  acute  endocarditis  has  been  so  frequently  found. 
And,  lastly,  simple  endocarditis  is  met  with  in  diseases  associated  with  loss 
of  flesh  and  progressive  debility,  as  cancer,  and  such  disorders  as  gout,  dia- 
betes, and  Bright's  disease. 

A  very  common  form  is  that  which  occurs  on  the  sclerotic  valves  in  old 
heart-disease — the  so-called  recurring  endocarditis. 

Maligxaxt  or  ixfective  E^^)OCARDITIS  is  met  with:  (a)  As  a  primary 
disease  of  the  lining  membrane  of  the  heart  or  of  its  valves. 

(&)  As  a  secondary  affection  in  acute  rheumatism,  pneumonia,  in  various 
specific  fevers,  in  septic  processes  of  all  sorts,  and  most  frequently  of  all  as 
an  infection  on  old  sclerotic  valves.  In  a  majorit}'  of  all  cases  it  is  a  local 
process  in  an  acute  infection.  Congenital  lesions  are  very  prone  to  the  severer 
t}^es  of  endocarditis,  particularly  affections  of  the  orifice  of  the  pulmonary 
artery  and  the  margins  of  the  imperfect  ventricular  septum  (C.  Eobinson). 

The  existence  of  a  primary  endocarditis  has  been  doubted ;  but  there 
are  instances  in  which  persons  previously  in  good  health,  without  any  history  of 
affections  with  which  endocarditis  is  usually  associated,  have  been  attacked 
with  s}Tnptoms  resembling  severe  tj^hus  or  typhoid.  In  one  case  which  I  saw, 
death  occurred  on  the  sixth  day  and  no  lesions  were  found  other  than  those  of 
malignant  endocarditis. 

The  simple  endocarditis  of  rheumatic  fever  or  of  chorea  rarely  progresses 
into  the  malignant  form.  In  only  21:  of  209  cases  the  spnptoms  of  severe  endo- 
carditis arose  in  the  progress  of  acute  or  subacute  rheumatism.  Of  all  acute 
diseases  complicated  with  severe  endocarditis  pneumonia  probably  heads  the 
list.  Gonorrhcea  is  a  much  more  common  cause  than  has  been  supposed. 
There  have  been  at  least  ten  instances  in  my  wards. 

The  affection  may  complicate  erysipelas,  septicsemia  (from  whatever  cause), 
and  puerperal  fever.  Malignant  endocarditis  is  very  rare  in  tuberculosis, 
typhoid  fever,  and  diphtheria. 

It  has  been  stated  by  many  -^Titers  that  endocarditis  occurs  in  malaria. 
With  the  unusual  facilities  for  the  study  of  this  disease  which  I  have  had  in  the 
past  sixteen  years  I  have  not  yet  met  with  an  instance.  In  dysentery,  in  small- 
pox, and  in  scarlet  fever,  with  which  simple  endocarditis  is  not  infrequently 
complicated,  the  malignant  form  is  extremely  rare. 

Morbid  Anatomy  of  Simple  and  Malignant  Endocarditis. — Simple  endo- 
CAEDiTis  is  characterized  by  the  presence  on  the  valves  or  on  the  lining  mem- 
brane of  the  chambers  of  minute  vegetations,  ranging  from  1  to  4  mm.  in 
diameter,  with  an  irregular  and  fissured  surface,  giving  to  them  a  warty  or 


DISEASES  OF   THE  HEART.  787 

verrucose  appearance.  Often  these  little  cauliflower-like  excrescences  are 
attached  by  very  narrow  pedicles.  They  are  more  common  on  the  left  side  of 
the  heart  than  the  right,  and  occur  on  the  mitral  more  often  than  on  the  aortic 
valves.  The  vegetations  are  upon  the  line  of  closure  of  the  valves — i.  e.,  on  the 
auricular  face  of  the  auriculo-ventricular  valves,  a  little  distance  from  the 
margin,  and  on  the  ventricular  side  of  the  sigmoid  valves,  festooned  on  either 
half  of  the  valve  from  the  corpus  Arantii.  It  is  rare  to  see  any  swelling  or 
macroscopic  evidence  of  infiltration  of  the  endocardium  in  the  neighborhood 
of  even  the  smallest  of  the  granulations,  or  of  redness,  indicative  of  distention 
of  the  vessels,  even  when  they  occur  upon  valves  already  the  seat  of  sclerotic 
changes,  in  which  capillary  vessels  extend  to  the  edges.  With  time  the  vegeta- 
tions may  increase  greatly  in  size,  but  in  what  may  be  called  simple  endo- 
carditis the  size  rarely  exceeds  that  mentioned  above. 

The  earliest  vegetations  consist  of  elements  derived  from  the  blood,  and 
are  composed  of  blood  platelets,  leucocytes,  and  fibrin  in  varying  proportions. 
At  a  later  stage  they  appear  as  small  outgrowths  of  connective  tissue.  The 
transition  of  one  form  into  the  other  can  often  be  followed.  The  process  con- 
sists of  a  proliferation  of  the  endothelial  cells  and  the  cells  of  the  subendo- 
thelial  layer  which  gradually  invade  the  fresh  vegetation,  and  ultimately 
entirely  replace  it.  The  blood-cells  and  fibrin  undergo  disintegration  and 
gradually  they  are  removed.  The  whole  process  has  received  the  name  of 
"  organization."  Even  when  the  vegetation  has  been  entirely  converted  into 
connective  tissue  it  is  often  found  at  autopsy  to  be  capped  with  a  thin  layer 
of  fibrin  and  leucocytes. 

Micro-organisms  are  generally,  even  if  not  invariably,  found  associated 
with  the  vegetations.  They  tend  to  be  entangled  in  the  granular  and  fibrillated 
fibrin  or  in  the  older  ones  to  cap  the  apices. 

Subsequent  Changes. —  (1)  The  vegetations  may  become  organized  and 
the  valve  restored  to  a  normal  state  (  ?).  (2)  The  process  may  extend,  and  a 
simple  may  become  an  ulcerative  endocarditis.  (3)  The  vegetations  may  be 
broken  off  and  carried  in  the  circulation  to  distant  parts.  (4)  The  vegeta- 
tions become  organized  and  disappear,  but  they  initiate  a  nutritive  change 
in  the  valve  tissue  which  ultimately  leads  to  sclerosis,  thickening,  and  de- 
formity. The  danger  in  any  case  of  simple  endocarditis  is  not  immediate, 
but  remote,  and  consists  in  this  perversion  of  the  normal  processes  of  nutri- 
tion which  results  in  sclerosis  of  the  valves. 

A  gradual  transition  from  the  simple  to  a  more  severe  affection,  to  which 
the  name  malignant  or  ulcerative  endocarditis  has  been  given,  may  be 
traced.  Practically  in  every  case  of  ulcerative  endocarditis  vegetations  are 
present.  In  this  form  the  loss  of  substance  in  the  valve  is  more  pronounced, 
the  deposition — thrombus  formation — from  the  blood  is  more  extensive,  and 
the  micro-organisms  are  present  in  greater  number  and  often  show  increased 
virulence.  Ulcerative  endocarditis  is  often  found  in  connection  with  heart 
valves  already  the  seat  of  chronic  proliferative  and  sclerotic  changes. 

In  this  form  there  is  much  loss  of  substance,  which  may  be  superficial  and 
limited  to  the  endocardium,  or,  what  is  more  common,  it  involves  deeper  struc- 
tures, and  not  very  infrequently  leads  to  perforation  of  a  valve,  the  septum, 
or  even  of  the  heart  itself. 

Upon  microscopical  examination  the  affected  valve  shows  necrosis,  with 


788  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

more  or  less  loss  of  substance;  the  tissue  is  devoid  of  preserved  nuclei  and 
presents  a  coagulated  appearance.  Upon  it  a  mixture  of  blood  platelets,  fibrin 
— granular  or  fibrillated — and  leucocytes  enclosing  masses  of  micro-organisms 
are  met  with.  The  subjacent  tissue  often  shows  sclerotic  thickening  and 
always  infiltration  with  exuded  cells. 

Paets  Affected. — The  following  figures,  taken  from  my  Goulstonian  lec- 
tures, give  an  approximate  estimate  of  the  frequency  with  which  in  209  cases 
different  parts  of  the  heart  were  affected  in  malignant  endocarditis:  Aortic 
and  mitral  valves  together,  in  41;  aortic  valves  alone,  in  53;  mitral  valves 
alone,  in  77;  tricuspid  in  19;  the  pulmonary  valves  in  15;  and  the  heart  walls 
in  33.  In  9  instances  the  right  heart  alone  was  involved,  in  most  cases  the 
auriculo-ventricular  valves. 

Mural  endocarditis  is  seen  most  often  at  the  upper  part  of  the  septum 
of  the  left  ventricle.  ;N"ext  in  order  is  the  endocarditis  of  the  left  auricle  on 
the  postero-external  wall.  The  vegetations  may  extend,  as  in  a  case  in  my 
wards,  along  the  intima  of  the  pulmonary  artery  into  the  hilum  of  the  lung. 
A  common  result  of  the  ulceration  is  the  production  of  valvular  aneurism. 
In  three-fourths  of  the  cases  the  affected  valves  present  old  sclerotic  changes. 
The  process  may  extend  to  the  aorta,  producing,  as  in  one  of  my  cases,  exten- 
sive endarteritis  with  multiple  acute  aneurisms. 

Associated  Lesioxs. — The  associated  changes  are  those  of  the  primary 
disease,  those  due  to  embolism,  and  the  changes  in  the  myocardium.  In  the 
endocarditis  of  septic  processes  there  is  the  local  lesion — an  acute  necrosis,  a 
suppurative  wound,  or  puerperal  disease.  In  many  cases  the  lesions  are  those 
of  pneumonia,  rheumatism,  or  other  febrile  processes. 

The  changes  due  to  embolism  constitute  the  most  striking  features,  but  it 
is  remarkable  that  in  some  instances,  even  with  endocarditis  of  a  markedly 
ulcerative  character,  there  may  be  no  trace  of  embolic  processes.  The  infarcts 
may  be  few  in  number — only  one  or  two,  perhaps,  in  the  spleen  or  kidney — 
or  they  may  exist  in  hundreds  throughout  the  various  parts  of  the  body.  They 
may  present  the  ordinary  appearance  of  red  or  white  infarcts  of  a  suppurative 
character.  They  are  most  common  in  the  spleen  and  kidneys,  though  they  may 
be  numerous  in  the  brain,  and  in  many  cases  are  very  abundant  in  the  intes- 
tines. In  right-sided  endocarditis  there  may  be  infarcts  in  the  lungs.  In 
many  of  the  cases  there  are  innumerable  miliar}^  abscesses.  Acute  suppurative 
meningitis  was  met  with  in  5  of  23  of  the  Montreal  cases,  and  in  over  10  per 
cent  of  the  209  cases  analyzed  in  the  literature.  Acute  suppurative  parotitis 
also  may  occur.  And,  lastly,  as  Eomberg  has  pointed  out,  the  oft  accompanying 
myocarditis  plays  an  important  role.  The  valvular  insufficiency  in  an  acute 
endocarditis  is  probably  not  due  to  the  row  of  little  vegetations,  but  to  the 
associated  myocarditis,  which  interferes  with  the  proper  closure  of  the  orifice. 

Bacteriology. — Xo  distinction  in  the  micro-organisms  found  in  the  two 
forms  of  endocarditis  can  be  made.  In  both  the  pyogenic  cocci — strepto- 
cocci, staph3'lococci,  pneumococci,  and  gonococci — are  the  most  frequent  bac- 
teria met  with.  More  rarely,  especially  in  the  simple  vegetative  endocarditis, 
the  bacilli  of  tuberculosis,  typhoid  fever,  and  anthrax  have  been  encountered. 
The  bacillus  coli  communis  has  also  been  found,  and  Howard  has  described 
a  case  of  malignant  endocarditis  due  to  an  attenuated  form  of  the  diphtheria 
bacillus.    Marshall  in  61  cases  found  the  pneumococci  in  21,  streptococci  alone 


DISEASES  OF  THE  HEART.  789 

or  with  other  bacteria  in  26,  staphylococcus  pyogenes  aureus  in  13.  Combined 
infections  are  not  uncommon. 

As  a  rule  no  organisms  are  found  in  the  simple  endocarditis  in  many 
chronic  diseases,  as  carcinoma,  tuberculosis,  nephritis,  etc.  They  may  have 
been  present  and  died  out,  or  the  lesions  may  be  caused  by  the  toxins. 

Symptoms. — Neither  the  clinical  course  nor  the  physical  signs  of  simple 
ENDOCARDITIS  are  in  any  respect  characteristic.  The  great  majority  of  the 
cases  are  latent  and  there  is  no  indication  whatever  of  cardiac  mischief. 
Experience  has  taught  us  that  endocarditis  is  frequently  found  post  mortem 
in  persons  in  whom  it  was  not  suspected  during  life.  There  are  certain  fea- 
tures, however,  by  which  its  presence  is  indicated  with  a  degree  of  probability. 
The  patient,  as  a  rule,  does  not  complain  of  any  pain  or  cardiac  distress.  In 
a  case  of  acute  rheumatism,  for  example,  the  symptoms  to  excite  suspicion 
would  be  increased  rapidity  of  the  heart's  action,  perhaps  slight  irregularity, 
and  an  increase  in  the  fever,  without  aggravation  of  the  joint  trouble.  Eows  of 
tiny  vegetations  on  the  mitral  or  on  the  aortic  segments  seem  a  trifling  matter 
to  excite  fever,  and  it  is  difficult  in  the  endocarditis  of  febrile  processes  to  say 
definitely  in  every  instance  that  an  increase  in  the  fever  depends  upon  this 
complication ;  but  a  study  of  the  recurring  endocarditis — which  is  of  the  warty 
variety,  consisting  of  minute  beads  on  old  sclerotic  valves — shows  that  the 
process  may  be  associated,  for  days  or  weeks  at  a  time,  with  slight  fever  ranging 
from  100°  to  102^°.  Palpitation  may  be  a  marked  feature  and  is  a  symptom 
upon  which  certain  authors  lay  great  stress. 

The  diagnosis  of  the  condition  rests  upon  physical  signs,  which  are 
notoriously  uncertain.  The  presence  of  a  murmur  at  one  or  other  of  the  car- 
diac areas  in  a  ease  of  fever  is  often  taken  as  proof  of  the  existence  of  endo- 
carditis— a  common  mistake  which  has  arisen  from  the  fact  that  the  hruit 
de  souffle  or  bellows  murmur  is  common  to  it  and  to  a  number  of  other  con- 
ditions. At  first  there  may  be  only  a  slight  roughening  of  the  first  sound, 
which  may  gradually  increase  to  a  distinct  murmur.  The  apex  systolic  bruit 
is  probably  more  often  the  result  of  a  myocarditis.  It  may  not  be  present  in 
the  endocarditis  of  such  chronic  maladies  as  tuberculosis  and  carcinoma,  since 
in  them  the  muscle  involvement  is  less  common  (Krehl).  Reduplication  and 
accentuation  of  the  pulmonic  second  sound  are  frequently  present. 

It  is  difficult  to  give  a  satisfactory  clinical  picture  of  malignant  endo- 
CAEDiTis  because  the  modes  of  onset  are  so  varied  and  the  symptoms  so  diverse. 
Arising  in  the  course  of  some  other  disease,  there  may  be  simply  an  intensifica- 
tion of  the  fever  or  a  change  in  its  character.  In  a  majority  of  the  cases  there 
are  present  certain  general  features,  such  as  irregular  pyrexia,  sweating,  delir- 
ium, and  gradual  failure  of  strength. 

Embolic  processes  may  give  special  characters,  such  as  delirium,  coma  or 
paralysis  from  involvement  of  the  brain  or  its  membranes,  pain  in  the  side  and 
local  peritonitis  from  infarction  of  the  spleen,  bloody  urine  from  implication 
of  the  kidneys,  impaired  vision  from  retinal  haemorrhage  and  suppuration, 
and  even  gangrene,  in  various  parts  from  the  distribution  of  the  emboli. 

Two  special  types  of  the  disease  have  been  recognized — the  septic  or  pysemic 
and  the  typhoid.  In  some  the  cardiac  symptoms  are  most  prominent,  while  in 
others  again  the  main  symptoms  may  be  those  of  an  acute  affection  of  the 
cerebro-spinal  system. 


790  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

The  septic  type  is  met  witli  usually  in  connection  with  an  external  wound, 
the  puerperal  process,  or  an  acute  necrosis  or  gonorrhoea.  There  are  rigors, 
sweats,  irregular  fever,  and  all  of  the  signs  of  septic  infection.  The  heart 
sj^mptoms  may  be  completely  masked  by  the  general  condition,  and  attention 
called  to  them  only  on  the  occurrence  of  embolism.  In  many  cases  the  features 
are  those  of  a  severe  septicemia,  and  the  organisms  may  be  isolated  from  the 
blood. 

The  typhoid  type  is  by  far  the  most  common  and  is  characterized  by  a 
less  irregular  temperature,  early  prostration,  delirium,  somnolence,  and  coma, 
relaxed  bowels,  sweating,  which  may  be  of  a  most  drenching  character, 
petechial  and  other  rashes,  and  occasionally  parotitis.  The  heart  symptoms 
may  be  comiDletely  overlooked,  and  in  some  instances  the  most  careful  exam- 
ination has  failed  to  discover  a  murmur. 

Under  the  cardiac  groups  as  suggested  by  Bramwell,  may  be  considered 
those  cases  in  which  patients  with  chronic  valve  disease  are  attacked  with 
marked  fever  and  evidence  of  recent  endocarditis.  Many  such  cases  present 
symptoms  of  the  pygemic  and  t^^hoid  character  and  run  a  most  acute  course. 
In  others  there  may  be  only  slight  fever  or  even  after  a  period  of  high  fever 
recovery  takes  place. 

In  what  may  be  termed  the  cerebral  group  of  cases  the  clinical  picture 
may  simulate  a  meningitis,  either  basilar  or  cerebro-spinal.  There  may  be 
acute  delirium  or,  as  in  three  of  the  Montreal  cases,  the  patient  may  be  brought 
into  the  hospital  unconscious.  Heineman  reports  an  instance,  with  autopsy, 
in  which  the  clinical  picture  was  that  of  an  acute  cerebro-spinal  meningitis. 

Certain  special  symptoms  may  be  mentioned.  The  fever  is  not  always  of 
a  remittent  tA-pe.  but  may  be  high  and  continuous.  Petechial  rashes  are  very 
common  and  render  the  similarity  very  strong  to  certain  cases  of  typhoid  and 
cerebro-spinal  fever.  In  one  case  the  disease  was  thought  to  be  hgemorrhagie 
small-pox.  Erythematous  rashes  are  not  uncommon.  The  sweating  may  be 
most  profuse,  even  exceeding  that  which  occurs  in  phthisis  and  ague.  Diar- 
rhoea is  not  necessarily  associated  vdth  embolic  lesions  in  the  intestines. 
Jaimdice  has  been  observed  and  cases  are  on  record  which  were  mistaken  for 
acute  yellow  atrophy. 

The  heart  symptoms  may  be  entirely  latent  and  are  not  found  unless  a 
careful  search  be  made.  Even  on  examination  there  may  be  no  murmur 
present.  Instances  are  recorded  by  careful  observers,  in  which  the  examination 
of  the  heart  has  been  negative.  Cases  with  chronic  valve  disease  usually  pre- 
sent no  diflBculty  in  diagnosis. 

The  course  of  the  disease  is  varied,  depending  largely  upon  the  nature  of 
the  primary  trouble.  Except  in  the  disease  grafted  upon  chronic  valvulitis 
the  course  is  rarely  extended  beyond  five  of  six  weeks.  The  most  rapidly  fatal 
case  on  record  is  described  by  Eberth,  the  duration  of  which  was  scarcely  two 
days.  There  is,  however,  a  remarkable  form  characterized  by  an  unusual 
chronicity,  to  which  the  name  may  be  given  of  cheoxic  ixfective  endo- 
CAEDiTis.  It  is  almost  always  engrafted  on  an  old,  sometimes  an  unrecog- 
nized, valve  lesion.  At  fii'st  fever  is  the  only  symptom;  in  a  few  cases  there 
have  been  chills  at  onset  or  recurring  chills  may  arouse  the  suspicion  of 
malaria.  The  patient  may  keep  at  work  for  months  with  a  daily  rise  of 
temperature,   or  perhaps  an  occasional   sweat.     The  heart  features  may  be 


DISEASES  OF   THE  HEART.  791 

overlooked.  The  murmur  of  the  old  valve  lesion  may  show  no  change,  and 
even  with  the  most  extensive  disease  of  the  mitral  cusps  the  heart's  action 
may  be  very  little  disturbed.  For  months — six,  eight,  ten,  even  thirteen ! — 
fever  and  progressive  weakness  may  be  the  only  symptoms.  These  are  the 
cases  in  which,  with  recurring  chills,  the  diagnosis  of  malaria  is  made.  With 
involvement  of  the  aortic  segments  the  signs  of  a  progressive  lesion  are  more 
common.  Embolic  features  are  not  common,  occurring  only  toward  the  close. 
Post  mortem  there  has  been  found  in  my  cases  a  remarkable  vegetative  endo- 
carditis, involving  usually  the  mitral  valves,  sometimes  with  much  encrusting 
of  the  chordge  tendine^,  and  large  irregular  firm  vegetations  quite  different 
to  those  of  the  ordinary  ulcerative  form  of  the  disease.  In  some  cases  the 
aortic  and  tricuspid  segments  are  also  involved,  and  the  vegetations  may  extend 
on  to  the  walls  of  the  heart. 

Diagnosis. — In  many  cases  the  detection  of  the  disease  is  very  difficult; 
in  others,  with  marked  embolic  symptoms,  it  is  easy.  From  simple  endocarditis 
it  is  readily  distinguished,  though  confusion  occasionally  occurs  in  the  tran- 
sitional stage,  when  a  simple  is  developing  into  a  malignant  form.  The  con- 
stitional  symptoms  are  of  a  graver  type,  the  fever  is  higher,  rigors  are  common, 
and  septic  and  typhoid  symptoms  occur.  Perhaps  a  majority  of  the  cases  not 
associated  with  puerperal  processes  or  bone-disease  are  confounded  with 
typhoid  fever.  A  differential  diagnosis  may  even  be  impossible,  particularly 
when  we  consider  that  in  typhoid  fever  infarctions  and  parotitis  may  occur. 
The  diarrhoea  and  abdominal  tenderness  may  also  be  present,  which  with  the 
stupor  and  progressive  asthenia  make  a  picture  not  to  be  distinguished  from 
this  disease.  Points  which  may  guide  us  are :  The  more  abrupt  onset  in  endo- 
carditis, the  absence  of  any  regularity  of  the  pyrexia  in  the  early  stage  of  the 
disease,  and  the  cardiac  pain.  Oppression  and  shortness  of  breath  may  be 
early  symptoms  in  malignant  endocarditis.  Eigors,  too,  are  not  uncommon. 
There  is  a  marked  leucocytosis  in  infective  endocarditis.  Between  pyaemia  and 
malignant  endocarditis  there  are  practically  no  differential  features,  for  the 
disease  really  constitutes  an  arterial  pywmia  (Wilks).  In  the  acute  cases 
resembling  malignant  fevers,  the  diagnosis  is  usually  made  of  typhus,  typhoid, 
cerebro-spinal  fever,  or  even  of  hsemorrhagic  small-pox.  The  intermittent 
pyrexia,  occurring  for  weeks  or  months,  has  led  in  some  cases  to  the  diagnosis 
of  malaria,  but  this  disease  could  now  be  positively  excluded  by  the  blood 
examination.    Blood  cultures  may  aid  greatly  in  the  diagnosis. 

The  cases  usually  terminate  fatally.  The  instances  of  recovery  are  those 
more  subacute  forms,  the  so-called  recurring  endocarditis  developing  on  old 
sclerotic  valves  in  cases  of  chronic  heart-disease. 

Treatment. — We  know  no  measures  by  which  in  rheumatism,  chorea,  or 
the  eruptive  fevers  the  onset  of  endocarditis  can  be  prevented.  As  it  is 
probable  that  many  cases  arise,  particularly  in  children,  in  mild  forms  of 
these  diseases,  it  is  well  to  guard  the  patients  against  taking  cgld  and  insist 
upon  rest  and  quiet,  and  to  bear  in  mind  that  of  all  complications  an  acute 
endocarditis,  though  in  its  immediate  effects  harmless,  is  perhaps  the  most 
serious.  This  statement  is  enforced  by  the  observations  of  Sibson  that  on  a 
system  of  absolute  rest  the  proportion  of  cases  of  rheumatism  attacked  by 
endocarditis  was  less  than  of  those  who  were  not  so  treated.  It  is  doubtful 
whether  the  salicylates  in  rheumatism  have  an  influence  in  reducing  the  lia- 


792  DISEASES  OF   THE  CIRCULATORY  SYSTEM. 

bility  to  endocarditis.  Considering  the  extremely  grave  after-results  of  simple 
endocarditis  in  children,  the  question  arises  whether  it  is  possible  to  do  any- 
thing, to  avert  the  onset  of  progressive  sclerosis  of  the  affected  valve.  Caton 
recommends  a  systematic  plan  of  treatment :  ( 1 )  Prolonged  rest  in  bed,  three 
months,  to  keep  the  heart  quiet;  (3)  a  series  of  small  blisters  over  the  heart; 
and  (3)  tlie  iodide  of  potassium  in  moderate  doses  for  many  months.  If 
there  is  much  vascular  excitement  aconite  may  be  given  and  an  ice-bag  placed 
over  the  heart.  The  salicylates  are  strongly  advised  by  some  writers.  The 
treatment  of  malignant  endocarditis  is  practically  that  of  septicaemia — ^useless 
and  hopeless  in  a  majority  of  the  cases.  Blood  cultures  should  be  taken  as 
soon  as  possible  and  a  vaccine  prepared.  Horder  and  others  have  reported 
good  results.     Personally  I  have  not  seen  a  successful  case. 

Chronic  Endocaeditis. 

Definition. — A  sclerosis  of  the  valves  leading  to  shrinking,  thickening,  and 
adhesion  of  the  cusps,  often  with  the  deposition  of  lime  salts,  with  shortening 
and  thickening  of  the  chordse  tendinese,  leading  to  insufficiency  and  to  narrow- 
ing of  the  orifice.  It  may  be  primary,  but  is  of  tener  secondary  to  acute  endo- 
carditis, particularly  the  rheumatic  form. 

Etiology. — As  age  advances  the  valves  begin  to  lose  their  pliancy,  show 
slight  sclerotic  changes  and  foci  of  atheroma  and  calcification.  Certain  poi- 
sons appear  capable  of  initiating  the  change,  such  as  alcohol,  lead,  syphilis, 
and  gout,  though  we  are  at  present  ignorant  of  the  way  in  which  they  act. 
The  poisons  of  the  specific  fevers  may  initiate  the  change.  A  very  important 
factor,  particularly  in  the  case  of  the  aortic  valves,  is  the  strain  of  prolonged 
and  heavy  muscular  exertion.  In  no  other  way  can  be  explained  the  occur- 
rence of  sclerosis  of  these  valves  in  young  and  middle-aged  men  whose  occu- 
pations necessitate  the  overuse  of  the  muscles.  In  the  aortic  segments  it  may 
be  only  the  valvular  part  of  a  general  arterio-sclerosis. 

The  frequency  with  which  chronic  endocarditis  is  met  with  may  be  gath- 
ered from  the  following  figures :  In  the  statistics,  amounting  to  from  12,000 
to  14,000  autopsies,  reported  from  Dresden,  Wiirzburg,  and  Prague  the  per- 
centage ranged  from  four  to  nine.  The  relative  frequency  of  involvement  of 
the  various  valves  is  thus  given  in  the  collected  statistics  of  Parrot :  The  mitral 
orifice  was  involved  in  631,  the  aortic  in  380,  the  tricuspid  in  46,  and  the  pul- 
monary in  11,    This  gives  57  instances  in  the  right  to  1,001  in  the  left  heart. 

Morbid  Anatomy. — Vegetations  in  the  form  in  which  they  occur  in  acute 
endocarditis  are  not  present.  In  the  early  stage,  which  we  have  frequent  oppor- 
tunities of  seeing,  the  edge  of  the  valve  is  a  little  thickened  and  perhaps  pre- 
sents a  few  small  nodular  prominences,  which  in  some  cases  may  represent  the 
healed  vegetations  of  the  acute  process.  In  the  aortic  valves  the  tissue  about 
the  corpora  Arantii  is  first  affected,  producing  a  slight  thickening  with  an 
increase  in  the  size  of  the  nodules.  The  substance  of  the  valve  may  lose  its 
translucency,  and  the  only  change  noticeable  be  a  grayish  opacity  and  a  slight 
loss  of  its  delicate  tenuity.  In  the  auriculo-ventricular  valves  these  early 
changes  are  seen  just  within  the  margin  and  here  it  is  not  uncommon  to  find 
swelHngs  of  a  grayish-red,  somewhat  infiltrated  appearance,  almost  identical 
with  the  similar  structures  on  the  intima  of  the  aorta  in  arterio-sclerosis. 
Even  early  there  may  be  seen  yellow  or  opaque-white  subintimal  fatty  degen- 


DISEASES  OF  THE  HEART.  793 

erated  areas.  As  the  sclerotic  changes  increase,  the  fibrous  tissue  contracts 
and  jaroduces  thickening  and  deformity  of  the  segment,  the  edges  of  which 
become  round,  curled,  and  incapable  of  that  delicate  apposition  necessary  for 
perfect  closure.  A  sigmoid  valve,  for  instance,  may  be  narrowed  one-fourth 
or  even  one-third  across  its  face,  the  most  extreme  grade  of  insufficiency  being 
induced  without  any  special  deformity  and  without  any  narrowing  of  the 
arterial  orifice.  In  the  auriculo-ventricular  segments  a  simple  process  of 
thickening  and  curling  of  the  edges  of  the  valves,  inducing  a  failure  to  close 
without  forming  any  obstruction  to  the  normal  course  of  the  blood-flow,  is  less 
common.  Still,  we  meet  with  instances  at  the  mitral  orifice,  particularly  in 
children,  in  which  the  edges  of  the  valves  are  curled  and  thickened,  so  that 
there  is  extreme  insufficiency  without  any  material  narrowing  of  the  orifice. 
More  frequently,  as  the  disease  advances,  the  chordae  tendinese  become  thick- 
ened, first  at  the  valvular  ends  and  then  along  their  course.  The  edges  of 
the  valves  at  their  angles  are  gradually  drawn  together  and  there  is  a  nar- 
rowing of  the  orifice,  leading  in  the  aorta  to  more  or  less  stenosis  and  in  the 
left  auriculo-ventricular  orifice — the  two  sites  most  frequently  involved — to 
constriction.  Finally,  in  the  sclerotic  and  necrotic  tissues  lime  salts  are  depos- 
ited and  may  even  reach  the  deeper  structures  of  the  fibrous  rings,  so  that  the 
entire  valve  becomes  a  dense  calcareous  mass  with  scarcely  a  remnant  of  nor- 
mal tissue.  The  chordae  tendinese  may  gradually  become  shortened,  greatly 
thickened,  and  in  extreme  cases  the  papillary  muscles  are  implanted  directly 
upon  the  sclerotic  and  deformed  valve.  The  apices  of  the  papillary  muscles 
usually  show  marked  fibroid  change. 

In  all  stages  of  the  process  the  vegetations  of  simple  endocarditis  may 
be  present,  and  the  severer,  ulcerative  forms  are  very  apt  to  attack  these 
sclerotic  valves. 

Chronic  mural  endocarditis  produces  cicatricial-like  patches  of  a  grayish- 
white  appearance  which  are  sometimes  seen  on  the  muscular  trabeculge  of 
the  ventricle  or  in  the  auricles.  It  often  occurs  in  association  with  myo- 
carditis. 

The  endocarditis  of  the.  foetus  is  usually  of  the  sclerotic  form  and  in- 
volves the  valves  of  the  right  more  frequently  than  those  of  the  left  side. 


II.     CHRONIC    VALVULAR   DISEASE. 

1.  General  Introduction. 

Effects  of  Valve  Lesions. — The  general  influence  on  the  work  of  the  heart 
may  be  briefly  stated  as  follows :  The  sclerosis  induces  insufficiency  or  stenosis, 
which  may  exist  separately  or  in  combination.  The  narrowing  retards  in  a 
measure  the  normal  outflow  and  the  insufficiency  permits  the  blood  current 
to  take  an  abnormal  course.  In  both  instances  the  effect  is  dilatation  of  a 
chamber.  The  result  in  the  former  case  is  an  increase  in  the  difficulty  which 
the  chamber  has  in  expelling  its  contents  through  the  narrow  orifice;  in  the 
other,  the  overfilling  of  a  chamber  by  blood  flowing  into  it  from  an  improper 
source,  as,  for  instance,  in  mitral  insufficiency,  when  the  left  auricle  receives 
blood  both  from  the  pulmonary  veins  and  from  the  left  ventricle. 

The  cardiac  mechanism  is  fully  prepared  to  meet  ordinary  grades  of 
52 


794 


DISEASES  OF  THE  CIRCULATORY  SYSTEM. 


dilatation  which  constantly  occur  during  sudden  exertion.  A  man,  for  in- 
stance, at  the  end  of  a  hundred-yard  race  has  his  right  cliambers  greatly  dilated 
and  his  reserve  cardiac  power  worked  to  its  full  capacity.  The  slow  progress 
of  the  sclerotic  changes  brings  about  a  gradual,  not  an  abrupt,  insufficiency, 
and  the  moderate  dilatation  which  follows  is  at  first  overcome  by  the  exercise 
of  the  ordinary  reserve  strength  of  the  heart  muscle.  Gradually  a  new  factor 
is  introduced.  The  reserve  power  which  is  capable  of  meeting  sudden  emer- 
gencies in  such  a  remarkable  manner  is  unable  to  cope  long  with  a  permanent 
and  perhaps  increasing  dilatation.  More  work  has  to  be  done  and,  in  accord- 
ance vrith  definite  physiological  laws,  more  power  is  given  by  increase  of  the 
muscles.  The  heart  h^-pertrophies  and  the  effect  of  the  valve  lesion  becomes, 
as  we  say,  compensated.  The  equilibrium  of  the  circulation  is  in  this  way 
maintained. 

The  nature  of  the  process  with  which  we  have  to  deal  is  graphically  illus- 
trated in  the  accompanying  diagram,  from  ]\Iartius.  The  perpendicular  lines 
in  the  figures  represent  the  power  of  work  of  the  heart.     While  the  muscle 


J?eserve-force  = 
Accommodation-  s 
capacity 


Reserve-force  = 
Accommodation- 
capacity 


•^b 


Power  of  work 
(body  at  rest) 


lb. 


K^  Power  of  work 
f^  (body  at  rest) 


Total  power  of  heart 
y  less  than  amount  needed 
when  the  body  is  at  rest. 
Insufficiency  of  the  heaiJi 


I.  Normal  heart 


Heart  in  valvular  disease  ir^ 
stage  of  compensation 

Chart  XXI. 


m.  Heart  in  uncompensated 
valvular  disease 


in  the  healthy  heart  (Diagram  I)  has  at  its  disposal  the  maximal  force,  a  c, 
it  carries  on  its  work  under  ordinary  circumstances  (when  the  body  is  at  rest) 
with  the  force  a  &.  &  c  is  the  reserve  force  by  means  of  which  the  heart 
accommodates  itself  to  greater  exertion. 

If  now  there  be  a  gross  valvular  lesion,  the  force  required  to  do  the  ordi- 
nary work  of  the  heart  (at  rest)  becomes  very  much  increased  (Diagram  II). 
But  in  spite  of  this  enormous  call  for  force,  insufficiency  of  the  heart  muscle 
does  not  necessarily  result,  for  the  working  force  required  is  still  within  the 
limits  of  the  maximal  power  of  the  heart,  fli  &i  being  less  than  a^  c^.     The 


DISEASES  OF   THE  HEART.  795 

muscle  accommodates  itself  to  the  new  conditions  by  making  its  reserve  force 
mobile.  If  nothing  further  occurred,  however,  this  condition  could  not  be 
permanently  maintained,  for  there  would  be  left  over  for  emergencies  only 
the  small  reserve  force,  h-^y.  Even  when  at  rest  the  heart  would  be  using  con- 
tinuously almost  its  entire  maximal  force.  Any  slight  exertion  requiring  more 
extra  force  than  that  represented  by  the  small  value  h^y  (say  the  effort  required 
on  walking  or  on  going  upstairs)  would  bring  the  heart  to  the  limit  of  its  work- 
ing power,  and  palpitation  and  dyspnoea  would  appear.  Such  a  condition  does 
not  last  long.  The  working  power  of  the  heart  gradually  increases.  More  and 
more  exertion  can  be  borne  without  causing  dyspnoea,  for  the  heart  hyper- 
trophies. Finally,  a  new,  more  or  less  permanent  condition  is  attained,  in  that 
the  hypertrophied  heart  possesses  the  maximal  force,  a^  c^.  Owing  to  the 
increase  in  volume  of  the  heart  muscle,  the  total  force  of  the  heart  is  greater 
absolutely  than  that  of  the  normal  heart  by  the  amount  y  c^.  It  is,  however, 
relatively  less  efficient,  for  its  reserve  force  is  much  less  than  that  of  the  healthy 
heart.  Its  capacity  for  accommodating  itself  to  unusual  calls  upon  it  is  accord- 
ingly permanently  diminished. 

Turning  now  to  the  disturbances  of  compensation,  it  is  to  be  distinctly 
borne  in  mind  that  any  heart,  normal  or  diseased,  can  become  insufficient 
whenever  a  call  upon  it  exceeds  its  maximal  working  capacity.  The  liability 
to  such  disturbance  will  depend,  above  all,  upon  the  accommodation  limits  of 
the  heart — the  less  the  width  of  the  latter,  the  easier  will  it  be  to  go  beyond  the 
heart's  efficiency.  A  comparison  of  Diagrams  I  and  II  will  immediately  make 
it  clear  that  the  heart  in  valvular  disea  se  will  much  earlier  become,  insufficient 
than  the  heart  of  a  healthy  individual.  If  the  heart  muscle  is  compelled  to  do 
maximal  or  nearly  maximal  work  for  a  long  time,  it  becomes  exhausted.  It  is 
obvious  that  the  heart  in  valvular  disease,  on  account  of  its  small  amount  of  re- 
serve force,  has  to  do  maximal  or  nearly  maximal  work  far  more  frequently  than 
does  the  normal  heart.  The  power  of  the  heart  may  become  decreased  to  the 
amount  necessary  simply  to  carry  on  the  work  of  the  heart  when  the  body  is 
at  rest,  or  it  may  cease  to  be  sufficient  even  for  this.  The  reserve  force  gained 
through  the  compensatory  process  may  be  entirely  lost  (Diagram  III).  If 
the  loss  be  only  temporary,  the  exhausted  heart  muscle  quickly  recovering, 
the  condition  is  spoken  of  as  a  "  disturbance  of  compensation."  The  term 
"  loss  of  compensation  "  is  reserved  for  the  condition  in  which  the  disturbance 
is  continuous. 

The  schema  of  Martins  (Chart  XXII)  will  enable  the  student  to  under- 
stand the  relation  of  the  pathological  phenomena  to  the  normal  cardiac  cycle. 
The  contraction  of  the  ventricle  takes  an  appreciable  period  of  time,  seven- 
hundred  ths  of  a  second  {a-b)  to  overcome  the  strong  arterial  pressure  which 
keeps  the  aortic  (and  pulmonary)  doors  tightly  shut.  This  closure-time  is  the 
only  brief  period  in  the  cycle  in  which  both  the  auriculo-ventricular  valves  and 
the  semilunar  valves  are  shut,  the  former  as  a  result  of  the  beginning  of  the 
systole,  the  latter  until  the  intra-ventricular  has  overcome  the  aortic  pressure. 
With  this  closure-time  correspond  the  first  sound  and  the  heart  beat.  In  the 
second  period  of  the  ventricular  systole  the  blood  is  driven  into  the  arteries — 
the  expulsion-time  (b-c) — and  this  corresponds  with  the  beginning  of  the 
aortic  pulse.  During  this  there  may  be  seen  at  the  apex  in  a  forcibly  beating 
heart  the  "back  stroke/'  as  Hope  called  it.     Following  the  expulsion-time 


796 


DISEASES  OF   THE  CIRCULATORY  SYSTEM. 


there  is  a  brief  period — waiting-time  (c-d) — before  the  diastole  begins.  Clini- 
cally the  murmur  of  mitral  insufficiency  (A)  coincides,  at  any  rate  in  its 
beginning,  with  the  closure-time,  the  murmur  of  aortic  stenosis  with  the 
expulsion-time.  The  semilunar  Talves  close  at  the  moment  when  the  ventricles 
begin  to  relax  (d)  and  with  this  coincides  the  second  sound.  At  the  same 
moment  the  auriculo-ventricular  valves  open.     The  murmur  of  aortic  insuf- 


Xitral 
InsufficiexLcy 


Aortic  Stenosis 


Ventricular  Systole 


Closure-Time 


I  Sound 

aud 
Impulse 


Expulsion  Time        tc 


''Back  Stroke" 


c 

Aortic  Insufficiency 


II  Sound 


a 

Closure  of 
the  Auriculo- 
ventricular 
Valves 


6 

Opening  of 

the  Semilunar 

Valves 


C      d 

Closure  of  the  Semilunar 
and  Opening  of  the  Auriculo- 
ventricular  Valves 


Chart  XXII. — Schematic  Division  of  the  Phases  of  the  Heart's  Action  (Martius). 

ficiency  (C)  is  heard  through  the  first  part  of  the  diastole,  sometimes  more, 
while  the  murmur  of  mitral  stenosis  {D)  corresponds  with  the  latter  part  of 
the  diastole  of  the  ventricles  and  with  the  systole  of  the  auricles  {D). 

The  incidence  of  valvular  lesions  may  be  gathered  from  the  following 
figures  compiled  by  Gillespie  from  the  records  of  the  Eoyal  Infirmary,  Edin- 
burgh: Of  "2,368  cases  with  cardiac  lesions,  valvular  disease  occurred  in  80.8 
per  cent;  endocarditis  and  pericarditis  in  5.3;  myocardial  lesions  in  11.9  per 
cent;  66.2  per  cent  of  the  cases  were  in  males. 


2.  Aortic  Ixcompetenct. 

Incompetency  of  the  aortic  valves  arises  either  from  inability  of  the  valve 
segments  to  close  an  abnormally  large  orifice  or  more  commonly  from  disease 
of  the  segments  themselves.  This  best-defined  and  most  easily  recognized  of 
valvular  lesions  was  first  carefully  studied  by  Corrigan,  whose  name  it  some- 
times bears. 

Etiology  and  Morbid  Anatomy. — It  is  more  frequent  in  males  than  in 
females,  affecting  chiefly  able-bodied,  vigorous  men  at  the  middle  period  of 
life.  The  ratio  which  it  bears  to  other  valve  diseases  has  been  variously 
given  as  from  30  to  50  per  cent. 


DISEASES  OF   THE  HEART.  797 

There  are  five  groups  of  cases:  I.  Those  due  to  congenital  malformation, 
particularly  fusion  of  two  of  the  cusps — most  commonly  those  behind  which 
the  coronary  arteries  are  given  off.  It  is  probable  that  an  aortic  orifice 
may  be  competent  with  this  bicuspid  state  of  the  valves,  but  a  great  dan- 
ger is  the  liability  of  these  malformed  segments  to  sclerotic  endocarditis. 
Of  17  cases  which  I  have  reported  all  presented  sclerotic  changes,  and  the 
majority  of  them  had,  during  life,  the  clinical  features  of  chronic  heart- 
disease. 

II.  The  endocarditic  group.  Endocarditis  may  produce  an  acute  insuffi- 
ciency by  ulceration  and  destruction  of  the  valves;  in  one  case  the  aortic 
valves  were  completely  eroded  away.  The  valvulitis  of  rheumatism  and  of 
the  fevers,  while  more  rarely  aortic,  is  common  enough  in  children,  and 
the  insufficiency  is  caused  by  nodular  excrescences  at  the  margins  or  in  the 
valves,  which  may  ultimately  become  calcified;  more  often  it  induces  a 
slow  sclerosis  of  the  valves  with  adhesions,  causing  also  some  degree  of 
narrowing. 

III.  The  arteriosclerotic  group.  By  far  the  most  frequent  cause  of  in- 
sufficiency is  a  slow,  progressive  sclerosis  of  the  segments,  resulting  in  a 
curling  of  the  edges,  which  lessens  the  working  surface  of  the  valve.  Most 
frequent  in  strong,  able-bodied  men,  there  are  three  main  factors  in  its  pro- 
duction :  Firsty  strain — not  a  sudden,  forcible  strain,  but  a  persistent  increase 
of  the  normal  tension  to  which  the  segments  are  subject  during  the  diastole 
of  the  ventricle.  Of  circumstances  increasing  this  tension,  repeated  and  exces- 
sive use  of  the  muscles  is  perhaps  the  most  important.  So  often  is  this  form 
of  heart-disease  found  in  persons  devoted  to  athletics  that  it  is  sometimes 
called  the  "  athlete's  heart.''  Secondly,  alcohol,  the  action  of  which  is  prob- 
ably direct  as  a  poison  to  the  vessel  wall  and  not,  as  we  have  supposed  here- 
tofore, in  keeping  up  a  high  blood  pressure.  Thirdly,  syphilis,  which  may 
be  only  one  of  several  elements  in  inducing  early  arterial  change,  an  added 
factor  to  the  wear  and  tear  of  the  tubing. 

There  is  a  small  group,  usually  in  young_  men,  in  which  syphilis  causes  a 
localized  arterio-sclerosis  at  the  root  of  the  aorta,  either  involving  the  valves 
themselves  or  more  frequently  causing  dilatation  of  the  aortic  ring  with  rela- 
tive insufficiency.  The  endarteritis  may  be  singularly  localized,  even  annular, 
sometimes  patchy.  It  may  be  difficult  or  impossible  from  the  lesion  itself  to 
determine  the  syphilitic  nature;  the  youth  of  the  patient,  the  peculiar  local- 
ization, the  history  of  syphilis,  and  the  existence  of  syphilitic  lesions  elsewhere, 
may  render  the  diagnosis  tolerably  certain.  I  am  in  the  habit  of  enforcing 
upon  my  students  the  etiological  lesson  of  this  type  of  aortic  insufficiency 
by  a  reference  to  Bacchus  and  Vulcan,  at  whose  shrines  a  majority  of  patients 
with  aortic  insufficiency  have  worshipped,  and  not  a  few  at  those  of  Mars 
and  Venus. 

The  condition  of  the  valves  is  such  as  has  already  been  described  in 
chronic  endocarditis.  It  may  be  noted,  however,  how  slight  a  grade  of  curl- 
ing may  produce  serious  incompetency.  Associated  with  the  valve  disease  is, 
in  a  majority  of  cases,  a  more  or  less  advanced  arterio-sclerosis  of  the  arch  of 
the  aorta,  one  serious  effect  of  which  may  be  a  narrowing  of  the  orifices  of 
the  coronary  arteries.  The  sclerotic  changes  are  often  combined  with  athe- 
roma, either  in  a  fatty  or  calcareous  stage.     This  may  exist  at  the  attached 


798  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

margin  of  the  valves  without  inducing  insuliiciency.  In  other  instances  insuf- 
ficiency may  result  from  a  calcified  spike  projecting  from  the  aortic  attach- 
ment into  the  body  of  the  valve,  and  so  preventing  its  proper  closure.  Some 
writers  (Peter)  have  laid  great  stress  upon  the  extension  of  the  endarteritis 
to  the  valve,  and  would  separate  the  instances  of  this  kind  from  those  of 
simple  valvular  endocarditis.  Anatomically  one  can  usually  recognize  the 
arterio-sclerotic  variety  by  the  smooth  surface,  the  rounded  edges,  and  the 
absence  of  excrescences. 

IV.  Insufficiency  may  be  induced  by  rupture  of  a  segment — a  very  rare 
event  in  healthy  valves,  but  not  uncommon  in  disease,  either  from  excessive 
effort  during  heavy  lifting  or  from  the  ordinary  endarterial  strain  on  a  valve 
eroded  and  weakened  by  ulcerative  endocarditis. 

V.  Relative  insufficiency^  due  to  dilatation  of  the  aortic  ring  and  adjacent 
arch,  is  not  very  infrequent.  It  occurs  in  extensive  arterial  sclerosis  of  the 
ascending  portion  of  the  arch  with  great  dilatation  just  above  the  valves. 
The  valve  segments  are  usually  involved  with  the  arterial  coats,  but  the  changes 
in  them  may  be  very  slight.  In  aneurism  just  above  the  aortic  ring,  relative 
insufficiency  of  the  valve  may  be  present. 

It  would  appear  from  the  careful  measurements  of  Beneke  that  the  aortic 
orifice,  which  at  birth  is  20  mm.,  increases  gradually  with  the  growth  of  the 
heart  until  at  one-and-twenty  it  is  about  60  mm.  At  this  it  remains  until  the 
age  of  forty,  beyond  which  date  there  is  a  gradual  increase  in  the  size  up 
to  the  age  of  eighty,  when  it  may  reach  from  68  to  70  mm.  There  is  thus 
at  the  very  period  of  life  in  which  sclerosis  of  the  valve  is  most  common  a 
physiological  tendency  toward  the  production  of  a  state  of  relative  insuf- 
ficiency. 

The  insufficiency  may  be  combined  with  various  grades  of  narrowing,  par- 
ticularly in  the  endocarditic  group.  In  a  majority  of  the  cases  of  the  arterio- 
sclerotic form  there  is  no  stenosis.  On  the  other  hand,  aortic  stenosis  almost 
without  exception  is  associated  with  some  grade,  however  slight,  of  regur- 
gitation. 

Effects. — The  direct  effect  of  aortic  insufficiency  is  the  regurgitation  of 
blood  from  the  artery  into  the  ventricle,  causing  an  overdistention  of  the 
cavity  and  a  reduction  of  the  blood  column;  that  is,  a  relative  anaemia  in  the 
arterial  tree.  The  amount  returning  varies  with  the  size  of  the  opening.  The 
double  blood-flow  into  the  left  ventricle  causes  dilatation  of  the  chamber,  and 
finally  hypertrophy,  the  grade  depending  upon  the  lesion.  In  this  way  the 
valve  defect  is  compensated,  and  as  with  each  ventricular  systole  a  larger 
amount  of  blood  is  propelled  into  the  arterial  system,  the  regurgitation  of  a 
certain  amount  during  diastole  does  not,  for  a  time  at  least,  seriously  impair 
the  nutrition  of  the  peripheral  parts.  For  a  time  at  least  there  is  little  or 
no  resistance  offered  to  the  blood-flow  from  the  auricle — the  ventricle  accom- 
modates itself  readily  to  the  extra  amount,  and  there  is  no  disturbance  in  the 
lesser  circulation.  In  acute  cases,  on  the  other  hand,  vdth  rapid  destruction 
of  the  segments,  there  may  be  the  most  intense  dyspncea  and  even  profuse 
haemoptysis.  In  this  lesion  dilatation  and  hypertrophy  reach  their  most  ex- 
treme limit.  The  heaviest  hearts  on  record  are  described  in  connection  with 
this  affection.  The  so-called  bovine  heart,  cor  iovinum,  may  weigh  35  or  40 
ounces,  or  even,  as  in  a  case  of  DuUes's,  48  ounces.    The  dilatation  is  usually 


DISEASES  OF   THE  HEART.  799 

extreme  and  is  in  marked  contrast  to  the  condition  of  the  chamber  in  cases  of 
pure  aortic  stenosis.  The  papillary  muscles  may  be  greatly  flattened.  The 
mitral  valves  are  usually  not  seriously  affected,  though  the  edges  may  present 
elight  sclerosis,  and  there  is  often  relative  incompetency,  owing  to  distention 
of  the  mitral  ring.  Dilatation  and  hypertrophy  of  the  left  auricle  are  com- 
mon, and  secondary  enlargement  of  the  right  heart  occurs  in  all  cases  of 
long  standing.  In  the  arterio-sclerotic  group  there  is  an  ever  present  pos- 
sibility of  narrowing  of  the  orifices  of  the  coronary  arteries  or  an  extension  of 
the  sclerosis  to  their  branches,  leading  to  fibroid  myocarditis.  In  the  endo- 
carditis cases,  particularly  those  following  rheumatism,  the  intima  is  perfectly 
smooth,  and  the  arch  with  its  main  branches  not  dilated.  A  normal  aorta  may 
be  found  post  mortem  when  during  life  there  have  been  the  most  character- 
istic signs  of  enlargement  of  the  arch  and  of  dilatation  of  the  innominate  and 
right  carotid.  The  so-called  dynamic  dilatation  of  the  arch  is  best  seen  in 
these  cases.  A  young  girl,  whose  case  has  been  reported  as  one  of  aneurism, 
had  forcible  pulsation  and  a  tumor  which  could  be  grasped  above  the  sternum. 
— post  mortem  the  innominate  artery  did  not  admit  the  little  finger  and  the 
arch  was  not  dilated ! 

Although  the  coronary  arteries,  as  shown  by  Martin  and  Sedgwick,  are 
filled  during  the  ventricular  systole,  the  circulation  in  them  must  be  embar- 
rassed in  aortic  incompetency.  They  must  miss  the  effect  of  the  blood-pressure 
in  the  sinuses  of  Valsalva  during  the  elastic  recoil  of  the  arteries,  which  surely 
aids  in  keeping  the  coronary  vessels  full.  The  arteries  of  the  body  usually 
present  more  or  less  sclerosis  consequent  upon  the  strain  which  they  undergo 
during  the  forcible  ventricular  systole. 

Symptoms. — The  condition  is  often  discovered  accidentally  in  persons  who 
have  not  presented  any  features  of  cardiac  disease. 

Headache,  dizziness,  flashes  of  light,  and  a  feeling  of  faintness  on  rising 
quickl}^  are  among  the  earliest  symptoms.  Palpitation  and  cardiac  distress  on 
slight  exertion  are  common.  Long  before  any  signs  of  failing  compensation 
pain  may  become  a  marked  and  troublesome  feature.  It  is  extremely  variable 
in  its  manifestations.  It  may  be  of  a  dull,  aching  character  confined  to  the 
prsecordia.  More  frequently,  however,  it  is  sharp  and  radiating,  and  is  trans- 
mitted up  the  neck  and  down  the  arms,  particularly  the  left.  Attacks  of  true 
angina  pectoris  are  more  frequent  in  this  than  in  any  other  valvular  disease. 
Anaemia  is  also  common,  much  more  so  than  in  aortic  stenosis  or  in  mitral 
affections. 

As  compensation  fails  more  serious  sjmiptoms  are  shortness  of  breath 
and  oedema  of  the  feet.  The  attacks  of  dyspnoea  are  liable  to  come  on  at 
night,  and  the  patient  has  to  sleep  with  his  head  high  or  even  in  a  chair. 
Cyanosis  is  rare.  It  is  most  commonly  due  to  complicating  valve  disease,  or 
it  is  stated  that  it  may  result  from  bulging  of  the  septum  ventriculorum  and 
encroachment  upon  the  right  ventricle.  Of  respiratory  symptoms  cough  is  com- 
mon, due  to  the  congestion  of  the  lungs  or  oedema.  Haemoptysis  is  less  fre- 
quent than  in  mitral  disease.  I  have  reported  a  case  in  which  it  was  profuse 
and  believed  to  be  due  to  tuberculosis  of  the  lungs,  inasmuch  as  the  patient  was 
admitted  in  a  state  of  emaciation  and  profound  exhaustion.  General  dropsy 
is  not  common,  but  cedema  of  the  feet  may  occur  early  and  is  sometimes  due 
to  the  anemia,  sometimes  to  the  venous  stasis,  at  times  to  both.    Unless  there 


800  DISEASES  OF   THE  CIRCULATORY  SYSTEM. 

is  coexisting  disease  of  the  mitral  valve,  it  is  rare  in  aortic  incompetency  for 
the  patient  to  die  with  general  anasarca.  Sudden  death  is  frequent;  more 
so  in  this  than  in  other  valvular  diseases.  As  compensation  fails  the  patient 
takes  to  bed  and  slight  irregular  fever,  associated  usually  with  a  recurring 
endocarditis,  is  not  uncommon  toward  the  close.  Embolic  symptoms  are  not 
infrequent — pain  in  the  splenic  region  with  enlargement  of  the  organ,  hsema- 
turia,  and  in  some  cases  paralysis.  .  Distressing  dreams  and  disturbed  sleep 
are  more  common  in  this  than  in  other  forms  of  valvular  disease. 

Mental  s}Tnptoms  are  often  seen  with  this  lesion;  toward  the  close  there 
may  be  delirium,  hallucinations,  and  morbid  impulses.  It  is  important  to  bear 
this  in  mind,  for  patients  occasionally  display  suicidal  tendencies.  I  have 
twice  had  patients  throw  themselves  from  a  window  of  the  ward. 

Physical  Sigxs. — Inspection  shows  a  wide  and  forcible  area  of  cardiac 
impulse  with  the  apex  beat  in  the  sixth  or  seventh  interspace,  and  perhaps 
as  far  out  as  the  anterior  axillary  line.  In  young  subjects  the  prtecordia 
may  bulge.  There  may  be  slight  visible  pulsation  in  the  second  right  inter- 
space, or,  in  some  acute  cases  of  insufficiency  or  ulcerative  endocarditis,  a 
couple  of  inches  from  the  sternal  margin.  In  very  slight  insufficiency  there 
may  be  little  or  no  enlargement  to  be  determined  clinically.  On  palpation  a 
thrill,  diastolic  in  time,  is  occasionally  felt,  but  is  not  common.  The  impulse 
is  usually  strong  and  heaving,  unless  in  conditions  of  extreme  dilatation,  when 
it  is  wavy  and  indefinite.  Occasionally  two  or  three  interspaces  between  the 
nipple  line  and  sternum  will  be  depressed  with  the  systole  as  the  result  of 
atmospheric  pressure.  Percussion  shows  a  greater  increase  in  the  area  of 
heart  dulness  than  is  found  in  any  other  valvular  lesion.  It  extends  chiefly 
downward  and  to  the  left. 

Auscultation. — A  murmur  is  heard  during  the  diastole  of  the  ventricles 
at  the  base  of  the  heart  and  propagated  down  the  sternum.  It  may  be  feeble 
or  inaudible  at  the  aortic  cartilage,  and  is  usually  heard  best  at  midsternum 
opposite  the  third  costal  cartilage  or  along  the  left  border  of  the  sternum 
as  low  as  the  ensiform  cartilage.  It  is  usually  soft,  blowing  in  quality,  and 
is  prolonged,  or  "  long  drawn,"  as  the  phrase  is.  It  is  produced  by  the  reflux 
of  blood  into  the  ventricle.  In  some  cases  it  is  loudly  transmitted  to  the 
axilla  at  the  level  of  the  fourth  interspace,  not  by  way  of  the  apex.  The 
second  sound  may  be  well  heard  or  it  may  be  replaced  by  the  murmur,  or 
with  a  dilated  and  calcified  arch  the  second  sound  may  have  a  ringing  metallic 
or  booming  quality,  and  the  diastolic  murmur  is  well  heard,  or  even  loudest, 
over  the  manubrium. 

The  first  sound  may  be  clear  at  the  base;  more  commonly  there  is  a  soft, 
short,  systolic  murmur.  In  the  arterio-sclerotic  group  the  systolic  bruit  is,  as 
a  rule,  short  and  soft,  while  in  the  endocarditic  group,  in  which  the  valve  seg- 
ments are  united  and  often  covered  with  calcified  vegetations  and  excrescences, 
the  sj^stolic  murmur  is  rough  and  may  be  accompanied  by  a  thrill. 

At  the  apex,  or  toward  it,  the  diastolic  murmur  may  be  faintly  heard  propa- 
gated from  the  base.  With  full  compensation  the  first  sound  is  usually  clear 
at  the  apex ;  with  dilatation  there  is  a  loud  systolic  murmur  of  relative  mitral 
insufficiency,  which  may  disappear  under  observation  as  the  dilatation  lessens. 

A  second  murmur  at  the  apex,  probably  produced  at  the  mitral  orifice, 
is  not  uncommon.     Attention  was  called  to  this  bv  the  late  Austin  Flint, 


DISEASES  OF   THE  HEART.  801 

and  the  murmur  usually  goes  by  his  name.  It  is  of  a  rumbling,  echoing 
character,  occurring  in  the  middle  or  latter  part  of  diastole,  usually  pre- 
systolic in  time,  and  limited  to  the  apex  region.  It  is  similar  to,  though 
less  intense  than,  the  louder  presystolic  murmurs  of  mitral  stenosis,  and  is 
often  associated  with  a  palpable  thrill.  It  is  probably  caused  by  the  imping- 
ing of  the  regurgitant  current  from  the  aortic  orifice  on  the  large,  anterior 
flap  of  the  mitral  valve,  so  as  to  cause  interference  with  the  entrance  of  blood 
at  the  time  of  auricular  contraction.  The  condition  is  thus  essentially  the 
same  as  in  a  moderate  mitral  stenosis.  This  late  diastolic  echoing  or  rum- 
bling murmur  is  present  in  about  half  of  the  cases,  of  uncomplicated  aortic 
insufficiency  (Thayer).  It  is  very  variable,  disappearing  and  reappearing 
again  without  apparent  cause.  The  sharp,  valvular  first  sound  and  abrupt 
systolic  shock,  so  common  in  true  mitral  stenosis,  are  rarely  present,  while  the 
pulse  is  characteristic  of  uncomplicated  aortic  insufficiency. 

Arteries. — The  examination  of  the  arteries  in  aortic  insufficiency  is  of  great 
value.  Visible  pulsation  is  more  commonly  seen  in  the  peripheral  vessels  in 
this  than  in  any  other  condition.  The  carotids  may  be  seen  to  throb  forcibly, 
the  temporals  to  dilate,  and  the  brachials  and  radials  to  expand  with  each 
heart-beat.  With  the  ophthalmoscope  the  retinal  arteries  are  seen  to  pulsate. 
JSTot  only  is  the  pulsation  evident,  but  the  characteristic  jerking  quality  is 
apparent.  In  the  throat  the  throbbing  carotids  may  lead  to  the  diagnosis  of 
aneurism.  In  many  cases  the  pulsation  can  be  seen  in  the  suprasternal  notch, 
and  prominent,  forcibly  throbbing  vessels  beneath  the  right  sterno-mastoid 
muscle.  The  abdominal  aorta  may  lift  the  epigastrium  with  each,  systole.  To 
be  mentioned  with  this  is  the  capillary  pulse,  met  very  often  in  the  aortic 
insufficiency,  and  best  seen  in  the  finger-nails  or  by  drawing  a  line  upon  the 
forehead,  when  the  margin  of  hypergemia  on  either  side  alternately  blushes  and 
pales.  In  extreme  grades  the  face  or  the  hand  may  blush  visibly  at  each 
systole.  It  is  met  with  also  in  profound  ansemia,  occasionally  in  neurasthenia, 
and  in  health  in  conditions  of  great  relaxation  of  the  peripheral  arteries.  Pul- 
sation may  also  be  present  in  the  peripheral  veins.  On  palpation  the  character- 
istic water-hammer  or  Corrigan  pulse  is  felt.  In  the  majority  of  instances  the 
pulse  wave  strikes  the  finger  forcibly  with  a  quick  jerking  impulse,  and  imme- 
diately recedes  or  collapses.  The  characters  of  this  are  sometimes  best  appre- 
ciated by  grasping  the  arm  above  the  wrist  and  holding  it  up.  Moreover,  the 
pulse  of  aortic  regurgitation  js  usually  retarded  or  delayed — i.  e.,  there  is  an 
appreciable  interval  between  the  beat  of  the  heart  and  the  pulsation  in  the 
radial  artery,  which  varies  according  to  the  extent  of  the  incompetence.  Occa- 
sionally in  the  carotid  artery  the  second  sound  is  distinctly  audible  when  absent 
at  the  aortic  cartilage.  Indeed,  according  to  Broadbent,  it  is  at  the  carotid 
that  we  must  listen  for  the  second  aortic  sound,  for  when  heard  it  indicates  that 
the  regurgitation  is  small  in  amount,  and  is  consequently  a  very  favorable 
prognostic  element.  In  the  larger  arteries  a  systolic  thud  or  shock  may  be 
heard  and  sometimes  a  double  murmur,  as  pointed  out  by  Duroziez.  The  sys- 
tolic pressure  is  high  and  the  diastolic  much  decreased.  The  sphygmo- 
graphic  tracing  is  very  characteristic.  The  high  ascent,  the  sharp  top,  the 
quick  drop  in  which  the  dicrotic  notch  and  wave  are  very  slightly  marked. 

Aortic  insufficiency  may  for  years  be  fully  compensated.  Persons  do  not 
necessarily  suffer  any  inconvenience,  and  the  condition  is  often  found  accident- 


S02  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

ally.  So  long  as  the  hypertrophy  just  equalizes  the  valvular  defect  there  may 
be  no  symptoms  and  the  individual  may  even  take  moderately  heavy  exercise 
without  experiencing  sensations  of  distress  about  the  heart.  The  cases  which 
last  the  longest  are  those  in  which  the  insufficiency  follows  endocarditis  and  is 
not  a  part  of  a  general  arterio-sclerosis.  The  age  of  the  patient,  too,  at  the 
time  of  onset,  is  a  most  important  consideration,  as  in  youth  the  lesion  is 
not  often  from  sclerosis,  and  the  coronary  arteries  are  unaffected.  Coexistent 
lesions  of  the  mitral  valves  tend  early  to  disturb  the  compensation.  Pure 
aortic  insufficiency  is  consistent  with  years  of  average  health  and  with  a 
tolerably  active  life. 

With  the  onset  of  myocardial  changes,  with  increasing  degeneration  of 
the  arteries,  particularly  with  a  progressive  sclerosis  of  the  arch  and  involve- 
ment of  the  orifices  of  the  coronary  arteries,  the  compensation  becomes  dis- 
turbed. In  advanced  cases  the  changes  about  the  aortic  ring  may  be  asso- 
ciated with  alterations  in  the  cardiac  nerves  and  ganglia,  and  so  introduce  an 
important  factor. 

3.  Aortic  Stenosis. 

Narrowing  or  stricture  of  the  aortic  orifice  is  not  nearly  so  common  as 
insuflficiency.  The  two  conditions,  as  already  stated,  may  occur  together,  how- 
ever, and  probably  in  almost  every  case  of  stenosis  there  is  some  leakage. 

Etiology  and  Morbid  Anatomy. — In  the  milder  grades  there  is  adhesion 
between  the  segments,  which  are  so  stiffened  that  during  systole  they  can  not 
be  pressed  back  against  the  aortic  wall.  The  process  of  cohesion  between  the 
segments  may  go  on  without  great  thickening,  and  produce  a  condition  in 
which  the  orifice  is  guarded  by  a  comparatively  thin  membrane,  on  the  aortic 
face  of  which  may  be  seen  the  primitive  raphes  separating  the  sinuses  of 
Valsalva.  In  some  instances  this  membrane  is  so  thin  and  presents  so  few 
traces  of  atheromatous  or  sclerotic  changes  that  the  condition  looks  as  if  it 
had  originated  during  foetal  life.  More  commonly  the  valve  segments  are 
thickened  and  rigid,  and  have  a  cartilaginous  hardness.  In  advanced  cases 
they  may  be  represented  by  stiff,  calcified  masses  obstructing  the  orifice, 
through  which  a  circular  or  slit-like  passage  can  be  seen.  The  older  the 
patient  the  more  likely  it  is  that  the  valves  will  be  rigid  and  calcified. 

We  may  speak  of  a  relative  stenosis  of  the  aortic  orifice  when  with  normal 
valves  and  ring  the  aorta  immediately  beyond  is  greatly  dilated.  A  stenosis 
due  to  involvement  of  the  aortic  ring  in  sclerotic  and  calcareous  changes  with- 
out lesion  of  the  valves  is  referred  to  by  some  authors.  I  have  never  met  with 
an  instance  of  this  kind.  A  subvalvular  stenosis,  the  result  of  endocarditis 
in  the  mitro-sigmoidean  sinus,  usually  occurs  as  the  result  of  foetal  endocar- 
ditis. In  comparison  with  aortic  insufficiency,  stenosis  is  a  rare  disease.  It 
is  usually  met  with  at  a  more  advanced  period  of  life  than  insufficiency,  and 
the  most  typical  cases  of  it  are  found  associated  with  extensive  calcareous 
changes  in  the  arterial  system  in  old  men. 

Owing  to  the  impeded  blood-fiow  the  ventricle  has  to  work  against  an 
increased  resistance  and  its  walls  become  hypertrophied,  usually  at  first  witli 
little  or  no  dilatation.  We  see  in  this  condition  the  most  typical  instances  of 
what  is  called  concentric  hypertrophy,  in  which,  without  much,  if  any,  en- 
largement of  the  cavity,  the  walls  are  greatly  thickened,  in  contradistinction 


DISEASES  OF   THE   HEART.  803 

to  the  so-called  eccentric  hypertrophy,  in  which,  with  the  increase  in  the  thick- 
ness of  the  walls,  the  chamber  itself  is  greatly  dilated.  The  systole  is  pro- 
longed, even  as  much  as  twenty-five  per  cent.  There  may  be  no  changes  in 
the  other  cardiac  cavities  if  compensation  is  well  maintained;  but  with  its 
failure  come  dilatation,  impeded  auricular  discharge,  pulmonary  congestion, 
and  increased  work  for  the  right  heart.  The  arterial  changes  are,  as  a  rule, 
not  so  marked  as  in  aortic  insufficiency,  for  the  walls  have  not  to  withstand 
the  impulse  of  a  greatly  increased  blood-wave  with  each  systole.  On  the  con- 
trary, the  amount  of  blood  propelled  through  the  narrow  orifice  may  be  smaller 
than  normal,  though  when  compensation  is  fully  established  the  pulse-wave 
may  be  of  medium  volume. 

Symptoms. — Physical  Signs. — Inspection  may  fail  to  reveal  any  area 
of  cardiac  impulse.  Particularly  is  this  the  case  in  old  men  with  rigid  chest 
walls  and  large  emphysematous  lungs.  Under  these  circumstances  there  may 
be  a  high  grade  of  hypertrophy  without  any  visible  impulse.  Even  when  the 
apex  beat  is  visible,  it  may  be,  as  Traube  pointed  out,  feeble  and  indefinite. 
In  many  cases  the  apex  is  seen  displaced  downward  and  outward,  and  the 
impulse  looks  strong  and  forcible. 

Palpation  reveals  in  many  cases  a  thrill  at  the  base  of  the  heart  of  maxi- 
mum force  in  the  aortic  region.  With  no  other  condition  do  we  meet  with 
thrills  of  greater  intensity.  The  apex  beat  may  not  be  palpable  under  the 
conditions  above  mentioned,  or  there  may  be  a  slow,  heaving,  forcible  impulse. 

Percussion  never  gives  the  same  wide  area  of  dulness  as  in  aortic  insuf- 
ficiency. The  extent  of  it  depends  largely  on  the  state  of  the  lungs,  whether 
emphysematous  or  not. 

Auscultation. — A  rough  systolic  murmur,  of  maximum  intensity  at  the 
aortic  cartilage,  and  propagated  into  the  great  vessels,  is  the  most  constant 
physical  sign  in  aortic  stenosis.  One  of  the  last  lessons  learned  by  the  student 
of  physical  diagnosis  is  to  recognize  that  the  systolic  murmur  at  the  aortic  area 
does  not  necessarily  mean  obstruction  at  the  orifice.  Eoughening  of  the  valves, 
or  of  the  intima  of  the  aorta,  and  haemic  states  are  much  more  frequent  causes. 
In  aortic  stenosis  the  murmur  often  has  a  much  harsher  quality,  is  louder, 
and  is  more  frequently  musical  than  in  the  conditions  just  mentioned.  When 
compensation  fails  and  the  ventricle  is  dilated  and  feeble,  the  murmur  may  be 
soft  and  distant.  The  second  sound  is  rarely  heard  at  the  aortic  cartilage, 
owing  to  the  thickening  and  stiffness  of  the  valve.  A  diastolic  murmur  is  not 
uncommon,  but  in  many  cases  it  can  not  be  heard.  Occasionally,  as  noted  by 
W.  H.  Dickinson,  there  is  a  musical  murmur  of  greatest  intensity  in  the  region 
of  the  apex,  due  probably  to  a  slight  regurgitation  at  high  pressure  through 
the  mitral  valves.  The  pulse  in  pure  aortic  stenosis  is  small,  usually  of  good 
tension,  well  sustained,  regular,  and  perhaps  slower  than  normal. 

The  condition  may  be  latent  for  an  indefinite  period,  as  long  as  the 
hypertrophy  is  maintained.  Early  symptoms  are  those  due  to  defective  blood- 
supply  to  the  brain,  dizziness,  and  fainting.  Palpitation,  pain  about  the 
heart,  and  anginal  symptoms  are  not  so  marked  as  in  insufficiency.  With 
degeneration  of  the  heart-muscle  and  dilatation  relative  insufficiency  of  the 
mitral  valve  is  established,  and  the  patient  may  present  all  the  features  of 
engorgement  in  the  lesser  and  systemic  circulations,  with  dyspnoea,  cough, 
rusty  expectoration,  and  the  signs  of  anasarca  in  the  lower  part  of  the  body. 


804  DISEASES  OF   THE   CIRCULATORY  SYSTEM. 

Many  of  the  cases  in  old  people,  without  presenting  any  dropsy,  have  symp- 
toms pointing  rather  to  general  arterial  disease.  Cheyne- Stokes  breathing  is 
not  uncommon  with  or  without  signs  of  uraemia. 

Diagnosis. — With  an  extremely  rough  or  musical  murmur  of  maximum 
intensity  at  the  aortic  region  and  signs  of  hypertrophy  of  the  left  ventricle,  a 
thrill,  and  especially  a  hard,  slow  pulse  of  moderate  volume  and  fairly  good 
tension,  which  in  a  sphygmographic  tracing  gives  a  curve  of  slow  rise,  a 
broad,  well -sustained  summit  and  slow  decline,  a  diagnosis  of  aortic  stenosis 
can  be  made  with  some  degree  of  certainty,  particularly  if  the  subject  is  an 
old  man.  Mistakes  are  common,  however,  and  a  roughened  or  calcified  valve 
segment,  or,  in  some  instances,  a  very  roughened  and  prominent  calcified 
plate  in  the  aorta,  and  hypertrophy  associated  with  renal  disease,  may  produce 
similar  symptoms.  Seldom  is  there  difficulty  in  distinguishing  the  murmur 
due  to  aneemia,  since  it  is  rarely  so  intense  and  is  not  associated  with  thrill 
or  with  marked  hypertrophy  of  the  left  ventricle.  In  aortic  insufficiency  a 
systolic  murmur  is  usually  present,  but  has  neither  the  intensity  nor  the 
musical  quality,  nor  is  it  accompanied  with  a  thrill.  With  roughening  and 
dilatation  of  the  ascending  aorta  the  murmur  may  be  very  harsh  or  musical; 
but  the  existence  of  a  second  sound,  accentuated  and  ringing  in  quality,  is 
usually  sufficient  to  differentiate  this  condition. 

4.  Mitral  Incompetency. 

Etiology. — Insufficiency  of  the  mitral  valve  ensues:  (a)  From  changes  in 
the  segments  whereby  they  are  contracted  and  shortened,  usually  combined 
with  changes  in  the  chordae  tendineae,  or  with  more  or  less  narrowing  of  the 
orifice.  (&)  As  a  result  of  changes  in  the  muscular  walls  of  the  ventricle, 
either  dilatation,  so  that  the  valve  segments  fail  to  close  an  enlarged  orifice, 
or  changes  in  the  muscular  substance,  so  that  the  segments  are  imperfectly 
coapted  during  the  systole — muscular  incompetency.  The  common  lesions 
producing  insufficiency  result  from  endocarditis,  which  causes  a  gradual  thick- 
ening at  the  edges  of  the  valves,  contraction  of  the  chordae  tendincEe,  and 
union  of  the  edges  of  the  segments,  so  that  in  a  majority  of  the  instances  there 
is  not  only  insufficiency,  but  some  grade  of  narrowing  as  well.  Except  in 
children,  we  rarely  see  the  mitral  leaflets  curled  and  puckered  without  narrow- 
ing of  the  orifice.  Calcareous  plates  at  the  base  of  the  valve  may  prevent 
perfect  closure  of  one  of  the  segments.  In  long-standing  cases  the  entire 
mitral  structures  are  converted  into  a  firm  calcareous  ring.  From  this  val- 
vular insufficiency  the  other  condition  of  muscular  incompetency  must  be  care- 
fully distinguished.  It  is  met  with  in  all  conditions  of  extreme  dilatation  of 
the  left  ventricle,  and  also  in  weakening  of  the  muscles  in  prolonged  fevers 
and  in  ansemia. 

Morbid  Anatomy. — The  effects  of  incompetency  of  the  mitral  segment 
upon  the  heart  and  circulation  are  as  follows :  (a)  The  imperfect  closure  allows 
a  certain  amount  of  blood  to  regurgitate  from  the  ventricle  into  the  auricle, 
so  that  at  the  end  of  auricular  diastole  this  chamber  contains  not  only  the 
blood  which  it  has  received  from  the  lungs,  but  also  that  which  has  regur- 
gitated from  the  left  ventricle.  This  necessitates  dilatation,  and,  as  increased 
work  is  thrown  upon  it  in  expelling  the  augmented  contents,  hypertrophy 
as  well. 


DISEASES  OF  THE  HEART.  805 

(h)  With  each  systole  of  the  left  auricle  a  larger  volume  of  blood  is  forced 
into  the  left  ventricle,  which  also  dilates  and  subsequently  becomes  hyper- 
trophied. 

(c)  During  the  diastole  of  the  left  auricle,  as  blood  is  regurgitated  into 
it  from  the  left  ventricle,  the  pulmonary  veins  are  less  readily  emptied.  In 
consequence  the  right  ventricle  expels  its  contents  less  freely,  and  in  turn 
becomes  dilated  and  hypertrophied. 

(^Z)  Finally,  the  right  auricle  also  is  involved,  its  chamber  is  enlarged,  and 
its  walls  are  increased  in  thickness. 

(e)  The  effect  upon  the  pulmonary  vessels  is  to  produce  dilatation  both 
of  the  arteries  and  veins — often  in  long-standing  cases,  atheromatous  changes ; 
the  capillaries  are  distended,  and  ultimately  the  condition  of  brown  induration 
is  produced.  Perfect  compensation  may  be  effected,  chiefly  through  the  hyper- 
trophy of  both  ventricles,  and  the  effect  upon  the  peripheral  circulation  may 
not  be  manifested  for  years,  as  a  normal  volume  of  blood  is  discharged  from 
the  left  heart  at  each  systole.  The  time  comes,  however,  when,  owing  either 
to  increase  in  the  grade  of  the  incompetency  or  to  failure  of  the  compensation, 
the  left  ventricle  is  unable  to  send  out  its  normal  volume  into  the  aorta. 
Then  there  is  overfilling  of  the  left  auricle,  engorgement  in  the  lesser  cir- 
culation, embarrassed  action  of  the  right  heart,  and  congestion  in  the  sys- 
temic veins.  For  years  this  somewhat  congested  condition  may  be  limited  to 
the  lesser  circulation,  but  finally  the  right  auricle  becomes  dilated,  the  tri- 
cuspid valves  incompetent,  and  the  systemic  veins  are  engorged.  This  grad- 
ually leads  to  the  condition  of  cyanotic  induration  in  the  viscera  and,  when 
extreme,  to  dropsical  effusion. 

Muscular  incompetency,  due  to  impaired  nutrition  of  the  mitral  and  papil- 
lary muscles,  is  rarely  followed  by  such  perfect  compensation.  There  may  be 
in  acute  destruction  of  the  aortic  segments  an  acute  dilatation  of  the  left 
ventricle  with  relative  incompetency  of  the  mitral  segments,  great  dilatation 
of  the  left  auricle,  and  intense  engorgement  of  the  lungs,  under  which  circum- 
stances profuse  haemorrhage  may  result.  In  these  cases  there  is  little  chance 
for  the  establishment  of  compensation.  In  cases  of  hypertrophy  and  dilatation 
of  the  heart,  without  valvular  lesions,  but  associated  with  heavy  work  and 
alcohol,  the  insufficiency  of  the  mitral  valve  may  be  extreme  and  lead  to  great 
pulmonary  congestion,  engorgement  of  the  systemic  veins,  and  a  condition 
of  cardiac  dropsy,  which  can  not  be  distinguished  by  any  feature  from  that 
of  mitral  incompetency  due  to  lesion  of  the  valve  itself.  In  chronic  Bright's 
disease  the  hypertrophy  of  the  left  ventricle  may  gradually  fail,  leading,  in  the 
later  stages,  to  relative  insufficiency  of  the  mitral  valve,  and  the  production 
of  a  condition  of  pulmonary  and  systemic  congestion,  similar  to  that  induced 
by  the  most  extreme  grade  of  lesion  of  the  valve  itself.  Adherent  pericardium, 
especially  in  children,  may  lead  to  like  results. 

Symptoms. — During  the  development  of  the  lesion,  unless  the  incom- 
petency comes  on  acutely  in  consequence  of  rupture  of  the  valve  segment  or  of 
ulceration,  the  compensatory  changes  go  hand  in  hand  with  the  defect,  and 
there  are  no  subjective  symptoms.  So,  also,  in  the  stage  of  perfect  compen- 
sation, there  may  be  the  most  extreme  grade  of  mitral  insufficiency  with  ejior- 
mous  hypertrophy  of  the  heart,  yet  the  patient  may  not  be  aware  of  the  exist- 
ence of  heart  trouble,  and  may  suffer  no  inconvenience  except  perhaps  a  little 


806  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

shortness  of  breath  on  exertion  or  on  going  upstairs.  It  is  only  when  from  any 
cause  the  compensation  has  not  been  perfectly  effected,  or,  having  been  so, 
is  broken  abruptly  or  gradually,  that  the  patients  begin  to  be  troubled.  The 
symptoms  may  be  divided  into  two  groups : 

(a)  The  minor  manifestations  while  compensation  is  still  good.  Pa- 
tients with  extreme  incompetency  often  have  a  congested  appearance  of 
the  face,  the  lips  and  ears  have  a  bluish  tint,  and  the  venules  on  the  cheeks 
may  be  enlarged — signs  in  many  cases  very  suggestive.  In  long-standing  cases, 
particularly  in  children,  the  fingers  may  be  clubbed,  and  there  is  shortness 
of  breath  on  exertion.  This  is  one  of  the  most  constant  features  in  mitral 
insufficiency,  and  may  exist  for  years,  even  when  the  compensation  is  perfect. 
Owing  to  the  somewhat  congested  condition  of  the  lungs  these  patients  have 
a  tendency  to  attacks  of  bronchitis  or  hemoptysis.  There  may  also  be  palpi- 
tation of  the  heart.  As  a  rule,  however,  in  well-balanced  lesions  in  adults, 
this  period  of  full  compensation  or  latent  stage  is  not  associated  with  symp- 
toms which  call  the  attention  to  an  affection  of  the  heart,  and  with  care  the 
patient  may  reach  old  age  in  comparative  comfort  without  being  compelled 
to  curtail  seriously  his  pleasures  or  his  work. 

(h)  Sooner  or  later  comes  a  period  of  disturbed  or  broken  compensation, 
in  which  the  most  intense  symptoms  are  those  of  venous  engorgement.  There 
are  palpitation,  weak,  irregular  action  of  the  heart,  and  signs  of  dilatation. 
Dyspnoea  is  an  especial  feature,  and  there  may  be  cough.  A  distressing  symp- 
tom is  the  cardiac  "  sleep-start,"  in  which,  just  as  the  patient  falls  asleep,  he 
wakes  gasping  and  feeling  as  if  the  heart  were  stopping.  There  is  usually  a 
slight  cyanosis,  and  even  a  jaundiced  tint  to  the  skin.  The  most  marked 
symptoms,  however,  are  those  of  venous  stasis.  The  overfilling  of  the  pul- 
monary vessels  accounts  in  part  for  the  dyspnoea.  There  is  cough,  often  with 
bloody  or  watery  expectoration,  and  the  alveolar  epithelium  containing  brown 
pigment-grains  is  abundant.  Dropsical  effusion  usually  sets  in,  beginning  in 
the  feet  and  extending  to  the  body  and  the  serous  sacs.  Right-sided  hydro- 
thorax  may  recur  and  require  repeated  tapping.  The  urine  is  usually  scanty 
and  albuminous,  and  contains  tube-casts  and  sometimes  blood-corpuscles.  With 
judicious  treatment  the  compensation  may  be  restored  and  all  the  serious  symp- 
toms may  pass  away.  Patients  usually  have  recurring  attacks  of  this  kind, 
and  die  of  a  general  dropsy;  or  there  is  progressive  dilatation  of  the  heart, 
and  death  from  asystole.  Sudden  death  in  these  cases  is  rare.  Some  cases  of 
mitral  disease — stenosis  and  insufficiency — ^reach  what  may  be  called  the  hepatic 
stage,  when  all  the  symptoms  are  due  to  the  secondary  changes  in  the  liver. 
Physical  Signs. — Inspection. — In  children  the  prsecordia  may  bulge  and 
there  may  be  a  large  area  of  visible  pulsation.  The  apex  beat  is  to  the  left 
of  the  nipple,  in  some  cases  in  the  sixth  interspace,  in  the  anterior  axillary 
line.  A  localized  right  ventricle  impulse  may  sometimes  be  seen  below  the 
right  costal  border  in  the  parsternal  line.  There  may  be  a  wavy  impulse  in 
the  cervical  veins  which  are  often  full,  particularly  when  the  patient  is 
recumbent. 

Palpation. — A  thrill  is  rare;  when  present  it  is  felt  at  the  apex,  often  in 
a  limited  area.  The  force  of  the  impulse  may  depend  largely  upon  the  stage 
in  which  the  case  is  examined.  In  full  compensation  it  is  forcible  and  heav- 
ing ;  when  the  compensation  is  disturbed,  usually  wavy  and  feeble. 


DISEASES  OF  THE  HEART.  807 

Permission. — The  dulness  is  increased,  particularly  in  a  lateral  direction. 
There  is  no  disease  of  the  valves  which  produces,  in  long-standing  cases,  a 
more  extensive  transverse  area  of  heart  dulness.  It  does  not  extend  so  much 
upward  along  the  left  margin  of  the  sternum  as  beyond  the  right  margin  and 
to  the  left  of  the  nipple  line. 

Auscultation. — At  the  apex  there  is  a  systolic  murmur  which  wholly  or 
partly  obliterates  the  first  sound.  It  is  loudest  here,  and  has  a  blowing,  some- 
times musical  character,  particularly  toward  the  latter  part.  The  murmur  is 
transmitted  to  the  axilla  and  may  be  heard  at  the  back,  in  some  instances 
over  the  entire  chest.  There  are  cases  in  which,  as  pointed  out  by  Naunj^n, 
the  murmur  is  heard  best  along  the  left  border  of  the  sternum.  Usually  in 
diastole  at  the  apex  the  loudly  transmitted  second  sound  may  be  heard.  Occa- 
sionally there  is  also  a  soft,  sometimes  a  rough  or  rumbling  presystolic  mur- 
mur. As  a  rule,  in  cases  of  extreme  mitral  insufficiency  from  valvular  lesion 
with  great  hypertrophy  of  both  ventricles,  there  is  heard  only  a  loud  blowing 
murmur  during  systole.  A  murmur  of  mitral  insufficiency  may  vary  a  great 
deal  according  to  the  position  of  the  patient.  It  may  be  present  in  the  recum- 
bent and  absent  in  the  erect  posture.  In  cases  of  dilatation,  particularly  when 
dropsy  is  present,  there  may  be  heard  at  the  ensiform  cartilage  and  in  the 
lower  sternal  region  a  soft  systolic  murmur  due  to  tricuspid  regurgitation.  An 
important  sign  on  auscultation  is  the  accentuated  pulmonary  second  sound. 
This  is  heard  to  the  left  of  the  sternum  in  the  second  interspace,  or  over  the 
third  left  costal  cartilage. 

The  pulse  in  mitral  insufficiency,  during  the  period  of  full  compensation, 
may  be  full  and  regular,  often  of  low  tension.  Usually  with  the  first  onset 
of  the  symptoms  the  pulse  becomes  irregular,  a  feature  which  then  dominates 
the  case  throughout.  There  may  be  no  two  beats  of  equal  force  or  volume. 
Often  after  the  disappearance  of  the  symptoms  of  failure  of  compensation  the 
irregularity  of  the  pulse  persists. 

The  three  important  physical  signs  then  of  mitral  regurgitation  are:  (a) 
Systolic  murmur  of  maximum  intensity  at  the  apex,  which  is  propagated  to 
the  axilla  and  heard  at  the  angle  of  the  scapula;  (&)  accentuation  of  the  pul- 
monary second  sound;  (c)  evidence  of  enlargement  of  the  heart,  particu- 
larly the  increase  in  the  transverse  diameter,  due  to  hypertrophy  of  both  right 
and  left  ventricles. 

Diagnosis. — There  is  rarely  any  difficulty  in  the  diagnosis  of  mitral  insuf- 
ficiency. The  physical  signs  just  referred  to  are  quite  characteristic  and 
distinctive.  Two  points  are  to  be  borne  in  mind.  First,  a  murmur,  systolic 
in  character,  and  of  maximum  intensity  at  the  apex,  and  propagated  even  to 
the  axilla,  does  not  necessarily  indicate  incompetency  of  the  mitral  valve. 
There  is  heard  in  this  region  a  large  group  of  what  are  termed  accidental 
murmurs,  the  precise  nature  of  which  is  still  doubtful.  They  are  probably 
formed,  however,  in  the  ventricle,  and  are  not  associated  with  hypertrophy, 
or  accentuation  of  pulmonary  second  sound. 

Second,  it  is  not  always  possible  to  say  whether  the  insufficiency  is  due 
to  lesion  of  the  valve  segment  or  to  dilatation  of  the  mitral  ring  and  rela- 
tive incompetency.  Here  neither  the  character  of  the  murmur,  the  propa- 
gation, the  accentuation  of  the  pulmonary  second  sound,  nor  the  hypertrophy 
assists  in  the  differentiation.    The  history  is  sometimes  of  greater  value  in  this 


808  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

matter  than  the  physical  examination.  Tlie  cases  most  likely  to  lead  to  error 
are  those  of  the  so-called  idiopathic  dilatation  and  h3^pertrophy  of  the  heart 
(in  which  the  systolic  murmur  may  be  of  the  greatest  intensity),  and  the 
instances  of  arterio-sclerosis  with  dilated  heart.  Balfour  and  others,  however, 
maintain  that  organic  disease  of  the  mitral  leaflets  sufficient  to  produce  incom- 
petency is  always  accompanied  with  a  certain  degree  of  narrowing  of  the  ori- 
fice, so  that  the  only  unequivocal  proof  of  the  actual  disease  of  the  mitral  valve 
is  the  presence  of  a  presystolic  murmur. 

5.  Mitral  Stenosis. 

Etiology. — Narrowing  of  the  mitral  orifice  is  usually  the  result  of  valvular 
endocarditis  occurring  in  the  earlier  years  of  life ;  very  rarely  it  is  congenital. 
It  is  very  much  more  common  in  women  than  in  men — in  63  of  80  cases  noted 
by  Duckworth,  while  in  4,791  autopsies  at  Guy's  Hospital  during  ten  years 
there  were  196  cases,  of  which  107  were  females  and  89  males  (Samways). 
This  is  not  easy  to  explain,  but  there  are  at  least  two  factors  to  be  considered. 
Eheumatism  prevails  more  in  girls  than  in  boys  and,  as  is  well  known,  endo- 
carditis of  the  mitral  valve  is  more  common  in  rheumatism.  Chorea,  also,  as 
suggested  by  Barlow,  has  an  important  influence,  occurring  more  frequently 
in  girls  and  being  often  associated  with  endocarditis.  Of  140  cases  of  chorea 
which  I  examined  at  a  period  more  than  two  j^ears  subsequent  to  the  attack, 
72  had  signs  of  organic  heart-disease,  among  which  were  24  instances  with  the 
physical  signs  of  mitral  stenosis.  Anaemia  and  chlorosis,  which  are  prevalent 
in  girls,  have  been  regarded  as  possible  factors.  In  a  surprising  number  of 
cases  no  recognizable  etiological  factor  can  be  discovered.  This  has  been  re- 
garded by  some  writers  as  favoring  the  view  that  many  cases  are  of  congenital 
origin ;  but  it  is  not  improbable  that  with  any  of  the  febrile  affections  of  child- 
hood endocarditis  may  be  associated.  Whooping-cough,  too,  with  its  terrible 
strain  on  the  heart-valves,  may  be  accountable  for  certain  cases.  Congenital 
affections  of  the  mitral  valve  are  notoriously  rare.  While  met  with  at  all 
ages,  stenosis  is  certainly  more  frequent  in  young  persons. 

Morbid  Anatomy. — With  the  stenosis  there  is  always  some  incompetency. 
The  narrowing  results  from  thickening  and  contraction  of  the  tissues  of  the 
ring,  of  the  valve  segments,  and  of  the  chordae  tendinese.  The  condition  varies 
a  good  deal  according  to  the  amount  of  atheromatous  change.  In  many  cases 
the  curtains  are  so  welded  together  and  the  whole  valvular  region  so  thickened 
that  the  orifice  is  reduced  to  a  mere  chink — Corrigan's  button-hole  contraction. 
In  other  cases  the  curtains  are  not  much  thickened,  but  narrowing  has  resulted 
Irom  gradual  adhesion  at  the  edges,  and  thickening  of  the  chordae  tendineae, 
50  that  from  the  auricle  it  looks  cone-like — the  so-called  funnel-shaped  variety 
of  stenosis.  The  instances  in  which  the  valve  segments  are  very  slightly  de- 
formed, but  in  which  the  orifice  is  considerably  narrowed,  are  regarded  by 
Bome  as  possibly  of  congenital  origin.  Occasionally  the  curtains  are  in  great 
part  free  from  disease,  but  the  narrowing  results  from  large  calcareous  masses, 
which  project  into  them  from  the  ring.  The  involvement  of  the  chordae 
tendinese  is  usually  extreme,  and  the  papillary  muscles  may  be  inserted  directly 
upon  the  valve.  In  moderate  grades  of  constriction  the  orifice  will  admit  the 
tip  of  the  index-finger;  in  more  extreme  forms,  the  tip  of  the  little  finger; 
and  occasionally  one  meets  with  a  specimen  in  which  the  orifice  seems  almost 


DISEASES  OF  THE  HEART.  809 

obliterated,  admitting  only  a  medium-sized  Bowman's  probe.  The  heart  is 
not  greatly  enlarged,  rarely  weighing  more  than  14  or  15  ounces.  Occasion- 
ally, in  an  elderly  person,  it  may  seem  only  slightly,  if  at  all,  enlarged,  and 
again  there  are  instances  in  which  the  weight  may  reach  as  much  as  20 
ounces.  The  left  ventricle  is  usually  small,  and  may  look  very  small  in  com- 
parison with  the  right  ventricle,  which  forms  the  greater  portion  of  the  apex. 
In  cases  in  which  with  the  narrowing  there  is  very  considerable  incompetency 
the  left  ventricle  may  be  moderately  dilated  and  hypertrophied. 

It  is  not  uncommon  at  the  examination  to  find  white  thrombi  in  the 
appendix  of  the  left  auricle.  Occasionally  a  large  part  of  the  auricle  is  occu- 
pied by  an  ante-mortem  thrombus.  Still  more  rarely  the  remarkable  ball 
thrombus  is  found,  in  which  a  globular  concretion,  varying  in  size  from  a 
walnut  to  a  small  egg,  lies  free  in  the  auricle,  two  examples  of  which  have 
come  under  my  observation. 

The  left  auricle  discharges  its  blood  with  greater  difficulty  and  in  conse- 
quence dilates,  and  its  walls  reach  three  or  four  times  their  normal  thickness. 
Although  the  auricle  is  by  structure  unfitted  to  compensate  an  extreme  lesion, 
the  probability  is  that  for  some  time  during  the  gradual  production  of  stenosis, 
the  increasing  muscular  power  of  the  walls  is  sufficient  to  counterbalance  the 
defect.  In  36  cases  of  well-marked  stenosis  Samways  found  the  auricle  hyper- 
trophied in  26,  dilatation  coexisting  in  14.  Eventually  the  tension  is  increased 
in  the  pulmonary  circulation,  owing  to  impeded  outflow  from  the  veins  and 
this  to  heightened  pressure  in  the  pulmonary  artery.  Extra  work  is  thus 
thrown  on  the  right  ventricle,  which  gradually  hypertrophies.  Eelative  incom- 
petency of  the  tricuspid  and  congestion  of  the  systemic  veins  at  last  supervene. 

Symptoms. — Physical  Signs. — Inspection. — In  children  the  lower  ster- 
num and  the  fifth  and  sixth  left  costal  cartilages  are  often  prominent,  owing 
to  hypertrophy  of  the  right  ventricle.  The  apex  beat  may  be  ill-defined.  Usu- 
ally, it  is  not  dislocated  far  beyond  the  nipple  line,  and  the  chief  impulse  is 
over  the  lower  sternum  and  adjacent  costal  cartilages.  Often  in  thin-chested 
persons  there  is  pulsation  in  the  third  and  fourth  left  interspaces  close  to 
the  sternum.  When  compensation  fails,  the  prsecordial  impulse  is  much 
feebler,  and  in  the  veins  of  the  neck  there  may  be  marked  systolic  regurgi- 
tation or  the  right  jugular  near  the  clavicle  may  stand  out  as  a  prominent 
tumor.  In  the  later  stage,  there  is  great  enlargement  with  pulsation  of  the 
liver. 

Palpation  reveals  in  a  majority  of  the  cases  a  characteristic,  well-defined 
fremitus  or  thrill,  which  is  best  felt,  as  a  rule,  in  the  fourth  or  fifth  inter- 
space within  the  nipple  line.  It  is  of  a  rough,  grating  quality,  often  pecul- 
iarly limited  in  area,  most  marked  during  expiration,  and  can  be  felt  to  ter- 
minate in  a  sharp,  sudden  shock,  synchronous  with  the  impulse.  This  most 
characteristic  of  physical  signs  is  pathognomonic  of  narrowing  of  the  mitral 
orifice,  and  is  perhaps  the  only  instance  in  which  the  diagnosis  of  a  valvular 
lesion  can  be  made  by  palpation  alone.  The  cardiac  impulse  is  felt  most  for- 
cibly in  the  lower  sternum  and  in  the  fourth  and  fifth  left  interspaces.  The 
impulse  is  felt  very  high  in  the  third  and  fourth  interspaces,  or  in  rare  cases 
even  in  the  second,  and  it  has  been  thought  that  in  the  latter  interspace  the 
impulse  is  due  to  pulsation  of  the  auricle.  It  is  always  the  impulse  of  the 
conus  arteriosus  of  the  right  ventricle;  even  in  the  most  extreme  grades  of 


810  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

mitral  stenosis,  there  is  never  sncli  tilting  forward  of  the  auricle  or  its  appen- 
dix as  would  enable  it  to  produce  an  impression  on  the  chest  wall. 

Percussion  gives  an  increase  in  the  cardiac  dulness  to  the  right  of  the 
sternum  and  along  the  left  margin;  not  usually  a  great  increase  beyond  the 
nipple  line,  except  in  extreme  cases,  when  the  transverse  dulness  may  reach 
from  5  cm.  beyond  the  right  margin  of  the  sternum  to  10  cm.  beyond  the 
nipple  line. 

Auscultation. — To  the  inner  side  of  the  apex  beat,  often  in  a  very  limited 
region,  there  is  heard  a.  rough,  vibratory  or  purring  murmur,  cumulative  or 
crescendo  in  character,  which  terminates  abruptly  in  the  first  sound.  By 
combining  palpation  and  auscultation  the  purring  murmur  is  found  to  be  syn- 
chronous with  the  thrill  and  the  loud  shock  with  the  first  sound.  The  mur- 
mur is  auricular  systolic,  due  to  the  blood  passing  through  the  narrow  orifice. 
Some  have  thought  it  to  be  early  systolic  in  time,  but  the  majority  of  observers 
hold  to  the  former  view  with  Gairdner.  The  presystolic  murmur  may  occupy 
the  entire  period  of  the  diastole,  or  the  middle  or  onl}^  the  latter  half,  corre- 
sponding to  the  auricular  systole.  The  difference  may  sometimes  be  noted 
between  the  first  and  second  portions  of  the  murmur,  when  it  occupies  the 
jentire  time.  Often  there  is  a  peculiar  rumbling  or  echoing  quality,  which  in 
some  instances  is  very  limited  and  may  be  heard  only  over  a  single  bell-space 
of  the  stethoscope.  A  rumbling,  echoing  presystolic  murmur  at  the  apex  is 
heard  in  some  cases  of  aortic  insufficiency  (Flint  murmur),  occasionally  in 
adherent  pericardium  with  great  dilatation  of  the  heart  and  in  upward  dis- 
location of  the  organ. 

A  systolic  murmur  may  be  heard  at  the  apex  or  along  the  left  sternal 
border,  often  of  extreme  softness  and  audible  only  when  the  breath  is  held. 
Sometimes  the  systolic  murmur  is  loud  and  distinct  and  is  transmitted  to 
the  axilla.  The  second  sound  in  the  second  left  interspace  is  loudly  accentu- 
ated, and  often  reduplicated.  It  may  be  transmitted  far  to  the  left  and  be 
heard  with  great  clearness  beyond  the  apex.  In  uncomplicated  cases  of  mitral 
stenosis  there  are  usually  no  murmurs  audible  at  the  aortic  region,  at  which 
spot  the  second  sound  is  less  intense  than  at  the  pulmonary  area.  In  advanced 
cases  at  the  lower  sternum  and  to  the  right  a  systolic  tricuspid  murmur  is 
sometimes  heard.  Other  points  to  be  noted  are  the  following :  The  unusually 
sharp,  clear  first  sound  which  follows  the  presystolic  murmur,  the  cause  of 
which  is  by  no  means  easy  to  explain.  It  can  scarcely  be  a  valvular  sound 
produced  chiefly  at  the  mitral  orifice,  since  it  may  be  heard  with  great  intensity 
in  cases  in  which  the  valves  are  rigid  and  calcified.  It  has  been  suggested  by 
A.  E.  Sansom  and  others  that  it  is  a  loud  "  snap  "  of  the  tricuspid  valves 
caused  by  the  powerful  contraction  of  the  greatly  hypertrophied  right  ven- 
tricle. Broadbent  thinks  it  may  be  due  to  the  abrupt  contraction  of  a  partially 
filled  left  ventricle.  The  valvular  sound  may  be  audible  at  a  distance,  as  one 
sits  at  the  bedside  of  the  patient  (Graves).  In  a  patient  I  saw  with  Dr.  C.  J. 
Blake  the  first  sound  was  audible  six  feet,  by  measurement,  from  the  chest  wall. 

These  physical  signs,  it  is  to  be  borne  in  mind,  are  characteristic  only 
of  the  stage  in  which  compensation  is  maintained.  The  murmur  may  be 
soft,  almost  inaudible,  and  only  brought  out  after  exertion.  Finally  there 
comes  a  period  in  which,  with  failure  of  compensation,  the  presystolic  mur- 
mur disappears  and  there  is  heard  in  the  apex  region  a  sharp  first  sound,  or 


DISEASES  OF  THE  HEART.  811 

sometimes  a  gallop  rhythm.  The  marked  systolic  shock  may  be  present  after 
the  disappearance  of  the  thrill  and  the  characteristic  murmur.  Under  treat- 
ment, with  gradual  recovery  of  compensation,  probably  with  increasing  vigor 
of  contraction  of  the  right  ventricle  and  left  auricle,  the  presystolic  murmur 
reappears.  In  cases  seen  at  this  stage  of  the  disease  the  nature  of  the  valve 
lesion  may  be  entirely  overlooked. 

Stenosis  of  the  mitral  valve  may  for  years  be  efficiently  compensated  by 
the  hypertrophy  of  the  right  ventricle.  Many  persons  with  the  characteristic 
physical  signs  of  this  lesion  present  no  symptoms.  They  may  for  years  per- 
haps be  short  of  breath  on  going  upstairs,  but  are  able  to  pass  through  the 
ordinary  duties  of  life  without  discomfort.  The  pulse  is  smaller  in  volume 
than  normal,  and  very  often  irregular.  A  special  danger  of  this  stage  is  the 
recurring  endocarditis.  Vegetations  may  be  whipped  off  into  the  circulation 
and,  blocking  a  cerebral  vessel,  may  cause  hemiplegia  or  aphasia,  or  both. 
This,  unfortunately,  is  not  an  uncommon  sequence  in  women.  Patients  with 
mitral  stenosis  may  survive  this  accident  for  an  indefinite  period.  A  woman, 
above  seventy  years  of  age,  died  in  one  of  my  wards  at  the  Philadelphia  Hos- 
pital, who  had  been  in  the  almshouse,  hemiplegic,  for  more  than  thirty  years. 
The  heart  presented  an  extreme  grade  of  mitral  stenosis  which  had  probably- 
existed  at  the  time  of  the  hemiplegic  attack. 

Pressure  of  the  enlarged  auricle  on  the  left  recurrent  laryngeal  nerve, 
causing  paralysis  of  the  vocal  cord  on  the  corresponding  side,  has  been  de- 
scribed by  Ortner  and  by  Herrick.  I  have  met  with  two  instances.  It  is  a 
point  to  be  borne  in  mind,  as  the  diagnosis  of  aneurism  of  the  arch  of  the 
aorta  may  be  made. 

Failure  of  compensation  brings  in  its  train  the  group  of  symptoms  which 
have  been  discussed  under  mitral  insufficiency.  Briefly  enumerated  they  are : 
Rapid  and  irregular  action  of  the  heart,  shortness  of  breath,  cough,  signs  of 
pulmonary  engorgement,  and  very  frequently  hfemoptysis.  Attacks  of  this 
kind  may  recur  for  years.  Bronchitis  or  a  febrile  attack  may  cause  shortness 
of  breath  or  slight  blueness.  Inflammatory  affections  of  the  lungs  or  pleura 
seriously  disturb  the  right  heart,  and  these  patients  stand  pneumonia  very 
badly.  Many,  perhaps  a  majority  of  cases  of  mitral  stenosis,  do  not  have 
dropsy.  The  liver  may  be  greatly  enlarged,  and  in  the  late  stages  ascites  is 
not  uncommon,  particularly  in  children.  General  anasarca  is  most  frequently 
met  with  in  those  cases  in  which  there  is  secondary  narrowing  of  the  tricuspid 
orifice  (Broadbent). 

6.  Tricuspid  Valve  Disease. 

(a)  Tricuspid  Regurgitation. — Occasionally  this  results  from  acute  or 
chronic  endocarditis  with  puckering;  more  commonly  the  condition  is  one 
of  relative  insufficiency,  and  is  secondary  to  lesions  of  the  valves  on  the  left 
side,  particularly  of  the  mitral.  It  is  met  with  also  in  all  conditions  of  the 
lungs  which  cause  obstruction  to  the  circulation,  such  as  cirrhosis  and  emphy- 
sema, particularly  in  combination  with  chronic  bronchitis.  The  symptoms  are 
those  of  obstruction  in  the  lesser  circulation  with  venous  congestion  in  the  sys- 
temic veins,  such  as  has  already  been  described  in  connection  with  mitral 
insufficiency.     The  signs  of  this  condition  are: 

(1)    Systolic  regurgitation  of  the  blood  into  the  right  auricle  and  the 


812  DISEASES  OF   THE  CIRCULATORY  SYSTEM. 

transmission  of  the  pulse-wave  into  the  veins  of  the  neck.  If  the  regurgitation 
is  slight  or  the  contraction  of  the  ventricle  is  feeble  there  may  be  no  venous 
throbbing,  but  in  other  cases  there  is  marked  systolic  pulsation  in  the  cervical 
veins.  That  in  the  right  jugular  is  more  forcible  than  that  in  the  left.  It  may 
be  seen  both  in  the  internal  and  the  external  vein,  particularly  in  the  latter. 
Marked  pulsation  in  these  veins  occurs  only  when  the  valves  guarding  them 
become  incompetent.  Slight  oscillations  are  by  no  means  uncommon,  even 
when  the  valves  are  intact.  The  distention  is  sometimes  enormous,  particu- 
larly in  the  act  of  coughing,  when  the  right  jugular  at  the  root  of  the  neck 
may  stand  out,  forming  an  extraordinary  prominent  ovoid  mass.  Occasionally 
the  regurgitant  pulse-wave  may  be  widely  transmitted  and  be  seen  in  the  sub- 
clavian and  axillary  veins,  and  even  in  the  subcutaneous  veins  over  the  shoul- 
der, or  in  the  superficial  mammary  veins. 

Eegurgitant  pulsation  through  the  tricuspid  orifice  may  be  transmitted 
to  the  inferior  cava,  and  so  to  the  hepatic  veins,  causing  a  systolic  distention 
of  the  liver.  This  is  best  appreciated  by  bimanual  palpation,  placing  one  hand 
over  the  fifth  and  sixth  costal  cartilages  and  the  other  in  the  lateral  region 
of  the  liver  in  the  mid-axillary  line.  The  rhythmical  expansile  pulsation  may 
be  readily  distinguished,  as  a  rule,  from  the  systolic  depression  of  the  liver 
due  to  communicated  pulsation  from  the  left  ventricle. 

(2)  The  second  important  sign  of  tricuspid  regurgitation  is  the  occur- 
rence of  a  systolic  murmur  of  maximum  intensity  in  the  lower  sternum.  It 
is  usually  a  soft,  low  murmur,  often  to  be  distinguished  from  a  coexisting 
mitral  murmur  by  differences  in  quality  and  pitch,  and  may  be  heard  to  the 
right  as  far  as  the  axilla.    Sometimes  it  is  very  limited  in  its  distribution. 

Together  these  two  signs  positively  indicate  tricuspid  regurgitation.  In 
addition,  the  percussion  usually  shows  increase  in  the  area  of  dulness  to  the 
right  of  the  sternum,  and  the  impulse  in  the  lower  sternal  region  is  forcible. 
In  the  great  majority  of  cases  the  symptoms  are  those  of  the  associated  lesions. 
In  cirrhosis  of  the  lung  and  in  chronic  emphysema  the  failure  of  compensation 
of  the  right  ventricle  with  insufficiency  of  the  tricuspid  not  infrequently  leads 
either  to  acute  asystole  or  to  gradual  failure  with  cardiac  dropsy. 

(&)  Tricuspid  Stenosis. — This  interesting  condition  may  be  either  con- 
genital or  acquired.  The  congenital  cases  are  not  uncommon,  and  are  asso- 
ciated usually  with  other  valvular  defects  which  cause  early  death.  The 
acquired  form  is  not  very  infrequent.  Bedford  Fenwick  collected  46  observa- 
tions, of  which  41  were  in  women.  Leudet  has  analyzed  117  cases.  Of  101 
of  these  in  which  the  ages  were  mentioned,  80  were  in  women  and  21  in  men. 
A  great  majority  of  the  cases  were  in  adults,  only  8  being  between  the  ages 
of  ten  and  twenty.  Its  rarity  as  an  isolated  condition  may  be  gathered  from 
the  fact  that  of  114  autopsies,  in  11  only  was  the  lesion  confined  to  this  valve. 
In  21  the  tricuspid,  mitral,  and  aortic  segments  were  involved,  and  in  78  the 
tricuspid  and  mitral.  Practically  the  condition  is  almost  always  secondary 
to  lesions  of  the  left  heart. 

The  physical  signs  are  sometimes  characteristic.  For  instance,  a  pre- 
systolic thrill  has  been  noted  by  several  observers.  The  percussion  shows 
dulness  to  be  increased,  particularly  to  the  right  of  the  sternum.  On  aus- 
cultation a  presystolic  murmur  has  been  determined  in  certain  cases,  and 
is  heard  best  at  the  root  of  the  ensiform  cartilage,  or  a  little  to  the  right  of 


DISEASES  OF  THE  HEART.  813 

it.  Of  general  symptoms,  cyanosis  of  the  face  and  lips  is  very  common,  and 
in  the  late  stages,  when  dropsy  supervenes,  it  is  apt  to  be  intense.  The  lesion 
is  interesting  chiefly  because  it  forms  one  of  the  most  serious  complications  of 
mitral  stenosis. 

7.  Pulmonary  Valve  Disease. 

Murnmrs  in  the  region  of  the  pulmonary  valves  are  extremely  common; 
lesions  of  the  valves  are  exceedingly  rare.  Balfour  has  well  called  the  pul- 
monic area  the  region  of  auscultatory  romance.  A  systolic  murmur  is  heard 
here  under  many  conditions — (1)  very  often  in  health,  in  thin-chested  persons, 
particularly  in  children,  during  expiration  and  in  the  recumbent  posture;  (2) 
when  the  heart  is  acting  rapidly,  as  in  fever  and  after  exertion;  (3)  it  is  a 
favorite  situation  of  the  cardio-respiratory  murmur;  (4)  in  anaemic  states; 
and  (5)  as  mentioned  previously,  the  systolic  murmur  of  mitral  insufficiency 
may  be  transmitted  along  the  left  sternal  margin.  Actual  lesions  of  the  valves 
of  the  pulmonary  artery  are  rare. 

(a)  Stenosis  is  almost  invariably  a  congenital  anomaly.  It  constitutes 
one  of  the  most  important  of  the  congenital  cardiac  affections.  The  valve 
segments  are  usually  united,  leaving  a  small,  narrow  orifice.  In  adults  cases 
occasionally  occur.  The  congenital  lesion  is  commonly  associated  with  patency 
of  the  ductus  Botali  and  imperfection  of  the  ventricular  septum.  There  may 
also  be  tricuspid  stenosis.  Acute  endocarditis  not  infrequently  attacks  the 
sclerotic  valves. 

The  physical  signs  are  extremely  uncertain.  There  may  be  a  systolic  mur- 
mur with  a  thrill  heard  best  to  the  left  of  the  sternum  in  the  second  inter- 
costal space.  This  murmur  may  be  very  like  a  murmur  of  aortic  stenosis,  but 
is  not  transmitted  into  the  vessels.  ISTaturally  the  pulmonary  second  sound  is 
weak  or  obliterated,  or  may  be  replaced  by  a  diastolic  murmur.  Usually  there 
is  hypertrophy  of  the  right  heart. 

(6)  Pulmonary  Insufficiency. — This  rare  affection  is  occasionally  due  to 
congenital  malformation,  particularly  fusion  of  two  of  the  segments.  It  is 
sometimes  present,  as  Bramwell  has  shown,  in  cases  of  malignant  endocar- 
ditis.   Barie  has  collected  58  cases. 

The  physical  signs  are  those  of  regurgitation  into  the  right  ventricle, 
but,  as  a  rule,  it  is  difficult  to  differentiate  the  murmur  from  that  of  aortic 
insufficiency,  though  the  maximum  intensity  may  be  in  the  pulmonary  area. 
The  absence  of  the  vascular  features  of  aortic  insufficiency  is  suggestive. 
Both  Gibson  and  Graham  Steell  have  called  attention  to  the  possibility  of  leak- 
age through  these  valves  in  cases  of  great  increase  of  pressure  in  the  pulmonary 
artery,  and  to  a  soft  diastolic  murmur  heard  under  these  circumstances,  which 
Steell  calls  "  the  murmur  of  high  pressure  in  the  pulmonary  artery." 

8.  Combined  Valvular  Lesions. 

Valvular  lesions  are  seldom  single  or  pure;  combined  lesions  are  more 
common.  This  is  particularly  the  case  in  congenital  disease.  In  young  chil- 
dren mitral  and  aortic  lesions,  the  result  of  rheumatic  fever,  are  common. 
Pure  mitral  insufficiency  and  pure  mitral  stenosis  may  exist  for  years,  but 
in  time  the  tricuspid  becomes  involved,  at  first  in  sclerosis  and  later  narrowing 
of  the  orifice.     Aortic  valve  lesions  are  more  commonly  uncombined  than 


814  DISEASES  OF   THE  CIRCULATORY  SYSTEM. 

mitral  lesions.  The  added  lesion  may  be  hurtful  or  helpful.  The  stenosis 
which  so  often  accompanies  the  endocarditic  variety  may  lessen  the  regurgi- 
tation in  aortic  insufficiency;  and  a  progressive  narrowing  of  the  mitral  orifice 
may  be  beneficial  in  mitral  regurgitation. 

Prognosis  in  Valvular  Disease. — The  question  is  entirely  one  of  efficient 
compensation.  So  long  as  this  is  maintained  the  patient  may  suffer  no  incon- 
venience, and  even  with  the  most  serious  forms  of  valve  lesion  the  function  of 
the  heart  may  be  little,  if  at  all,  disturbed. 

Practitioners  who  are  not  adepts  in  auscultation  and  feel  unable  to  esti- 
mate the  value  of  the  various  heart  murmurs  should  remember  that  the  best 
Judgment  of  the  conditions  may  be  gathered  from  inspection  and  palpation. 
With  an  apex  beat  in  the  normal  situation  and  regular  in  rhythm  the  auscul- 
tatory phenomena  may  be  practically  disregarded. 

A  murmur  per  se  is  of  little  or  no  moment  in  determining  the  prognosis 
in  any  given  case.  There  is  a  large  group  of  patients  who  present  no  other 
symptoms  than  a  systolic  murmur  heard  over  the  body  of  the  heart,  or  over 
the  apex,  in  whom  the  left  ventricle  is  not  hypertrophied,  the  heart  rhythm  is 
normal,  and  who  may  not  have  had  rheumatism.  Indeed,  the  condition  is 
accidentally  discovered,  often  during  examination  for  life  insurance.  Among 
the  conditions  influencing  prognosis  are : 

(a)  Age. — Children  under  ten  are  bad  subjects.  Compensation  is  well 
effected,  and  they  are  free  from  many  of  the  influences  which  disturb  com- 
pensation in  adults.  The  coronary  arteries  are  healthy,  and  nutrition  of  the 
heart-muscle  can  be  readily  maintained.  Yet,  in  spite  of  this,  the  outlook  in 
cardiac  lesions  developing  in  very  young  children  is  usually  bad.  One  reason 
is  that  the  valve  lesion  itself  is  apt  to  be  rapidly  progressive,  and  the  limit  of 
cardiac  reserve  force  is  in  such  cases  early  reached.  There  seems  to  be  pro- 
portionately a  greater  degree  of  hypertrophy  and  dilatation.  Among  other 
causes  of  the  risks  of  this  period  are  to  be  mentioned  insufficient  food  in  the 
poorer  classes,  the  recurrence  of  rheumatic  attacks,  and  the  existence  of  peri- 
cardial adhesions.  The  outlook  in  a  child  who  can  be  carefully  supervised 
and  prevented  from  damaging  himself  by  overexertion  is  naturally  better  than 
in  one  who  is  constantly  overtasking  his  muscles.  The  valvular  lesions  which 
occur  at,  or  subsequent  to,  the  period  of  puberty  are  more  likely  to  be  perma- 
nently and  efficiently  compensated.  Sudden  death  from  heart-disease  is  very 
rare  in  children. 

(&)  Sex. — Women  bear  valve  lesions,  as  a  rule,  better  than  men,  owing 
partly  to  the  fact  that  they  live  quieter  lives,  partly  to  the  less  common  involve- 
ment of  the  coronary  arteries,  and  to  the  greater  frequency  of  mitral  lesions. 
Pregnancy  and  parturition  are  disturbing  factors,  but  are,  I  think,  less  serious 
than  some  writers  would  have  us  believe. 

( c)  Valve  Affected. — The  relative  prognosis  of  the  different  valve  lesions 
is  very  difficult  to  estimate.  Each  case  must,  therefore,  be  judged  on  its  own 
merits.  4ortic  insufficiency  is  unquestionably  the  most  serious;  yet  for  years 
it  may  be  perfectly  compensated.  Favorable  circumstances  in  any  case  are 
the  moderate  grade  of  hypertrophy  and  dilatation,  the  absence  of  all  symptoms 
of  cardiac  distress,  and  the  absence  of  extensive  arterio-sclerosis  and  of  angina. 
The  prognosis  rests  in  reality  with  the  condition  of  the  coronary  arteries. 
Kheumatic  lesions  of  the  valves,  inducing  insufficiency,  are  less  apt  to  be  asso- 


DISEASES  OF  THE  HEART.  815 

ciated  with  endarteritis  at  the  root  of  the  aorta ;  and  in  sucli  cases  the  coronary 
arteries  may  escape  for  years.  On  the  other  hand,  when  the  aortic  insufficiency 
is  only  a  part  of  an  extensive  arterio-sclerosis  at  tlie  root  of  the  aorta,  the  coro- 
nary arteries  are  almost  invariably  involved,  and  the  outlook  in  such  cases  is 
much  more  serious.  Sudden  death  is  not  uncommon,  either  from  acute  dila- 
tation during  some  exertion,  or,  more  frequently,  from  blocking  of  one  of  the 
branches  of  the  coronary  arteries.  The  liability  of  this  form  to  be  associated 
with  angina  pectoris  also  adds  to  its  severity.  Aortic  stenosis  is  a  compara- 
tively rare  lesion,  most  commonly  met  with  in  middle-aged  or  elderly  men, 
and  is,  as  a  rule,  well  compensated.  In  Broadbent's  series  of  cases,  in  which 
autopsy  showed  definite  aortic  narrowing,  forty  years  was  the  average  age  at 
death,  and  the  oldest  was  but  fifty-three. 

In  mitral  lesions  the  outlook  on  the  whole  is  much  more  favorable  than 
in  aortic  insufficiency.  Mitral  insufficiency,  when  well  compensated,  carries 
with  it  a  better  prognosis  than  mitral  stenosis.  Except  aortic  stenosis,  it  is 
the  only  lesion  commonly  met  with  in  patients  over  threescore  years.  It  must 
be  borne  in  mind  that  the  cases  which  last  the  longest  are  those  in  which  the 
valve  orifice  is  more  or  less  narrowed,  as  well  as  incompetent.  There  is,  in 
reality,  no  valve  lesion  so  poorly  compensated  and  so  rapidly  fatal  as  that  in 
which  the  mitral  segments  are  gradually  curled  and  puckered  until  they  form 
a  narrow  strip  around  a  wide  mitral  ring — a  condition  specially  seen  in  chil- 
dren. There  are  many  cases  of  mitral  insufficiency  in  which  the  defect  is 
thoroughly  balanced  for  thirty  or  even  forty  years,  without  distress  or  incon- 
venience. Even  with  great  hypertrophy  and  the  apex  beat  almost  in  the  mid- 
axillary  line,  there  may  be  little  or  no  distress,  and  the  compensation  may  be 
most  effective.  Women  may  pass  safely  through  repeated  pregnancies,  though 
here  they  are  liable  to  accidents  associated  with  the  severe  strain.  I  have  had 
under  observation  for  many  years  a  patient  who  had  her  first  attack  of  rheuma- 
tism at  the  age  of  fifteen,  when  she  already  had  a  well-marked  mitral  murmur. 
She  first  came  under  my  observation,  thirty-three  years  ago,  with  signs  of 
hypertrophy  of  the  left  ventricle  and  a  loud  systolic  murmur.  She  has  lived 
a  very  active  life,  has  been  unusually  vigorous,  has  borne  eleven  children,  and 
has  passed  through  three  subsequent  attacks  of  rheumatism.  She  is  now  in 
her  sixty-third  year.  The  loud  mitral  systolic  murmur  persists,  but  she  is 
very  well,  only  a  little  short  of  breath  on  exertion. 

In  mitral  stenosis  the  prognosis  is  usually  regarded  as  less  favorable.  My 
own  experience  has  led  me,  however,  to  place  this  lesion  almost  on  a  level,  par- 
ticularly in  women,  with  the  mitral  insufficiency.  It  is  found  very  often  in 
persons  in  perfect  health,  who  have  had  neither  palpitation  nor  signs  of  heart- 
failure,  and  who  have  lived  laborious  lives.  The  figures  given,  too,  by  Broad- 
bent  indicate  that  the  date  of  death  in  mitral  stenosis  is  comparatively  ad- 
vanced. Of  53  cases  abstracted  from  the  post-mortem  records  of  St.  Mary's 
Hospital,  thirty-three  was  the  age  for  males,  and  thirty-seven  or  thirty-eight 
for  females.  These  women,  too,  pass  through  repeated  pregnancies  with  safety. 
There  are  of  course  those  too  common  accidents,  the  result  of  cerebral  embol- 
ism, which  are  more  likely  to  occur  in  this  than  in  other  forms. 

Hard  and  fast  lines  caa  not  be  drawn  in  the  question  of  prognosis  in 
valvular  disease.  Every  case  must  be  judged  separately,  and  all  the  circum- 
stances carefully  balanced.    There  is  no  question  which  requires  greater  expe- 


816  DISEASES  OF   THE  CIRCULATORY  SYSTEM. 

rience  and  more  mature  judgment,  and  even  the  most  experienced  are  some- 
times at  fault. 

The  following  conditions  justify  a  favorable  prognosis:  Good  general 
health  and  good  habits;  no  exceptional  liability  to  rheumatic  or  catarrhal 
affections;  origin  of  the  valvular  lesion  independently  of  degeneration;  exist- 
ence of  the  valvular  lesion  without  change  for  over  three  years;  sound  ven- 
tricles, of  moderate  frequency  and  general  regularity  of  action ;  sound  arteries, 
vrith  a  normal  amount  of  blood  and  tension  in  the  smaller  vessels ;  and,  lastly, 
freedom  from  pulmonary,  hepatic,  and  renal  congestion. 

Treatment  of  Valvular  Lesions. — (a)  Stage  of  Compexsatio^j". — Medici- 
nal treatment  at  this  period  is  not  necessary  and  is  often  hurtful.  A  very 
common  error  is  to  administer  cardiac  drugs,  such  as  digitalis,  on  the  discov- 
ery of  a  murmur  or  of  hypertrophy.  If  the  lesion  has  been  found  accidentally, 
it  may  be  best  not  to  tell  the  patient,  but  rather  an  intimate  friend.  Often 
it  is  necessary,  however,  to  be  perfectly  frank  in  order  that  the  patient  may 
take  certain  preventive  measures.  He  should  lead  a  quiet,  regulated,  orderly 
life,  free  from  excitement  and  worry,  and  the  risk  of  sudden  death  makes  it 
imperative  that  the  patient  suffering  from  aortic  disease  should  be  specially 
warned  against  overexertion  and  hurry.  An  ordinary  wholesome  diet  in  mod- 
erate quantities  should  be  taken;  tobacco  may  be  allowed  in  moderation,  but 
stimulants  should  be  interdicted  or  used  in  very  small  amount.  Exercise 
should  be  regulated  entirely  by  the  feelings  of  the  patient.  So  long  as  no 
cardiac  distress  or  palpitation  follows,  moderate  exercise  will  prove  very  bene- 
ficial. The  skin  should  be  kept  active  by  a  daily  bath.  Hot  baths  should  be 
avoided  and  the  Turkish  bath  should  be  interdicted.  In  the  case  of  full- 
blooded,  somewhat  corpulent  individuals,  an  occasional  saline  purge  should  be 
taken.  Patients  with  valvular  lesions  should  not  go  into  very  high  altitudes. 
The  act  of  coition  has  serious  risks,  particularly  in  aortic  insufficiency.  Know- 
ing that  the  causes  which  most  surely  and  powerfully  disturb  the  compensation 
are  overexertion,  mental  worry,  and  malnutrition,  the  physician  should  give 
suitable  instructions  in  each  case.  As  it  is  always  better  to  have  the  co-opera- 
tion of  an  intelligent  patient,  he  should,  as  a  rule,  be  told  of  the  condition, 
but  in  this  matter  the  physician  must  be  guided  by  circumstances,  and  there 
are  cases  in  which  reticence  is  the  wiser  policy. 

(&)  Stage  of  Broken  Compensation. — The  break  may  be  immediate  and 
final,  as  when  sudden  death  results  from  acute  dilatation  or  from  blocking  of 
a  branch  of  the  coronary  artery,  or  it  may  be  gradual.  Among  the  first  indi- 
cations are  shortness  of  breath  on  exertion  or  attacks  of  nocturnal  dyspnoea. 
These  are  often  associated  with  impaired  nutrition,  particularly  with  angemia, 
and  a  course  of  iron  or  change  of  air  may  suffice  to  relieve  the  s}Tnptoms. 

Irregularity  of  the  action  of  the  heart  can  not  always  be  termed  an  in- 
dication of  failing  compensation,  particularly  in  instances  of  mitral  disease. 
It  has  greater  significance  in  aortic  lesions.  Serious  failure  of  compensation 
is  indicated  by  signs  of  dilatation  of  the  heart,  marked  cyanosis,  the  gallop 
rhythm,  or  various  forms  of  arrhj^thmia,  with  or  without  the  existence  of 
dropsy.  Under  these  circumstances  the  following  measures  are  to  be  carried 
out:     . 

(1)  Rest. — Disturbed  compensation  may  be  completely  restored  by  rest 
of  the  body.    In  many  cases  with  cedema  of  the  ankles,  moderate  dilatation  of 


DISEASES  OF  THE  HEART.  817 

the  heart,  and  irregularity  of  the  pulse,  the  rest  in  bed,  a  few  doses  of  the 
compound  tincture  of  cardamoms,  and  a  saline  purge  suffice,  within  a  week  or 
ten  days,  to  restore  the  compensation. 

(2)  The  relief  of  the  embarrassed  circulation. 

(a)  By  Venesection. — In  cases  of  dilatation,  from  whatever  cause,  whether 
in  mitral  or  aortic  lesions  or  distention  of  the  right  ventricle  in  emphysema, 
when  signs  of  venous  engorgement  are  marked  and  when  there  is  orthopnoea 
with  cyanosis,  the  abstraction  of  from  20  to  30  ounces  of  blood  is  indicated. 
This  is  the  occasion  in  which  timely  venesection  may  save  the  patient's  life. 
It  is  particularly  helpful  in  the  dilated  heart  of  arterio-sclerosis. 

(&)  By  Depletion  through  the  Bowels. — This  is  particularly  valuable  when 
dropsy  is  present.  Of  the  various  purges  the  salines  are  to  be  preferred,  and 
may  be  given  by  Matthew  Hay's  method.  Half  an  hour  to  an  hour  before 
breakfast  from  half  an  ounce  to  an  ounce  and  a  half  of  Epsom  salts  may  be 
given  in  a  concentrated  form.  This  usually  produces  from  three  to  five  liquid 
evacuations.  The  compound  jalap  powder  in  half -drachm  doses,  or  elaterium, 
may  be  employed  for  the  same  purpose.  Even  when  the  pulse  is  very  feeble 
these  hydragogue  cathartics  are  well  borne,  and  they  deplete  the  portal  system 
rapidly  and  efficiently. 

(c)  The  Use  of  Remedies  which  stimulate  the  Heart's  Action. — Of  these, 
by  far  the  most  important  is  digitalis,  which  was  introduced  into  practice 
by  Withering.  The  indication  for  its  use  is  weakness  of  the  heart-muscle ;  the 
contra-indication  is  a  perfectly  balanced  compensatory  hypertrophy,  such  as 
we  see  in  all  forms  of  valvular  disease.  Broken  coriipensation,  no  matter  what 
the  valve  lesion  may  be,  is  the  signal  for  its  use.  It  acts  upon  the  heart,  slow- 
ing and  at  the  same  time  increasing  the  force  of  the  contractions.  It  acts 
on  the  peripheral  arteries,  raising  their  tension,  so  that  a  steady  and  equable 
flow  of  blood  is  maintained  in  the  capillaries,  which,  after  all,  is  the  prime 
aim  and  object  of  the  circulation.  The  beneficial  effects  are  best  seen  in  cases 
of  mitral  disease  with  small,  irregular  pulse  and  cardiac  dropsy.  Its  effects 
are  not  less  striking  in  the  dilatation  of  the  left  ventricle,  in  the  failing  com- 
pensation of  aortic  insufficiency  or  of  arterio-sclerosis.  On  theoretical  grounds 
it  has  been  urged  that  its  use  is  not  so  advantageous  in  aortic  insufficiency, 
since  it  prolongs  the  diastole  and  leads  to  greater  distention.  This  need  not 
be  considered,  and  digitalis  is  just  as  serviceable  in  this  as  in  any  other  con- 
dition associated  with  progressive  dilatation;  larger  doses  are  often  required. 
It  may  be  given  as  the  tincture  or  the  infusion.  In  cases  of  cardiac  dropsy, 
from  whatever  cause,  15  minims  of  the  tincture  or  half  an  ounce  of  the  in- 
fusion may  be  given  every  three  hours  for  two  days,  after  which  the  dose  may 
be  reduced.  Some  prefer  the  tincture,  others  the  infusion;  it  is  a  matter  of 
indifference  if  the  drug  is  good.  The  urine  of  a  patient  taking  digitalis  should 
be  carefully  estimated  each  day.  As  a  rule,  when  its  action  is  beneficial,  there 
is  within  twenty- four  hours  an  increase  in  the  amount;  often  the  flow  is  very 
great.  Under  its  use  the  dyspnoea  is  relieved,  the  dropsy  gradually  disappears, 
the  pulse  becomes  firmer,  fuller  in  volume,  and  sometimes,  if  it  has  been  very 
intermittent,  regular. 

Ill  effects  sometimes  follow  digitalis.  There  is  no  such  thing  as  a  cumu- 
lative action  of  the  drug  manifested  by  sudden  symptoms.  Toxic  effects  are 
seen  in  the  production  of  nausea  and  vomiting.  The  pulse  becomes  irregular 
53 


818  DISEASES  OF   THE  CIRCULATORY  SYSTEM. 

and  small,  and  there  may  be  t^vo  beats  of  the  heart  to  one  of  the  pulse,  which, 
as  pointed  out  by  Broadbent,  is  found  particularly  in  cases  of  mitral  stenosis 
when  they  are  under  the  influence  of  this  drug.  The  urine  is  reduced  in 
amount.  These  sjmiptoms  subside  on  the  withdrawal  of  the  digitalis,  and  are 
rarely  serious.  There  are  patients  who  take  digitalis  uninterruptedly  for 
years,  and  feel  palpitation  and  distress  if  the  drug  is  omitted.  In  mitral  dis- 
ease, even  when  it  does  good  it  does  not  always  steady  the  pulse.  There  are 
many  cases  in  which  the  irregularity  is  not  affected  by  the  digitalis.  When 
the  compensation  has  been  re-established  the  drug  may  be  omitted.  When 
there  is  dyspnoea  on  exertion  and  cardiac  distress,  from  5  to  10  minims  three 
times  a  day  may  be  advantageously  given  for  prolonged  periods,  but  the  effects 
should  be  carefully  watched.  In  cardiac  dropsy  digitalis  should  be  used  at  the 
outset  with  a  free  hand. .  Small  doses  should  not  be  given,  but  from  the  first 
half-ounce  doses  of  the  infusion  every  three  hours,  or  from  15  to  20  minims  of 
the  tincture.  Digitalin,  hypodermic  ally  (gr.  -^),  every  three  or  four  hours, 
may  be  substituted. 

Of  other  remedies  strophanthus  alone  is  of  service.  Given  in  doses  of  from 
5  to  8  minims  of  the  tincture,  it  acts  like  digitalis.  It  certainly  will  sometimes 
steady  the  intermittent  heart  of  mitral  valve  disease  when  digitalis  fails  to  do 
so,  but  it  is  not  to  be  compared  with  this  drug  when  dropsy  is  present.  Conval- 
laria,  citrate  of  caffeine,  and  adonis  vernalis  and  sparteine  are  warmly  recom- 
mended as  substitutes  for  digitalis,  but  their  inferiority  is  so  manifest  that 
their  use  is  rarely  indicated. 

There  are  two  valuable  adjuncts  in  the  treatment  of  valvular  disease — iron 
and  strychnia.  When  anaemia  is  a  marked  feature  iron  should  be  given  in 
full  doses.  In  some  instances  of  failing  compensation  this  is  the  only  medi- 
cine needed  to  restore  the  balance.  Arsenic  is  occasionally  an  excellent  substi- 
tute, and  one  or  other  of  them  should  be  administered  in  all  instances  of  heart- 
trouble  when  pallor  is  present.  Stryclinia  is  a  heart  tonic  of  very  great  value. 
It  may  be  given  alone  or  in  combination  with  the  digitalis  in  1  or  2  drop  doses 
of  the  l-per-cent  solution,  or  M^odermically  in  doses  of -^-y^Q-gr.  Alcoholic 
stimulants  in  moderation  are  occasionally  useful,  especially  in  tiding  over  a 
period  of  acute  cardiac  weakness. 

Treatment  of  Special  Symptoms. — (a)  Dropsy. — The  increased  arterial 
tension  and  activity  of  the  capillary  circulation  under  the  influence  of  digitalis 
hastens  the  interstitial  hinph  flow  and  favors  resorption  of  the  fluid.  The 
hydragogue  cathartics,  by  rapidly  depleting  the  blood,  promote,  too,  the  absorp- 
tion of  the  fluid  from  the  lymph  spaces  and  the  lymph  sacs.  These  two  meas- 
ures usually  suffice  to  rid  the  patient  of  the  dropsy.  In  some  cases,  however, 
it  can  not  be  relieved,  and  then  Southej^'s  tubes  may  be  used  or  the  legs  punc- 
tured. If  done  with  care,  after  a  thorough  washing  of  the  parts,  and  if  anti- 
septic precautions  are  taken,  scarification  is  a  very  serviceable  measure,  and 
should  be  resorted  to  more  frequently  than  it  is.  Canton  flannel  bandages  may 
be  applied  on  the  cedematous  legs. 

(&)  Dtspxcea. — The  patients  are  usually  unable  to  lie  down.  A  comfort- 
able bed-rest  should  therefore  be  provided — if  possible,  one  with  lateral  projec- 
tions, so  that  in  sleeping  the  head  can  be  supported  as  it  falls  over.  The 
shortness  of  breath  is  associated  with  dilatation,  chronic  bronchitis,  or  hydro- 
thorax.    The  chest  should  be  carefully  examined  in  all  these  cases,  as  hydro- 


DISEASES  OF  THE  HEART.  819 

thorax  of  one  side  or  of  both  is  a  common  cause  of  shortness  of  breath. 
There  are  cases  of  mitral  regurgitation  with  recurring  hydrothorax  usually 
on  the  right  side,  which  is  relieved,  week  by  week  or  month  by  month,  by 
tapping.  For  the  nocturnal  dyspnoea,  particularly  when  combined  with  rest- 
lessness, morphia  is  invaluable  and  may  be  given  without  hesitation. ,,  The 
value  of  the  calming  influence  of  opium  in  all  conditions  of  cardiac  insuf- 
ficiency is  not  sufficiently  recognized.  There  are  instances  of  cardiac  dyspnoea 
unassociated  with  dropsy,  particularly  in  mitral  valve  disease,  in  which  nitro- 
glycerin is  of  great  service,  if  given  in  the  1-per-cent  solution  in  increasing 
doses.  It  is  especially  serviceable  in  the  cases  in  which  the  pulse  tension  is 
high. 

(c)  Palpitation  and  Cardiac  Distress. — In  instances  of  great  hyper- 
trophy and  in  the  throbbing  which  is  so  distressing  in  some  cases  of  aortic  in- 
sufficiency, aconite  is  of  service  in  doses  of  from  1  to  3  minims  every  two  or 
three  hours.  An  ice-bag  over  the  heart  or  Leiter's  coil  is  also  of  service  in 
allaying  the  rapid  action  and  the  throbbing.  For  the  pains,  which  are  often 
so  marked  in  aortic  lesions,  iodide  of  potassium  in  10-grain  doses,  three  times 
a  day,  or  the  nitroglycerin  may  be  tried.  Small  blisters  are  sometimes  advan- 
tageous. It  must  be  remembered  that  an  important  cause  of  palpitation  and 
cardiac  distress  is  flatulent  distention  of  the  stomach  or  colon,  against  which 
suitable  measures  must  be  directed. 

(d)  Gastric  Symptoms. — The  cases  of  cardiac  insufficiency  which  do 
badly  and  fail  to  respond  to  digitalis  are  most  often  those  in  which  nausea 
and  vomiting  are  prominent  features.  The  liver  is  often  greatly  enlarged  in 
these  cases;  there  is  more  or  less  stasis  in  the  hepatic  vessels,  and  but  little 
can  be  expected  of  drugs  until  the  venous  engorgement  is  relieved.  If  the 
vomiting  persists,  it  is  best  to  stop  the  food  and  give  small  bits  of  ice,  small 
quantities  of  milk  and  lime  water,  and  effervescing  drinks,  such  as  Apol- 
linaris  water  and  champagne.  Creasote,  hydrocyanic  acid,  and  the  oxalate  of 
cerium  are  sometimes  useful;  but,  as  a  rule,  the  condition  is  obstinate  and 
always  serious. 

(e)  Cough  and  Hemoptysis. — The  former  is  almost  a  necessary  con- 
comitant of  cardiac  insufficiency,  owing  to  engorgement  of  the  pulmonary  ves- 
sels and  more  or  less  bronchitis.  It  is  allayed  by  measures  directed  rather  to 
the  heart  than  to  the  lungs.  Hemoptysis  in  chronic  valvular  disease  is  some- 
times a  salutary  symptom.  An  army  surgeon,  who  was  invalided  during  the 
American  civil  war  on  account  of  hsemoptysis,  supposed  to  be  due  to  tuber- 
culosis, had  for  many  years,  in  association  with  mitral  insufficiency  and  en- 
larged heart,  many  attacks  of  hasmoptysis.  He  assured  me  that  his  condition 
was  invariably  better  after  the  attack.  It  is  rarely  fatal,  except  in  some  cases 
of  acute  dilatation,  and  seldom  calls  for  special  treatment. 

(/)  Sleeplessness. — One  of  the  most  distressing  features  of  valvular 
lesions,  even  in  the  stage  of  compensation,  is  disturbed  sleep.  Patients  may 
wake  suddenly  with  throbbing  of  the  heart,  often  in  an  attack  of  nightmare. 
Subsequently,  Avhen  the  compensation  has  failed,  it  is  also  a  worrying  symp- 
tom. The  sleep  is  broken,  restless,  and  frequently  disturbed  by  frightful 
dreams.  Sometimes  a  dose  of  the  spirits  of  chloroform  or  of  ether,  with  half 
a  drachm  of  spirits  of  camphor,  given  in  a  little  hot  whisky,  will  give  a  quiet 
night.    The  compound  spirits  of  ether,  Hoffmann's  anodyne,  though  very  un- 


820  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

pleasant  to  take,  is  frequently  a  great  boon  in  the  intermediate  period  when 
compensation  has  partially  failed  and  the  patients  sufEer  from  restless  and 
sleepless  nights.  Paraldehyde  and  amylene  hydrate  are  sometimes  serviceable. 
Urethan,  sulphonal,  and  chloralamide  are  rarely  efficacious,  and  it  is  best,  after 
a  few  trials,  particularly  if  the  paraldehyde  does  not  answer,  to  resort  to 
morphia.     It  may  be  given  in  combination  with  atropine. 

(g)  Eenal  Symptoms. — With  broken  compensation  and  lowering  of 
the  tension  in  the  aorta,  the  urinary  secretion  is  greatly  diminished,  and 
the  amount  may  sink  to  5  or  6  ounces  in  the  day.  Digitalis,  and  strophan- 
thus  when  efficient,  usually  increase  the  flow.  A  brisk  purge  may  be  followed 
by  augmented  secretion.  The  combination  in  pill  form  of  digitalis,  squill, 
and  the  black  oxide  of  mercury,  will  sometimes  prove  eflective  when  the  infu- 
sion or  tincture  -of  digitalis  alone  has  failed.  Calomel  acts  well  in  some  cases, 
given  in  S-grain  doses  every  six  hours  for  three  or  four  days. 

The  DIET  in  chronic  valve-diseases  is  often  very  difficult  to  regulate.  Widal 
and  others  have  shown  that  retention  of  the  chlorides  is  an  important  factor 
in  cardiac  dropsy  and  heart  failure.  A  milk  diet,  3  liters  a  day,  favors  their 
elimination,  and  in  the  intervals  between  attacks  a  salt-free  diet  as  far  as 
possible  should  be  used.  Starchy  foods,  and  all  articles  likely  to  cause  flatu- 
lency, should  be  forbidden.  Stimulants  are  often  necessary,  either  whisky  or 
brandy. 

III.    AFFECTIONS    OF    THE    MYOCARDIUM. 

1.  Dilatation  and  Hypeeteophy, 

As  with  other  muscular  hollow  organs,  the  size  of  the  chambers  of  the 
heart  varies  greatly  within  normal  limits.  Dilatation  may  be  an  acute  process, 
and  quite  transitory  as  after  severe  muscular  effort,  or  it  may  be  chronic,  in 
which  case  it  is  associated  with  hypertrophy.  Kot  always,  however;  there  is 
an  extraordinary  heart  in  the  McGill  College  Museum  showing  a  parchment- 
like thinning  of  the  walls  with  uniform  dilatation  of  all  the  chambers;  in 
places  in  the  right  auricle  and  ventricle  only  the  epicardium  remains.  Dila- 
tation is  pathological  only  when  permanent.  Increase  in  capacity  means 
increased  work  for  the  walls,  which  in  consequence  hypertrophy  to  meet  the 
demand. 

Dilatation. — Two  important  causes  combine  to  produce  dilatation — in- 
creased pressure  within  the  cavities  and  impaired  resistance,  due  to  weakening 
of  the  muscular  wall — which  may  act  singly,  but  are  often  combined.  A 
weakened  wall  may  yield  to  a  normal  distending  force,  or  a  normal  wall  may 
yield  under  a  heightened  blood-pressure. 

(1)  Heightened  endocaediac  peessuee  results  either  from  an  increased 
quantity  of  blood  to  be  moved  or  an  obstacle  to  be  overcome,  and  is  the  more 
frequent  cause.  It  does  not  necessarily  bring  about  dilatation;  simple  hyper- 
trophy may  follow,  as  in  the  early  period  of  aortic  stenosis,  and  in  the  hyper- 
trophy of  the  left  ventricle  in  Bright's  disease. 

The  size  of  the  cardiac  chambers  varies  in  health.  With  slow  action  of 
the  heart  the  dilatation  is  complete  and  fuller  than  it  is  with  rapid  action. 
Physiologically,  the  limits  of  dilatation  are  reached  when  the  chamber  does 
not  empty  itself  during  the  systole.    This  may  occur  as  an  acute,  transient  con- 


DISEASES  OF   THE  HEART.  821 

dition  in  severe  exertion— during,  for  example,  the  ascent  of  a  mountain. 
There  may  be  great  dilatation  of  the  right  heart,  as  shown  by  the  increased 
epigastric  pulsation,  and  even  increase  in  the  cardiac  dulness.  The  safety- 
valve  action  of  the  tricuspid  valves  may  here  come  into  play,  relieving  the 
lungs  by  permitting  regurgitation  into  the  auricle.  With  rest  the  condition 
is  removed,  but  if  it  has  been  extreme,  the  heart  may  suffer  a  strain  from 
which  it  may  recover  slowly,  or,  indeed,  the  individual  may  never  be  able 
again  to  undertake  severe  exertion.  In  the  process  of  training,  the  getting 
wind,  as  it  is  called,  is  largely  a  gradual  increase  in  the  capability  of  the 
heart,  particularly  of  the  right  chambers,  A  degree  of  exertion  can  be  safely 
maintained  in  full  training  which  would  be  quite  impossible  under  other  cir- 
cumstances, because,  by  a  gradual  process  of  what  we  may  call  physical  edu- 
cation, the  heart  has  strengthened  its  reserve  force — widened  enormously  its 
limits  of  physiological  work.  Endurance  in  prolonged  contests  is  measured 
by  the  capabilities  of  the  heart,  and  its  essence  consists  in  being  able  to  meet' 
the  continuous  tendency  to  overstep  the  limits  of  dilatation.  We  have  no 
positive  knowledge  of  the  nature  of  the  changes  in  the  heart  which  occur  in 
this  process,  but  it  must  be  in  the  direction  of  increased  muscular  and  nervous 
energy.  The  large  heart  of  athletes  may  be  due  to  the  prolonged  use  of  their 
muscles,  but  no  man  becomes  a  great  runner  or  oarsman  who  has  not  natu- 
rally a  capable  if  not  a  large  heart.  Master  McGrath,  the  celebrated  grey- 
hound, and  Eclipse,  the  race-horse,  both  famous  for  endurance  rather  than 
speed,  had  very  large  hearts. 

Excessive  dilatation  during  severe  muscular  effort  results  in  heart-strain. 
A  man,  perhaps  in  poor  condition,  calls  upon  his  heart  for  extra  work  during 
the  ascent  of  a  high  mountain,  and  is  at  once  seized  with  pain  about  the  heart 
and  a  sense  of  distress  in  the  epigastriuni.  He  breathes  rapidly  for  some  time, 
is  "  puffed,"  as  we  say,  but  the  symptoms  pass  off  after  a  night's  quiet.  An 
attempt  to  repeat  the  exercise  is  followed  by  another  attack,  or,  indeed,  an 
attack  of  cardiac  dyspnoea  may  come  on  while  he  is  at  rest.  For  months  such 
a  man  may  be  unfitted  for  severe  exertion,  or  he  may  be  permanently  incapac- 
itated. In  some  way  he  has  overstrained  his  heart  and  become  "broken- 
winded."  Exactly  what  has  taken  place  in  these  hearts  we  can  not  say,  but 
their  reserve  force  is  lost,  and  with  it  the  power  of  meeting  the  demands 
exacted  in  maintaining  the  circulation  during  severe  exertion.  The  "  heart- 
shock"  of  Latham  includes  cases  of  this  nature — sudden  cardiac  breakdown 
during  exertion,  not  due  to  rupture  of  a  valve.  It  seems  probable  that  sudden 
death  in  men  during  long-continued  efforts,  as  in  a  race,  is  sometimes  due  to 
overdistention  and  paralysis  of  the  heart. 

Acute  dilatative  heart  weakness  is  seen  in  many  conditions,  as  in  Graves' 
disease,  in  paroxysmal  tachycardia,  in  old  myocardial  cases  following  exertion, 
and  in  angina  pectoris.  There  is  usually  a  striking  contrast  between  the  wide 
and  forcible  cardiac  impulse  and  the  small,  feeble,  irregular  pulse. 

Dilatation  occurs  in  all  forms  of  valve  lesions.  In  aortic  incompetency 
blood  enters  the  left  ventricle  during  diastole  from  the  unguarded  aorta  and 
from  the  left  auricle,  and  the  quantity  of  blood  at  the  termination  of  diastole 
subjects  the  walls  to  an  extreme  degree  of  pressure,  under  which  they  inevitably 
yield.  In  time  they  augment  in  thickness,  and  present  the  typical  eccentric 
hypertrophy  of  this  condition. 


822  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

In  mitral  insufficiency  blood  which  should  have  been  driven  into  the  aorta 
is  forced  into  and  dilates  the  auricle  from  which  it  came,  and  then  in  the 
diastole  of  the  ventricle  a  large  amount  is  returned  from  the  auricle,  and  with 
increased  force.  In  mitral  stenosis  the  left  auricle  is  the  seat  of  greatly  in- 
creased tension  during  diastole,  and  dilates  as  well  as  hj'pertrophies ;  the  dis- 
tention, too,  ma}'  be  enormous.  Dilatation  of  the  right  ventricle  is  produced 
by  a  number  of  conditions,  which  were  considered  under  h3^ertrophy.  All 
circumstances,  such  as  mitral  stenosis,  emphysema,  etc.,  which  permanently 
increase  the  tension  of  the  Ijlood  in  the  pulmonary  vessels,  cause  its  dilatation. 

The  idiopathic  dilatation  and  hj-pertrophy  of  beer  drinkers  also  comes  in 
this  group,  as  it  is  brought  about  gradually  by  increased  endocardial  pressure. 

(2)  Impaired  xutritiox  of  the  heart- walls  may  lead  to  a  diminution 
of  the  resisting  power  so  that  dilatation  readily  occurs. 

The  loss  of  tone  due  to  parenchjinatous  degeneration  or  myocarditis  in 
fevers  may  lead  to  a  fatal  condition  of  acute  dilatation.  It  is  a  recognized 
cause  of  death  in  scarlatinal  dropsy  (Goodhart),  and  may  occur  in  rheumatic 
fever,  typhus,  tj-phoid,  erysipelas,  etc.  The  changes  in  the  heart-muscle  which 
accompany  acute  endocarditis  or  pericarditis  may  lead  to  dilatation,  especially 
in  the  latter  disease.  In  ansemia,  leuksemia,  and  chlorosis  the  dilatation 
may  be  considerable.  In  sclerosis  of  the  walls,  the  yielding  is  always  where 
this  process  is  most  advanced,  as  at  the  left  apex.  Under  any  of  these  cir- 
cumstances the  walls  may  yield  with  normal  blood-pressure. 

Pericardial  adhesions  are  a  cause  of  dilatation,  and  we  generally  find  in 
eases  with  extensive  and  firm  union  considerable  hypertrophy  and  dilatation. 
There  is  usually  here  some  impairment  as  well  of  the  superficial  layers  of 
muscle. 

Hypertrophy. — There  are  two  forms  of  kypertropliy,  one  in  which  the 
cavity  or  cavities  are  of  normal  size;  and  the  other  with  dilatation  (eccentric 
hypertrophy),  in  which  the  cavities  are  enlarged  and  the  walls  increased  in 
thickness.  The  condition  formerly  spoken  of  as  concentric  hjqDertrophy,  in 
which  there  is  diminution  in  the  size  of  the  cavity  with  tliickening  of  the 
walls,  is,  as  a  rule,  a  post-mortem  change. 

The  enlargement  may  affect  the  entire  organ,  one  side,  or  only  one  cham- 
ber. Xaturally,  as  the  left  ventricle  does  the  chief  work  in  forcing  the  blood 
through  the  systemic  arteries,  the  change  is  most  frequently  found  in  it. 

H}"pertrophy  of  the  heart  follows  the  law  governing  muscles,  that  within 
certain  limits,  if  the  nutrition  is  kept  up,  increased  work  is  followed  by 
increased  size — i.  e.,  h3'pertrophy. 

Htperteopht  oe  the  left  vextricle  aloxe^  or  with  general  enlarge- 
ment of  the  heart,  is  brought  about  b}' — 

Conditions  affecting  the  lieart  itself:  (1)  Disease  of  the  aortic  valve;  (3) 
mitralinsufficiency;  (3)  pericardial  adhesions;  (-4)  sclerotic  myocarditis ;  (5) 
disturbed  innervation,  with  overaction,  as  in  exophthalmic  goitre,  in  long- 
continued  nervous  palpitation,  and  as  a  result  of  the  action  of  certain  articles, 
such  as  tea,  coffee,  and  tobacco.  In  all  of  these  the  work  of  the  heart  is 
increased.  In  the  case  of  the  valve  lesions  the  increase  is  due  to  the  increased 
intraventricular  pressure;  in  the  case  of  the  adherent  pericardium  and  myo- 
carditis, to  direct  interference  with  the  symmetrical  and  orderly  contraction  of 
the  chambers. 


DISEASES  OF  THE  HEART.  823 

Conditions  acting  upon  the  blood-vessels:  (1)  General  arterio-sclerosis, 
with  or  without  renal  disease;  (3)  all  states  of  increased  arterial  tension 
induced  by  the  contraction  of  the  smaller  arteries  under  the  influence  of 
certain  toxic  substances,  which,  as  Bright  suggested,  "  by  affecting  the 
minute  capillary  circulation,  render  greater  action  necessary  to  send  the  blood 
through  the  distant  subdivisions  of  the  vascular  system";  (3)  prolonged  hius- 
cular  exertion,  which  enormously  increases  the  blood-pressure  in  the  arteries; 
(4)  narrowing  of  the  aorta,  as  in  the  congenital  stenosis. 

Hypeetroppiy  of  the  right  ventricle  is  met  with  under  the  following 
conditions — 

(1)  Lesions  of  the  mitral  valve,  either  incompetence  or  stenosis,  which 
act  by  increasing  the  resistance  in  the  pulmonary  vessels.  (3)  Pulmonary 
lesions,  obliteration  of  any  number  of  blood-vessels  within  the  lungs,  such 
as  occurs  in  emphysema  or  cirrhosis,  is  followed  by  hypertrophy  of  the  right 
ventricle.  (3)  Valvular  lesions  on  the  right  side  occasionally  cause  hyper- 
trophy in  the  adult,  not  infrequently  in  the  foetus.  (4)  Chronic  valvular  dis- 
ease of  the  left  heart  and  pericardial  adhesions  are  sooner  or  later  associated 
with  hypertrophy  of  the  right  ventricle. 

In  the  auricles  simple  hypertrophy  is  never  seen;  there  is  always  dilata- 
tion with  hypertrophy.  In  the  left  auricle  the  condition  develops  in  lesions 
at  the  mitral  orifice,  particularly  stenosis.  The  right  auricle  hypertrophies 
when  there  is  greatly  increased  blood-pressure  in  the  lesser  circulation,  whether 
due  to  mitral  stenosis  or  pulmonary  lesions.  ISTarrowing  of  the  tricuspid  orifice 
is  a  less  frequent  cause. 

2.  Lesions  due  to  Disease  of  the  Coronary  Arteries. 

A  knowledge  of  the  changes  produced  in  the  myocardium  by  disease  of  the 
coronary  vessels  gives  a  key  to  the  understanding  of  many  problems  in  cardiac 
pathology.  The  terminal  branches  of  the  coronary  vessels  are  end-arteries; 
that  is,  the  communication  between  neighboring  branches  is  through  capillaries 
only.  J.  H.  Pratt  has  shown  that  the  vessels  of  Thebesius,  which  open  from 
the  ventricles  and  auricles  into  a  system  of  fine  branches  and  thus  communi- 
cate with  the  cardiac  capillaries  and  coronary  veins,  may  be  capable  of  feeding 
the  myocardium  sufficiently  to  keep  it  alive  even  when  the  coronary  arteries 
are  occluded.  The  blocking  of  one  of  these  vessels  by  a  thrombus  or  an 
embolus  leads  usually  to  a  condition  which  is  known  as — 

(a)  Anaemic  necrosis,  or  white  infarct.  When  this  does  not  occur  the 
reason  may  be  sought  in  (1)  the  existence  of  abnormal  anastomoses,  which 
by  their  presence  take  the  coronary  system  out  of  the  group  of  end-arteries; 
or  (3)  the  vicarious  flow  through  the  vessels  of  Thebesius  and  the  coronary 
veins.  The  condition  is  most  commonly  seen  in  the  left  ventricle  and  in  the 
septum,  in  the  territory  of  distribution  of  the  anterior  coronary  artery.  The 
affected  area  has  a  yellowish-white  color,  sometimes  a  turbid,  parboiled  aspect, 
at  other  times  a  grayish-red  tint.  It  ma}^  be  somewhat  wedge-shaped,  more 
often  it  is  irregular  in  contour  and  projects  above  the  surface.  Microscopically 
the  changes  are  very  characteristic.  The  nuclei  either  disappear  from  the 
muscle  fibres  or  they  undergo  fragmentation.  Leucocytes  wander  in  from 
the  surrounding  tissue,  and  these  may  suffer  disintegration.  At  a  later  stage 
a  new  growth  of  fibrous  tissue  is  found  in  the  periphery  of  the  infarct  which 


824  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

■ultimately  may  entirely  replace  the  dead  fibres.  The  fibres  present  a  homo- 
geneous, hyaline  appearance.  In  some  instances  there  is  complete  transforma- 
tion, and  even  to  the  naked  eye  a  firm  white  patch  of  hyaline  degeneration 
may  appear  in  the  centre  of  the  area.  Eupture  of  the  heart  may  be  asso- 
ciated with  angemic  necrosis. 

(&)  The  second  important  effect  of  coronar3^-artery  disease  upon  the  myo- 
cardium is  seen  in  the  production  of  fibrous  myocarditis.  This  may  result 
from  the  gradual  transformation  of  areas  of  anaemic  necrosis.  More  commonly 
it  is  caused  by  the  narrowing  of  a  coronary  branch  in  a  process  of  obliterative 
endarteritis.  Where  the  process  is  gradual  evidences  of  granulation  tissue 
are  often  wanting,  and  any  distinction  between  the  necrotic  muscle  fibres  and 
the  new  scar  tissue  is  difficult  to  establish.  J.  B.  MacCallum  has  shown  that 
the  muscle  fibres  undergo  a  change  the  reverse  of  that  of  their  normal  develop- 
ment and  lose  their  fibril  bundles  preliminary  to  their  complete  replacement 
by  connective  tissue.  The  sclerosis  is  most  frequently  seen  at  the  apex  of  the 
left  ventricle  and  in  the  septum,  but  it  may  occur  in  any  portion.  In  the 
septum  and  walls  there  are  often  streaks  and  patches  which  are  only  seen 
in  carefully  made  serial  sections.  II}"pertrophy  of  the  heart  is  commonly 
associated  with  this  degeneration.  It  is  the  invariable  precursor  of  aneurism 
of  the  heart. 

(c)  Sudden  Death  in  Coronary  Artery  Disease. — Complete  obliteration 
of  one  coronary  artery,  if  produced  suddenly,  is  usually  fatal.  When  in- 
duced slowly,  either  by  arterio-sclerosis  at  the  orifice  of  the  artery  at  the  root  of 
the  aorta  or  by  an  obliterating  endarteritis  in  the  course  of  the  vessel,  the  circu- 
lation may  be  carried  on  through  the  other  vessel.  Sudden  death  is  not  uncom- 
mon, owing  to  thrombosis  of  a  vessel  which  has  become  narrowed  by  sclerosis. 
In  medico-legal  cases  it  is  a  point  of  primary  importance  to  rememher  that  this 
is  one  of  the  common  causes  of  sudden  death.  This  condition  should  be  care- 
fully sought  for,  inasmuch  as  it  may  be  the  sole  lesion,  except  a  general,  some- 
times slight  arterio-sclerosis.  In  the  most  extreme  grade  one  coronary  artery 
may  be  entirely  blocked,  with  the  production  of  extensive  fibroid  disease,  and 
a  main  branch  of  the  other  also  may  be  occluded.  A  large,  powerfully  built 
imbecile,  aged  thirty-five,  at  the  Elw^m  Institution,  Pennsylvania,  who  had  for 
years  enjoyed  doing  the  heavy  work  about  the  place,  died  suddenly,  without 
any  preliminaiy  sj^mptoms.  The  heart  weighed  over  600  grammes;  the  an- 
terior coronary  artery  was  practically  occluded  by  obliterating  endarteritis, 
and  of  the  posterior  artery  one  main  branch  was  blocked. 

{d)  Septic  Infarcts. — In  pyemia  the  smaller  branches  of  the  coronary 
.  arteries  may  be  blocked  with  emboli  which  give  rise  to  infectious  or  septic 
infarcts  in  the  myocardium  in  the  form  of  abscesses,  varying  in  size  from  a 
pea  to  a  pin's  head.  These  may  not  cause  any  disturbance,  but  when  large  they 
may  perforate  into  the  ventricle  or  into  the  pericardium,  forming  what  has 
been  called  acute  ulcer  of  the  heart. 

3.  Acute  Inteestitial  Mtocaeditis. 

In  some  infectious  diseases  and  in  acute  pericarditis  the  intermuscular  con- 
nective tissue  may  be  swollen  and  infiltrated  with  small  round  cells  and 
leucoc}'i:es,  the  blood-vessels  dilated,  and  the  muscle  fibres  the  seat  of  granular, 
fatty,  and  hyaline  degeneration.    Occasionally,  in  pyaemia  the  infiltration  with 


DISEASES  OF  THE  HEART.  825 

pus-cells  has  been  diffuse  and  confined  chiefly  to  the  interstitial  tissue.  Coun- 
cilman has  described  this  condition  of  the  heart  wall  in  gonorrhoea,  and 
succeeded  in  demonstrating  the  gonococcus  in  the  diseased  areas.  The  com- 
monest examples  are  found  in  diphtheria,  typhoid  fever,  and  acute  endo- 
carditis, as  shown  by  the  studies  of  Eomberg,  The  foci  may  be  the  starting- 
points  of  patches  of  fibrous  myocarditis. 

4.  Feagmentation"  and  Segmentation. 

This  condition  was  described  by  Renaut  and  Landouzy  in  1877,  and  has 
been  carefully  studied  by  different  pathologists.     Two  forms  are  met  with: 

1.  Segmentation.      The   muscle   fibres   have    separated   at   the   cement  line. 

2.  Fragmentation.  The  fracture  has  been  across  the  fibre  itself,  and  perhaps 
at  the  level  of  the  nucleus.  Longitudinal  division  is  unusual.  Although  the 
condition  doubtless  arises  in  some  instances  during  the  death  agony,  as  in 
cases  of  sudden  death  by  violence,  in  others  it  would  seem  to  have  clinical  and 
pathological  significance.  It  is  found  associated  with  other  lesions,  fibrous 
myocarditis,  infarction,  and  fatty  degeneration.  J.  B.  MacCallum  distin- 
guishes a  simple  from  a  degenerative  fragmentation.  The  first  takes  place 
in  the  normal  fibre,  which,  however,  shows  irregular  extensions  and  contrac- 
tions. The  second  succeeds  degeneration  in  the  fibre.  Hearts  the  seat  of 
marked  fragmentation  are  lax,  easily  torn,  the  muscle  fibres  widely  separated, 
and  often  pale  and  cloudy. 

5.  Parenchymatous  Degeneration. 

This  is  usually  met  with  in  fevers,  or  in  connection  with  endocarditis  or 
pericarditis,  and  in  infections  and  intoxications  generally.  It  is  characterized 
by  a  pale,  turbid  state  of  the  cardiac  muscle,  which  is  general,  not  localized. 
Turbidity  and  softness  are  the  special  features.  It  is  the  softened  heart  of 
Laennec  and  Louis.  Stokes  speaks  of  an  instance  in  which  "  so  great  was  the 
softening  of  the  organ  that  when  the  heart  was  grasped  by  the  great  vessels  and 
held  with  the  apex  pointing  upward,  it  fell  down  over  the  hand,  covering  it  like 
a  cap  of  a  large  mushroom.'' 

Histologically,  there  is  a  degeneration  of  the  muscle  fibres,  which  are 
infiltrated  to  a  various  extent  with  granules  which  resist  the  action  of  ether, 
but  are  dissolved  in  acetic  acid.  Sometimes  this  granular  change  in  the  fibres 
is  extreme,  and  no  trace  of  the  striae  can  be  detected.  It  is  probably  the  effect 
of  a  toxic  agent,  and  is  seen  in  its  most  exquisite  form  in  the  lumbar  muscles 
in  cases  of  toxic  hsemoglobinuria  in  the  horse.  It  is  met  with  in  cases  of 
typhoid,  typhus,  small-pox,  and  other  infectious  diseases,  particularly  when 
the  course  is  protracted.  There  is  no  definite  relation  between  it  and  the  high 
temperature. 

6.  Fatty  Heart. 

Under  this  term  are  embraced  fatty  degeneration  and  fatty  overgrowth. 

(a)  Fatty  degeneration  is  a  very  common  condition,  and  mild  grades  are 
met  with  in  many  diseases.  It  is  found  in  the  failing  nutrition  of  old  age, 
of  wasting  diseases,  and  of  cachectic  states;  in  prolonged  infectious  fevers,  in 
which  it  may  follow  or  accompany  the  parenchymatous  change.  In  pernicious 
anaemia  and  in  phosphorus  poisoning  the  most  extreme  degrees  are  seen.  Peri- 
54 


826  DISEASES  OF   THE  CIRCULATORY  SYSTEM. 

carditis  is  usually  associated  with  fatty  or  parenchymatous  changes  in  the 
superficial  layers  of  the  myocardium.  Disease  of  the  coronary  arteries  is  a 
much  more  common  cause  of  fibroid  degeneration  than  of  fatty  heart.  Lastly, 
in  the  hypertrophied  ventricular  wall  in  chronic  heart-disease  fatty  change  is 
by  no  means  infrequent.  This  degeneration  may  be  limited  to  the  heart  or  it 
may  be  more  or  less  general  in  the  solid  viscera.  The  diaphragm  may  also  be 
involved;  even  vrhen  the  other  muscles  show  no  special  changes.  There  appears 
to  be  a  special  proneness  to  fatty  degeneration  in  the  heart-muscle,  which  may 
perhaps  be  connected  with  its  incessant  activity.  So  great  is  its  need  of  an 
abundant  ox3"gen  supply  that  it  feels  at  once  any  deficiency,  and  is  in  conse- 
quence the  first  muscle  to  show  nutritional  changes. 

Anatomically  the  condition  may  be  local  or  general.  The  left  ventricle  is 
most  frequently  affected.  If  the  process  is  advanced  and  general,  the  heart 
looks  large  and  is  flabby  and  relaxed.  It  has  a  light  yellowish-bro"v\ai  tint, 
or,  as  it  is  called,  a  faded-leaf  color.  Its  consistence  is  reduced  and  the  sub- 
stance tears  easily.  In  the  left  ventricle  the  papillary  columns  and  the  muscle 
beneath  the  endocardium  show  a  streaked  or  patchy  appearance.  Micro- 
scopically, the  fibres  are  seen  to  be  occupied  by  minute  globules  distributed 
in  rows  along  the  line  of  the  primitive  fibres  (Welch).  In  advanced  grades 
the  fibres  seem  completely  occupied  by  the  minute  globules. 

(&)  Fatty  Overgrowth.- — This  is  usually  a  simple  excess  of  the  normal 
subpericardial  fat,  to  which  the  term  cor  adiposum  was  given  by  the  older 
writers.  In  pronounced  instances  the  fat  infiltrates  between  the  muscular  sub- 
stance and,  separating  the  strands,  may  reach  even  to  the  endocardium.  In 
corpulent  persons  there  is  always  much  pericardial  fat.  It  forms  part  of  the 
general  obesit}^,  and  occasionally  leads  to  dangerous  or  even  fatal  impairment 
of  the  contractile  power  of  the  heart.  Of  123  cases  analyzed  by  Forchheimer 
there  were  88  males  and  34  females.  Over  80  per  cent  occurred  between  the 
fortieth  and  seventieth  years. 

The  entire  heart  may  be  enveloped  in  a  thick  sheeting  of  fat  through 
which  not  a  trace  of  muscle  substance  can  be  seen.  On  section,  the  fat  infil- 
trates the  muscle,  separating  the  fibres,  and  in  extreme  cases — ^particularly 
in  the  right  ventricle — reaches  the  endocardium.  In  some  places  there  may 
be  even  complete  substitution  of  fat  for  the  muscle  substance.  In  rare  in- 
stances the  fat  may  be  in  the  papillary  muscles.  The  heart  is  usually  much 
relaxed  and  the  chambers  are  dilated.  Microscopically  the  muscle  fibres  may 
show,  in  addition  to  the  atrophy,  marked  fatty  degeneration. 

7.  Other  Degenerations  of  the  Myocardium. 

(a)  Brown  Atrophy. — This  is  a  common  change  in  the  heart-muscle,  par- 
ticularly in  chronic  valvular  lesions  and  in  the  senile  heart.  When  advanced, 
the  color  of  the  muscles  is  a  dark  red-brown,  and  the  consistence  is  usually 
increased.  The  fibres  present  an  accumulation  of  yellow-brown  pigment  chiefly 
about  the  nuclei.  The  cement  substance  is  often  unusually  distinct,  but  seems 
more  fragile  than  in  healthy  muscle. 

(b)  Amyloid  degeneration  of  the  heart  is  occasionally  seen.  It  occurs  in 
the  intermuscular  connective  tissue  and  in  the  blood-vessels,  not  in  the  fibres. 

(c)  The  hyaline  transformation  of  Zenker  is  sometimes  met  with  in  pro- 


■      DISEASES  OF   THE  HEART.  827 

longed  fevers.     The  affected  fibres  are  swollen,  homogeneous,  translucent,  and 
the  striae  are  very  faint  or  entirely  absent. 

(d)  Calcareous  degeneration  may  occur  in  the  myocardium,  and  the  muscle 
fibres  may  be  infiltrated  and  yet  retain  their  appearance  as  figured  and  de- 
scribed by  Coats  in  his  Text-book  of  Pathology. 

Symptoms  of  Myocardial  Disease. 

With  a  "  weak  heart,"  without  valvular  disease  or  renal  changes,  the  patient 
has  shortness  of  breath  on  exertion,  a  feeble,  irregular  pulse,  and  there  are  signs 
of  cardiac  dilatation — feeble  impulse,  increased  area  of  flatness,  and  usually 
a  gallop  rhythm,  sometimes  a  soft  apex-systolic  murmur.  The  myocardial 
lesion  is  not  always  proportionate  to  the  intensity  of  the  symptoms.  A  patient 
may  present  enfeebled,  irregular  action  and  signs  of  dilatation — shortness  of 
breath,  oedema,  and  the  general  symptoms  believed  to  be  characteristic  of 
cases  of  fibroid  and  fatty  heart — and  the  post  mortem  show  little  or  no 
change  in  the  myocardium. 

Cardiosclerosis  or  fibroid  heart  is  in  some  cases  characterized  by  a  feeble, 
irregular,  slow  pulse,  with  dyspnoea  on  exertion  and  occasional  attacks  of 
angina.  Irregularity  is  present  in  many,  but  not  in  all  cases.  The  pulse 
may  be  very  slow,  even  30  or  40  per  minute,  and  the  features  those  of  Stokes- 
Adams  disease.  A  man  with  advanced  fibroid  myocarditis  may  die  suddenly 
while  at  work,  without  having  ever  complained  of  heart  trouble.  Ultimately 
the  cases  come  under  observation  with  the  symptoms  of  cardiac  insufficiency. 
The  arrhythmia,  which  may  have  been  present,  becomes  aggravated  and, 
according  to  Kiegel,  may  not  only  precede,  but  also  persist  after  the  cardiac 
insufficiency  has  passed  away. 

Fatty  degeneration  of  the  heart  presents  the  same  difficulties.  Extreme 
fatty  changes,  as  in  pernicious  anaemia,  may  be  present  with  a  full  pulse  and 
regularly  acting  heart.  The  fat  does  not  appear  to  interfere  seriously  with  the 
function  of  the  organ.  The  truth  is,  it  may  be  present  in  an  extreme  grade 
without  producing  symptoms,  so  long  as  great  dilatation  of  the  chambers  does 
not  occur.  The  cardiac  irregularity,  the  dyspnoea,  palpitation,  and  small  pulse 
are  in  reality  not  symptoms  of  the  fatty  degeneration,  but  of  dilatation  which 
has  supervened.  The  fatty  arcus  senilis  is  of  no  moment  in  the  diagnosis  of 
fatty  heart.     The  heart-sounds  may  be  weak  and  the  action  irregular. 

When  dilatation  occurs,  there  is  gallop  rhythm,  shortening  of  the  long 
pause,  and  a  systolic  murmur  at  the  apex.  Shortness  of  breath  on  exertion 
is  an  early  feature  in  many  cases,  and  anginal  attacks  may  occur.  There  is 
sometimes  a  tendency  to  syncope,  and  in  both  fibroid  and  fatty  heart  there 
are  attacks  in  which  the  patient  feels  cold  and  dej^ressed  and  the  pulse  sinks 
to  40  or  30,  or  even,  as  in  one  case  which  I  saw,  to  36.  The  patient  may 
wake  from  sleep  in  the  early  morning  with  an  attack  of  severe  cardiac  asthma. 
These  "  spells  "  may  be  associated  with  nausea  and  may  alternate  with  others 
in  which  there  are  anginal  symptoms.  These  are  the  cases,  too,  in  which  for 
weeks  there  may  be  mental  symptoms.  The  patient  has  delusions  and  may 
even  become  maniacal.  Toward  the  close,  the  type  of  breathing  known  as 
Cheyne-Stokes  may  occur.  It  was  described  in  the  following  terms  by  John 
Cheyne,  speaking  of  a  case  of  fatty  heart  (Dublin  Hospital  Eeports,  vol.  ii, 
p.  231, 1818)  :  "  For  several  days  his  breathing  was  irregular;  it  would  entirely 


828  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

cease  for  a  quarter  of  a  minute,  then  it  would  become  perceptible,  though  very 
low,  then  by  degrees  it  became  heaving  and  quick,  and  then  it  would  gradually 
cease  again :  this  revolution  in  the  state  of  his  breathing  lasted  about  a  minute, 
during  which  there  were  about  thirty  acts  of  respiration/'  It  is  seen  much 
more  frequently  in  arterio-sclerosis  and  ursemic  states  than  in  fatty  heart. 

Fatty  overgrowth  of  the  heart  is  a  condition  certain  to  exist  in  very  obese 
persons.  It  produces  no  sj^mptoms  until  the  muscular  fibre  is  so  weakened 
that  dilatation  occurs.  These  patients  may  for  years  present  a  feeble  but 
regular  pulse;  the  heart-sounds  are  weak  and  muffled,  and  a  murmur  may  be 
heard  at  the  apex.  Attacks  of  cardiac  asthma  are  not  uncommon,  and  the 
patient  may  suffer  from  bronchitis.  Dizziness  and  pseudo-apoplectic  seizures 
may  occur.  Sudden  death  may  result  from  syncope  or  from  rupture  of  the 
heart.  The  physical  examination  is  often  difficult  because  of  the  great  increase 
in  the  fat,  and  it  may  be  impossible  to  define  the  area  of  dulness. 

For  clinical  purposes  we  may  group  the  cases  of  myocardial  disease  as 
follows : 

(1)  Those  in  which  sudden  death  occurs  with  or  without  previous  indi- 
cations of  heart-trouble.  Sclerosis  of  the  coronary  arteries  exists — in  some 
instances  with  recent  thrombus  and  white  infarcts ;  in  others,  extensive  fibroid 
disease;  in  others  again,  fatty  degeneration.  Many  patients  never  complain 
of  cardiac  distress,  but,  as  in  the  case  of  Chalmers,  the  celebrated  Scottish 
divine,  enjoy  unusual  vigor  of  mind  and  body. 

(2)  Cases  in  which  there  are  cardiac  arrhythmia,  shortness  of  breath  on 
exertion,  attacks  of  cardiac  asthma,  sometimes  anginal  attacks,  collapse  symp- 
toms with  sweats  and  extremely  slow  pulse,  and  occasionally  marked  mental 
symptoms. 

(3)  Cases  with  general  arterio-sclerosis  and  hypertrophy  and  dilatation 
of  the  heart.  They  are  robust  men  of  middle  age  who  have  worked  hard 
and  lived  carelessly.  Dyspnoea,  cough,  and  swelling  of  the  feet  are  the  early 
symptoms,  and  the  patient  comes  under  observation  either  with  a  gallop 
rhythm,  embryocardia,  or  an  irregular  heart  with  an  apex  systolic  murmur 
of  mitral  insufficiency.  Eecovery  from  the  first  or  second  attack  is  the  rule. 
It  is  one  of  the  most  common  forms  of  heart-disease. 

Prognosis. 

The  outlook  in  affections  of  the  myocardium  is  extremely  grave.  Patients 
recover,  however,  in  a  surprising  way  from  the  most  serious  attacks,  particu- 
larly those  of  the  third  group. 

Treatment. 

Many  cases  never  come  under  treatment;  the  first  are  the  final  symptoms. 

Cases  with  signs  of  well-marked  cardiac  insufficiency,  as  manifested  by 
dyspnoea,  weak,  irregular,  rapid  heart,  and  oedema,  may  be  treated  on  the 
plan  laid  down  for  the  treatment  of  broken  compensation  in  valvular  disease. 
Digitalis  may  be  given  even  if  fatty  degeneration  is  suspected,  and  is  often 
very  beneficial. 

Much  more  difficult  is  the  management  of  those  cases  in  which  there  is 
marked  cardiac  arrhythmia,  with  a  feeble,  irregular,  very  slow  pulse,  and  syn- 
cope or  angina.     Dropsy  is  not,  as  a  rule,  present;  the  heart-sounds  may  be 


DISEASES  OF  THE  HEART.  829 

perfectly  clear,  and  there  are  no  signs  of  dilatation.  Digitalis,  under  these 
circumstances,  is  not  advisable,  particularly  when  the  pulse  is  infrequent. 
Complete  rest  in  bed,  a  carefully  regulated  diet,  and  the  use  of  the  aromatic 
spirits  of  ammonia,  sulphuric  ether,  and  stimulants  are  indicated.  For  the 
restlessness  and  distressing  feelings  of  anxiety  morphia  is  invaluable.  From 
an  eightieth  to  a  sixtieth  of  a  grain  of  strychnia  may  be  given  three  times 
a  day.  If  the  pulse  is  hard  and  firm  and  the  blood  pressure  high  the  sodium 
nitrites  or  nitroglycerin  should  be  given  freely. 

In  certain  cases  of  weak  heart,  particularly  when  it  is  due  to  fatty  over- 
growth, the  plans  recommended  by  Oertel  and  by  Schott  are  advantageous. 
They  are  invaluable  methods  in  those  forms  of  heart-weakness  due  to  intem- 
perance in  eating  and  drinking  and  defective  bodily  exercise.  The  Oertel 
plan  consists  of  three  parts:  First,  the  reduction  in  the  amount  of  liquid. 
This  is  an  important  factor  in  reducing  the  fat  in  these  patients.  It  also 
slightly  increases  the  density  of  the  blood.  Oertel  allows  daily  about  36  ounces 
of  liquid,  which  includes  the  amount  taken  with  the  solid  food.  Free  perspira- 
tion is  promoted  by  bathing  (if  advisable,  the  Turkish  bath),  or  even  by  the 
use  of  pilocarpine. 

The  second  important  point  in  his  treatment  is  the  diet,  which  should 
consist  largely  of  proteids. 

Morning. — Cup  of  coffee  or  tea,  with  a  little  milk,  about  6  ounces  alto- 
gether.    Bread,  3  ounces. 

Noon. — Three  to  4  ounces  of  soup,  7  to  8  ounces  of  roast  beef,  veal,  game, 
or  poultry,  salad  or  a  light  vegetable,  a  little  fish ;  1  ounce  of  bread  or  farina- 
ceous pudding;  3  to  6  ounces  of  fruit  for  dessert.  No  liquids  at  this  meal,  as 
a  rule,  but  in  hot  weather  6  ounces  of  light  wine  may  be  taken. 

Afternoon. — Six  ounces  of  coffee  or  tea,  with  as  much  water.  As  an 
indulgence  an  ounce  of  bread. 

Evening. — One  or  2  soft-boiled  eggs,  an  ounce  of  bread,  perhaps  a  small 
slice  of  cheese,  salad,  and  fruit;  6  to  8  ounces  of  wine  with  4  or  5  ounces  of 
water  (Yeo). 

The  most  important  element  of  all  is  graduated  exercise,  not  on  the  level, 
but  up  hills  of  various  grades.  The  distance  walked  each  day  is  marked  off 
and  is  gradually  lengthened.  In  this  way  the  heart  is  systematically  exer- 
cised and  strengthened. 

The  Schott  Treatment. — This  consists  in  a  combination  of  baths  with 
exercises  at  liauheim.  The  water  has  a  temperature  of  from  83°-95°  F., 
and  is  very  richly  charged  with  COg.  The  good  effects  of  the  bath  are  claimed 
by  Schott  to  come  from  a  cutaneous  excitation,  induced  by  the  mineral  and 
gaseous  constituents  of  the  bath,  and  a  stimulation  of  the  sensory  nerves. 
There  is  no  question  that  the  bath,  in  suitable  cases,  will  alter  the  position 
of  the  apex  beat,  and  that  it  lessens  the  area  of  cardiac  dulness;  this  means 
that  it  diminishes  the  dilatation  of  the  heart.  Artificial  baths  are  used,  con- 
sisting of  forty  gallons  of  water,  with  various  strengths  of  sodium  chloride  and 
calcium  chloride.  The  exercises,  resistance  gymnastics,  consist  in  slow  move- 
ments executed  by  the  patient  and  resisted  by  the  operator.  The  best  cases  for 
the  ISTauheim  treatment  are  those  with  myocardial  weakness  from  whatever 
cause.  For  valvular  heart  diseases  in  the  stage  of  broken  compensation  with 
dropsy,  etc.,  it  is  not  so  suitable.    The  neurotic  heart  is  often  much  benefited. 


830  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 


IV.     ANEURISM    OF    THE    HEART. 

(a)  Aneurism  of  a  valve  results  from  acute  endocarditis,  which  produces 
softening  or  erosion  and  may  lead  either  to  perforation  of  the  segment  or  to 
gradual  dilatation  of  a  limited  area  under  the  influence  of  the  blood-pressure. 
The  aneurisms  are  usually  spheroidal  and  project  from  the  ventricular  face 
of  a  sigmoid  valve.  They  are  much  less  common  on  the  mitral  segments. 
They  frequently  rupture  and  produce  extensive  destruction  and  incompetency 
of  the  valves. 

(&)  Aneurism  of  the  walls  results  from  the  weakening  induced  by  chronic 
myocarditis,  or  occasionally  it  follo^ys  acute  mural  endocarditis,  which  more 
commonly,  however,  leads  to  perforation.  It  has  followed  a  stab-wound,  a 
gumma  of  the  ventricle,  and,  according  to  some  authors,  pericardial  adhesions. 
The  left  ventricle  near  the  apex  is  usually  the  seat,  this  being  the  situation 
in  which  fibrous  degeneration  is  most  common.  Fifty-nine  of  the  60  cases 
collected  by  Legg  were  situated  here.  In  the  early  stages  the  anterior  wall 
of  the  ventricle,  near  the  septum,  sometimes  even  the  septum  itself,  is  slightly 
dilated,  the  endocardium  opaque,  and  the  muscular  tissue  sclerotic.  In  a 
more  advanced  stage  the  dilatation  is  pronounced  and  layers  of  thrombi  occupy 
the  sac.  Ultimately  a  large  rounded  tumor  may  project  from  the  ventricle  and 
may  attain  a  size  equal  to  that  of  the  heart.  Occasionally  the  aneurism  is 
sacculated  and  communicates  with  the  ventricle  through  a  very  small  orifice. 
The  sac  may  be  double,  as  in  the  cases  of  Janeway  and  Sailer.  In  the  museum 
of  Guy's  Hospital  there  is  a  specimen  showing  the  wall  of  the  ventricle  cov- 
ered with  aneurismal  bulgings.  Eupture  occurred  in  7  of  the  90  cases  col- 
lected by  Legg. 

The  symptoms  produced  by  aneurism  of  the  heart  are  indefinite.  Occa- 
sionally there  is  marked  bulging  in  the  apex  region  and  the  tumor  may 
perforate  the  chest  wall.  In  mitral  stenosis  the  right  ventricle  may  bulge 
and  produce  a  visible  pulsating  tumor  below  the  left  costal  border,  which  I 
have  known  to  be  mistaken  for  cardiac  aneurism.  When  the  sac  is  large  and 
produces  pressure  upon  the  heart  itself,  there  may  be  a  marked  disproportion 
between  the  strong  cardiac  impulse  and  the  feeble  pulsation  in  the  peripheral 
arteries. 

V.     RUPTURE    OF    THE    HEART. 

This  rare  event  is  usually  associated  with  fatty  infiltration  or  degenera- 
tion of  the  heart-muscles.  In  some  instances,  acute  softening  in  consequence 
of  embolism  of  a  branch  of  the  coronary  artery,  suppurative  myocarditis,  or 
a  gummatous  growth  has  been  the  cause.  Of  100  cases  collected  by  Quain, 
fatty  degeneration  was  noted  in  77.  Two-thirds  of  the  patients  were  over 
sixty  years  of  age.  It  may  occur  in  infants.  Schaps  reports  a  case  in  an 
infant  of  four  months  associated  with  an  embolic  infarct  of  the  left  ventricle. 
Harvey,  in  his  second  letter  to  Eiolan  (1649),  described  the  case  of  Sir  Robert 
Darcy,  who  had  distressing  pain  in  the  chest  and  s3aicopal  attacks  with  suffoca- 
tion, and  finally  cachexia  and  dropsy.  Death  occurred  in  one  of  the  parox- 
ysms.    The  wall  of  the  left  ventricle  of  the  heart  was  ruptured,  "  having  a 


DISEASES  OF  THE  HEART.  831 

rent  in  it  of  size  sufficient  to  admit  any  of  my  fingers,  although  the  wall  itself 
appeared  sufficiently  thick  and  strong." 

The  rent  may  occur  in  any  of  the  chambers,  but  is  found  most  frequently 
in  the  left  ventricle  on  the  anterior  wall,  not  far  from  the  septum.  The 
accident  usually  takes  place  during  exertion.  There  may  be  no  preliminary 
symptoms,  but  without  any  warning  the  patient  may  fall  and  die  in  a  few 
moments.  Sudden  death  occurred  in  71  per  cent  of  Quain^s  cases.  In  other 
instances  there  may  be  in  the  cardiac  region  a  sense  of  anguish  and  suffoca- 
tion, and  life  may  be  prolonged  for  several  hours.  In  a  Montreal  case,  which 
I  examined,  the  patient  walked  up  a  steep  hill  after  the  onset  of  the  symptoms, 
and  lived  for  thirteen  hours.  A  case  is  on  record  in  which  the  patient  lived 
for  eleven  days. 

VI.  NEW    GROWTHS    AND    PARASITES. 

Tubercle  and  syphilis  have  already  been  considered.  Primary  cancer  or 
sarcoma  is  extremely  rare.  Secondary  tumors  may  be  single  or  multiple,  and 
are  usually  unattended  with  symptoms,  even  when  the  disease  is  most  exten- 
sive. In  one  case  I  found  in  the  wall  of  the  right  ventricle  a  mass  which 
involved  the  anterior  segment  of  the  tricuspid  valve  and  partly  blocked  the 
orifice.  The  surface  was  eroded  and  there  were  numerous  cancerous  emboli 
in  the  pulmonary  artery.  In  another  instance  the  heart  was  greatly  enlarged, 
owing  to  the  presence  of  innumerable  masses  of  colloid  cancer  the  size  of 
cherries.  The  mediastinal  sarcoma  may  penetrate  the  heart,  though  it  is 
remarkable  how  extensive  the  disease  of  the  mediastinal  glands  may  be  with- 
out involvement  of  the  heart  or  vessels. 

Cysts  in  the  heart  are  rare.  They  are  found  in  different  parts,  and  are 
filled  either  with  a  brownish  or  a  clear  fluid.     Blood-cysts  occasionally  occur. 

The  parasites  have  been  discussed  under  the  appropriate  section,  but  it 
may  be  mentioned  here  that  both  the  cysticerus  cellulosce  and  the  echinococcus 
cysts  occur  occasionally. 

VII.  WOUNDS    AND    FOREIGN    BODIES. 

Wounds  of  the  heart  may  be  caused  by  external  injuries,  as  stabs  and 
bullet  wounds,  by  foreign  bodies  passing  from  the  gullet  or  oesophagus,  or  by 
puncture  for  therapeutic  purposes. 

(1)  Bullet  wounds  of  the  heart  are  common.  Eecovery  may  take  place, 
and  bullets  have  been  found  encysted  in  the  organ.  Stab  wounds  are  still 
more  common.  A  medical  student,  while  on  a  spree,  passed  a  pin  into  his 
heart.  The  pericardium  was  opened,  and  the  head  of  the  pin  was  found  out- 
side of  the  right  ventricle.  It  was  grasped  and  an  attempt  made  to  remove 
it,  but  it  was  withdrawn  into  the  heart  and,  it  is  said,  caused  the  patient  no 
further  trouble  (Moxon).  In  recent  stab  wounds  it  is  a  good  practice  to 
expose  the  heart  and  attempt  to  suture  the  wound.  Sherman  has  collected  34 
operations  performed  in  the  six  years  ending  1901,  of  which  13  recovered.  In 
a  case  of  stab-wound  Pagenstecher  tied  the  left  coronary  artery,  which  had 
been  divided. 

(3)  Hysterical  girls  sometimes  swallow  pins  and  needles,  which,  passing 


832  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

through  the  oesophagus  and  stomach,  are  found  in  various  parts  of  the  body. 
A  remarkable  case  is  reported  by  Allen  J.  Smith  of  a  girl  from  whom  several 
dozen  needles  and  pins  were  removed,  chiefly  from  subcutaneous  abscesses. 
Several  years  later  she  developed  s}Tnptoms  of  chronic  heart-disease.  At  the 
post  mortem  needles  were  found  in  the  tissues  of  the  adherent  pericardium,  and 
between  thirty  and  forty  were  embedded  in  the  thickened  pleural  membranes 
of  the  left  side. 

(3)  Puncture  of  the  heart  (cardiocentesis)  has  been  recommended  as  a 
therapeutic  procedure,  as  in  chloroform  narcosis,  and  experimental  evidence 
has  been  brought  forward  by  B.  A.  Watson  in  favor  of  the  operation.  He 
advises  abstraction  of  blood  in  combination  with  the  puncture — cardiocentesis. 
The  proceeding  is  not  without  risk.  Haemorrhage  may  take  place  from  the 
puncture,  though  it  is  not  often  extensive.  Sloane  has  recently  urged  its  use 
in  all  cases  of  asphyxia  and  in  suffocation  by  dro^vning  and  from  coal-gas. 
The  successful  case  which  he  reports  illustrates  forcibly  its  stimulating  action. 


VIII.     FUNCTIONAL    AFFECTIONS    OF    THE    HEART. 

I.  Palpitation. 

In  health  we  are  unconscious  of  the  action  of  the  heart.  One  of  the  first 
indications  of  debility  or  overwork  is  the  consciousness  of  the  cardiac  pulsa- 
tions, which  may,  however,  be  perfectly  regular  and  orderly.  This  is  not 
palpitation.  The  term  is  properly  limited  to  irregular  or  forcible  action  of  the 
heart  perceptible  to  the  individual.  The  condition  of  extra-systole  described 
in  the  next  section  is  present  in  many  cases. 

Etiology. — The  expression  "  perceptible  to  the  individual "  covers  the 
essential  element  in  palpitation  of  the  heart.  The  most  extreme  disturbance 
of  rhythm,  a  condition  even  of  what  is  termed  delirium  cordis,  may  be  unat- 
tended with  subjective  sensations  of  distress,  and  there  may  be  no  conscious- 
ness of  disturbed  action.  On  the  other  hand,  there  are  cases  in  which  com- 
plaint is  made  of  the  most  distressing  palpitation  and  sensations  of  throbbing, 
in  which  the  physical  examination  reveals  a  regularly  acting  heart,  the  sensa- 
tions being  entirel}''  subjective.  We  meet  with  this  symptom  in  a  large  group 
of  cases  in  which  there  is  increased  excitability  of  the  nervous  system.  Palpi- 
tation may  be  a  marked  feature  at  the  time  of  puberty,  at  the  climacteric,  and 
occasionally  during  menstruation.  It  is  a  very  common  symptom  in  hysteria 
and  neurasthenia,  particularly  in  the  form  of  the  latter  which  is  associated 
with  dyspepsia.  Emotions,  such  as  fright,  are  common  causes  of  palpitation. 
It  may  occur  as  a  sequence  of  the  acute  fevers.  Females  are  more  liable  to  the 
affection  than  males. 

In  a  second  group  the  palpitation  results  from  the  action  upon  the  heart 
of  certain  substances,  such  as  tobacco,  coffee,  tea,  and  alcohol.  And,  lastly, 
palpitation  may  be  associated  with  organic  disease  of  the  heart,  either  of  the 
myocardium  or  of  the  valves.  As  a  rule,  however,  it  is  a  purely  nervous  phe- 
nomenon— seldom  associated  with  organic  disease — in  which  the  most  violent 
action  and  the  most  extreme  irregularity  may  exist  without  that  subjective 
element  of  consciousness  of  the  disturbance  which  constitutes  the  essential 
feature  of  palpitation. 


DISEASES  OF  THE  HEART.  833 

The  irritable  heart  described  by  Da  Costa,  which  was  so  common  among 
the  young  soldiers  during  the  civil  war,  is  a  neurosis  of  this  kind.  The  chief 
symptoms  were  palpitation  with  great  frequency  of  the  pulse  on  exertion,  a 
variable  amount  of  cardiac  pain,  and  dyspnoea.  The  factors  at  work  in  pro- 
ducing this  condition  appeared  to  be  the  mental  excitement,  the  unwonted 
muscular  exertion  associated  with  the  drill,  and  diarrhosa.  The  condition  is 
not  infrequent  in  civil  life  among  young  men,  and  when  persistent  it  may 
lead  to  hypertrophy  of  the  heart. 

Symptoms. — In  the  mildest  form,  such  as  occurs  during  a  dyspeptic  attack, 
there  is  slight  fluttering  of  the  heart  and  a  sense  of  what  patients  sometimes 
call  "goneness."  In  more  severe  attacks  the  heart  beats  violently,  its  pulsa- 
tions against  the  chest  wall  are  visible,  the  rapidity  of  the  action  is  much 
increased,  the  arteries  throb  forcibly,  and  there  is  a  sense  of  great  distress.  In 
some  instances  the  heart's  action  is  not  at  all  quickened.  The  most  striking 
cases  are  in  neurasthenic  women,  in  whom  the  mere  entrance  of  a  person  into 
the  room  may  cause  the  most  violent  action  of  the  heart  and  throbbing  of  the 
peripheral  arteries.  The  pulse  may  be  rapidly  increased  until  it  reaches  150 
or  160.  A  diffuse  flushing  of  the  skin  may  appear  at  the  same  time.  After 
such  attacks,  there  may  be  the  passage  of  a  large  quantity  of  pale  urine.  In 
many  cases  of  palpitation,  particularly  in  young  men,  the  condition  is  at  once 
relieved  by  exertion.  A  patient  with  extreme  irregularity  of  the  heart  may, 
after  walking  quickly  100  yards  or  running  upstairs,  return  with  the  pulse 
perfectly  regular.  This  is  not  infrequently  seen,  too,  in  the  irregular  action  of 
the  heart  in  mitral  valve  disease. 

The  physical  examination  of  the  heart  is  usually  negative.  The  sounds, 
the  shock  of  which  may  be  very  palpable,  are  on  auscultation  clear,  ringing, 
and  metallic,  but  not  associated  with  murmurs.  The  second  sound  at  the 
base  may  be  greatly  accentuated.  A  murmur  may  sometimes  be  heard  over 
the  pulmonary  artery  or  even  at  the  apex  in  cases  of  rapid  action  in  neuras- 
thenia or  in  severe  ansemia.  The  attacks  may  be  transient,  lasting  only  for  a 
few  minutes,  or  may  persist  for  an  hour  or  more.  In  some  instances  any 
attempt  at  exertion  renews  the  attack. 

The  prognosis  is  usually  good,  though  it  may  be  extremely  difficult  to 
remove  the  conditions  underlying  the  palpitation. 

II.  Arrhythmia. 

The  work  of  Gaskell  and  of  Engelmann  on  the  function  of  the  heart- 
muscle,  and  the  clinical  studies  of  James  Mackenzie,  Wenckebach,  and  others, 
have  modified  the  older  views  of  the  neurogenic  cardiac  mechanism  with  its 
musculo-motor  nerve  centre  upon  which  the  higher  centres  played  through 
the  vagi  and  the  sympathetic  nerves.  The  source  of  the  action  of  the  heart  is 
now  placed  in  the  muscle  itself — myogenic — and  Gaskell  describes  as  its  func- 
tions rhythmicity,  excitability,  contractility,  conductivity,  and  tonicity ;  "  that 
is  to  say,  the  muscular  fibres  of  the  heart  possess  the  power  of  rhythmically 
creating  a  stimulus,  of  being  able  to  receive  a  stimulus,  of  responding  to  a 
stimulus  by  contracting,  of  conveying  the  stimulus  from  muscle  fibre  to  muscle 
fibre,  and  of  maintaining  a  certain  ill-defined  condition  called  tone."  Wencke- 
bach and  James  Mackenzie  have  studied  the  disturbances  of  these  functions 
of  the  heart  clinically,  and  have  endeavored  to  classify  them  in  harmony  with 


834  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

the  myogenic  theory.  I  am  indebted  to  Joseph  Erlanger,  of  the  Johns  Hop- 
kins Physiological  Laboratory^  for  the  following  classification  based  on  that  of 
Wenckebach : 

I.  Arrhythmia  resulting  from  decreased  conductivity  in  the  auriculo- 
ventricular  junction — heart-hlock.  Characteristics :  Auricular  rhythm  perfect, 
rate  normal  or  accelerated ;  ventricular  rhythm  may  or  may  not  be  perfect ;  if 
perfect  its  rate  will  be  one-half  of  that  of  the  auricles,  or  less ;  if  not  perfect  the 
irregularities  will  bear  some  direct  relation  to  the  contractions  of  the  auricles. 

A.  Partial  heart-block:  (1)  Occasional  ventricular  silence;  (2)  regularly 
recurring  ventricular  silence,  either  one  ventricular  beat  missed  in  7,  6,  5,  4, 
etc.,  auricular  beats,  or  a  2 : 1,  3  : 1,  4 :  1  rhythm,  or  either  of  these  alternating, 

B.  Complete  heart-block:  Auricular  and  ventricular  rhythms  perfect  but 
independent, 

XJ,  Paroxysmal  bradycardia  ( Stokes- Adams  disease)  affecting  the  ventricu- 
lar rate  alone. 

II.  Arrhythmia  resulting  from  increased  irritability  of  the  heart. 

A.  Ventricular  extra-systoles,  characterized  by  an  early  systole,  which  is 
associated  with  the  phenomena  of  a  retrograde  impulse.  There  may  be  one 
or  more  extra-systoles  following  a  normal  systole;  when  regularly  recurring, 
one  or  more  extra-systoles  after  5,  4,  3,  2,  or  1  normal  systoles,  the  last  giving 
the  bigeminal  or  trigeminal  pulse,  or  there  may  be  irregularly  recurring  extra- 
systoles  causing  delirium  cordis. 

B.  Auricular  extra-systoles. 

III.  Arrhythmia  resulting  from  the  influence  of  extrinsic  nerves  upon  the 
heart-rate.     (1)  Vagus  effects.     (2)  Accelerator  effects, 

IV.  Arrhythmia  resulting  from  disturbed  diastolic  filling  of  the  heart. 

A.  Disturbed  filling  resulting  from  violent  respiratory  movements:  may 
give  the  paradoxical  pulse. 

B.  Disturbed  filling  from  adherent  pericardium  or  mediastinal  tumor :  may 
give  the  paradoxical  pulse. 

C.  Associated  respiratory  and  cardiac  rhythm.    Alternating  pulse  (  ?). 
The  senior  student  is  referred  to  the  work  of  Wenckebach,  translated  by 

Thomas  Snowball  (1904),  and  to  the  writings  of  James  Mackenzie.  I  can 
here  only  refer  to  the  more  common  and  important  disturbances  of  rhythm. 

Intermittency.  Extra-systoles. — The  commonest  type  of  arrhythmia  is  that 
now  known  as  the  extra-systole,  to  explain  which  it  must  be  remembered  that 
to  a  stimulus  strong  enough  to  set  up  a  contraction  the  heart  answers  with  all 
the  contractility  of  which  it  is  capable  at  the  moment  (Bowditch's  law  of  maxi- 
mal contraction).  A  second  property  of  the  heart-muscle  is  that  it  possesses 
a  "  refractory  phase  "  in  which  normally  it  is  not  excitable,  or  answers  only 
to  very  strong  stimuli.  During  this  refractory  stage,  beginning  shortly  before 
the  systole  and  continuing  a  short  time  after  it,  the  heart  is  inexcitable. 
When  not  refractory  it  may  again  contract  during  this  phase  and  produce  an 
extra-systole,  which  is  followed  by  a  long  pause.  Engelmann  explains  this 
long  pause  as  follows :  "  In  consequence  of  the  extra-systole  the  ventricle  is  still 
in  the  refractory  stage  when  the  next  physiological  stimulus  reaches  it.  This 
stimulus  therefore  has  no  effect,  no  contraction  takes  place,  and  it  is  not  till 
the  next  stimulus  after  it  that  a  contraction  can  again  be  produced.  Thus 
the  normal  systole  that  would  follow  the  extra-systole  is  missed ;  then  the  first 


DISEASES  OF  THE  HEART.  835 

systole  that  comes  after  the  compensatory  pause  occurs  exactly  at  the  moment 
at  which  it  would  have  occurred  had  no  extra-systole  preceded  it"  (Wencke- 
bach). The  irregularity,  inequality,  and  intermission  of  the  pulse  as  met 
with  in  every-day  clinical  experience  is  largely  due  to  the  occurrence  of  these 
extra-systoles,  which  may  present  all  sorts  of  combinations  and  groupings, 
bigeminal,  trigeminal,  etc.,  depending  upon  whether  the  extra  pulse-beats  are 
perceptible  or  not.  And  yet  in  spite  of  this  most  extreme  irregularity  there 
may  be  no  actual  pathological  change,  and  so  far  as  the  maintenance  of  the 
circulation  is  concerned  the  heart  may  be  acting  in  a  most  satisfactory  man- 
ner. Patients  may  feel  the  extra-systole  as  a  definite  thud,  and  the  compen- 
satory pause  is  perceptible,  but  very  often  there  are  no  subjective  sensations. 

Extra-systoles  occur  at  all  ages  and  under  the  most  varied  conditions  in 
health  and  disease.  Mackenzie  recognizes  a  youthful  and  an  adult  type  of 
arrhythmia,  in  which  the  latter  is  due  chiefly  to  the  presence  of  the  systoles. 
There  are  several  classes  of  cases.  The  arrhythmia  may  be  a  life-long  condi- 
tion. Without  any  recognizable  disease,  without  any  impairment  of  the 
action  of  the  heart,  there  is  permanent  irregularity.  This  may  be  a  peculiarity 
of  the  heart-muscle  of  the  individual,  who  has  extra-systole  for  the  same 
reason — physiological  but  not  well  understood — as  the  dog  and  horse,  in  which 
animals  this  phenomenon  is  common.  The  late  Chancellor  Ferrier,  of  McGill 
University,  who  died  at  the  age  of  eighty-seven,  had  an  extremely  irregular 
heart  action  for  the  last  fifty  years  of  his  life.  I  know  several  men  who  have 
had  for  many  years  irregularity  without  the  slightest  discomfort.  In  debili- 
tated and  neurasthenic  persons  there  may  be  an  irritable  weakness  of  the  heart 
associated  with  extra- systole,  and  palpitation  of  a  most  distressing  character. 
In  a  second  group  toxic  agents,  as  tobacco,  tea,  coffee,  or  the  poisons  of  the  in- 
fectious diseases  or  those  originating  in  the  intestines  or  metabolic  poisons, 
cause  arrhythmia.  Even  reflexly,  as  in  flatulent  dyspepsia,  extra-systoles  may 
arise.  Thirdly,  a  high  blood  pressure  can  set  up  extra-systoles ;  also  change  in 
posture.  And  lastly,  organic  disease  of  the  heart  itself,  "  dilatation,  inflamma- 
tion, poor  blood  supply  to  the  muscle,  overexertion  can  all  supply  stimuli  to 
set  up  extra-systoles  either  directly  or  reflexly"  (Wenckebach).  Too  much 
stress  should  not  be  laid  upon  arrhythmia  per  se  in  the  absence  of  organic 
disease. 

III.  Eapid  Heart — Tachycardia. 

The  rapid  action  may  bp  perfectly  natural.  There  are  individuals  whose 
normal  heart  action  is  at  100  or  even  more  per  minute.  Emotional  causes, 
violent  exercise,  and  fevers  all  produce  great  increase  in  the  rapidity  of  the 
heart's  action.  The  extremely  rapid  action  which  follows  fright  may  persist 
for  days,  or  even  weeks.  Traube  reports  an  instance  in  which,  after  violent 
exercise,  the  rapidity  of  the  heart  continued.  Cases  are  not  uncommon  at  the 
menopause. 

There  are  cases  again  in  which  the  condition  can  hardly  be  termed  a 
neurosis,  since  it  depends  upon  definite  changes  in  the  pneumogastrics  or 
in  the  medulla.  Cases  have  been  reported  in  which  tumor  or  clot  in  or  about 
the  medulla  or  pressure  upon  the  vagi  has  been  associated  with  heart  hurry. 
Some  of  the  cases  of  frequent  action  of  the  heart  in  women  have  been  thought 
to  be  due  to  reflex  irritation  from  ovarian  or  uterine  disease. 


836  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

Paroxysmal  tachycardia  is  a  remarkable  affection,  characterized  by  spells 
of  heart  hurry,  during  which  the  action  is  greatly  increased,  the  pulse  reach- 
ing 200  and  over.  ■  The  cases  are  not  common.  The  attack  may  be  quite  short 
and  persist  only  for  an  hour  or  so.  A  patient  at  the  Philadelphia  Infirmary 
for  fsTervous  Diseases  was  attacked  every  week  or  two;  the  pulse  would  rise 
to  220  or  230,  and  there  were  such  feelings  of  distress  and  uneasiness  that 
the  patient  always  had  to  lie  down.  There  may  be,  however,  no  subjective 
disturbance,  and  in  another  case  the  patient  was  able  to  walk  about  during 
the  paroxysm  and  had  no  dyspnoea.  One  of  the  most  remarkable  cases  is 
reported  by  H.  C.  Wood.  A  physician  in  his  eighty-seventh  year  had  had 
attacks  at  intervals  from  his  thirty-seventh  year.  The  onset  was  abrupt  and 
the  pulse  would  rapidly  rise  to  200  a  minute.  For  more  than  twenty  years 
the  taking  of  ice-water  or  strong  coffee  would  arrest  the  attacks.  Bouveret 
has  analyzed  a  number  of  cases  of  this  essential  or  idiopathic  form;  he  finds 
that  a  permanent  cure  is  rare,  and  that  the  patients  suffer  for  ten  or  more 
years.  Four  instances  terminated  fatally  from  heart-failure.  Martins  looks 
upon  it  as  a  sjonptom  of  an  acute  dilatation  of  the  heart,  appearing  paroxys- 
mally.  One  of  the  most  remarkable  features  is  the  abruptness  of  onset  and  the 
abruptness  with  which  an  attack  may  end.  One  of  my  cases  had  recurring 
attacks  lasting  ten  to  thirty  days,  and  the  heart  would  suddenly  "  flop,"  as  she 
expressed  it,  the  rate  falling  from  180  to  80  or  90  per  minute. 

IV.  Slow  Heaet — Beadycaedia — Heart-Block. 

Slow  action  of  the  heart  is  sometimes  normal  and  may  be  a  family  peculi- 
arity.   Xapoleon  is  stated  to  have  had  a  pulse  of  only  40  per  minute. 

In  any  case  of  slow  pulse  it  is  important  first  to  make  sure  that  the 
number  of  heart  and  arterial  beats  correspond.  In  many  instances  this  is 
not  the  case,  and  with  a  radial  pulse  at  40  the  cardiac  pulsations  may  be  80, 
half  the  beats  not  reaching  the  wrist.  The  heart  contractions,  not  the  pulse 
wave,  should  be  taken  into  account. 

(a)  Physiological  Bradycardia. — As  age  advances  the  pulse-rate  becomes 
slow.  In  the  puerperal  state  the  pulse  may  beat  from  44  to  60  per  minute,  or 
may  even  be  as  low  as  34.  It  is  seen  in  premature  labor  as  well  as  at  term. 
The  explanation  of  its  occurrence  at  this  period  is  not  clear.  Slowness  of  the 
pulse  is  associated  with  hunger.  Bradycardia  depending  on  individual  peculi- 
arity is  extremely  rare. 

(&)  Pathological  bradycardia^  which  is  met  with  under  the  following  con- 
ditions: (1)  In  convalescence  from  acute  fevers.  This  is  extremely  common, 
particularly  after  pneumonia,  t3rphoid  fever,  acute  rheumatism,  and  diph- 
theria. It  is  most  frequently  seen  in  young  persons  and  in  cases  which  have 
run  a  normal  course.  (2)  In  diseases  of  the  digestive  system,  such  els  chronic 
dyspepsia,  ulcer  or  cancer  of  the  stomach,  and  jaundice.  (3)  In  diseases  of 
the  respiratory  system.  Here  it  is  by  no  means  so  common,  but  it  is  seen  not 
infrequently  in  emphysema.  (4)  In  diseases  of  the  circulatory  system.  Ex- 
cluding all  cases  of  irregularity  of  the  heart,  bradycardia  is  not  common  in 
diseases  of  the  valves.  It  is  most  frequently  seen  in  fatty  and  fibroid  changes 
in  the  heart,  but  is  not  constant  in  them.  (5)  In  diseases  of  the  urinary 
organs.     It  occurs  occasionally  in  nephritis  and  may  be  a  feature  of  uraemia. 


DISEASES  OF  THE  HEART.  837 

(6)  From  the  action  of  toxic  agents.  It  occurs  in  uremia,  poisoning  by 
lead,  alcohol,  and  follows  the  use  of  tobacco,  coffee,  and  digitalis.  (7)  In 
constitutional  disorders,  such  as  anaemia,  chlorosis,  and  diabetes.  (8)  In 
diseases  of  the  nervous  system.  Apoplexy,  epilepsy,  the  cerebral  tumors,  affec- 
tions of  the  medulla,  and  diseases  and  injuries  of  the  cervical  cord  may  be 
associated  with  very  slow  pulse.  In  general  paresis,  mania,  and  melancholia 
it  is  not  infrequent.  (9)  It  occurs  occasionally  in  affections  of  the  skin  and 
sexual  organs,  and  in  sunstroke,  or  in  prolonged  exhaustion  from  any  cause. 

V.  Heart-block.     Stokes-Adams  Disease. 

The  impulse  causing  the  heart  to  beat  originates  at  the  venous  end  of  the 
heart  and  is  transmitted  in  such  a  way  that  the  auricles  contract  first,  the  ven- 
tricles a  moment  later,  the  impulse  being  propagated  like  a  peristaltic  wave 
through  the  heart-walls.  In  passing  from  the  auricle  to  the  ventricle  the 
stimulus  traverses  a  narrow  band  of  muscle,  the  only  demonstrable  muscular 
connection  between  the  venous  and  arterial  chambers.  In  the  adult  heart  this 
auriculo- ventricular  bundle  of  His  is  18  mm.  long,  2.5  mm.  broad,  and  1.5 
mm.  thick ;  it  arises  in  the  septum  of  the  auricles  below  the  foramen  ovale  and 
passes  downward  and  forward  through  the  trigonum  fibrosum  of  the  auriculo- 
ventricular  junction,  where  it  comes  into  close  relation  with  the  mesial  leaflet  of 
the  tricuspid  valve.  Passing  along  the  upper  edge  of  the  muscular  septum,  just 
where  it  joins  with  the  posterior  edge  of  the  membranous  septum,  it  radiates 
from  this  point  throughout  the  heart  as  the  junctional  system  of  Tawara.  In 
the  dog  destruction  of  the  bundle  prevents  the  passage  from  the  auricle  to  the 
ventricle  of  the  impulse  which  normally  causes  the  ventricles  to  contract.  They 
immediately  assume  a  rate  of  beating  which  is  very  much  slower  than  that  of 
the  auricles  and  is  totally  independent,  as  they  possess  their  own  automatic 
rhythmicity.  Under  ordinary  circumstances  this  inherent  rhythmicity  can  not 
manifest  itself  because  the  much  more  rapidly  beating  venous  end  of  the  heart 
sets  the  pace  for  the  sluggish  arterial  end.  But  if  the  auricular  impulse  is 
blocked,  the  ventricles  released  from  the  control  of  their  normal  pace  maker 
assume  their  own  rate.  This  condition  has  been  called  complete  heart-block. 
By  an  ingenious  contrivance  Erlanger  has  been  able  in  the  dog  to  gradually 
compress  the  auriculo-ventricular  bundle  and  produce  the  various  stages  of 
this  condition,  namely,  one  ventricular  silence  in  27  auricular  beats,  and 
one  ventricular  silence  with  every  other  auricular  beat,  giving  a  2 : 1  rhythm, 
and  proceeding  to  a  3:1  and  a  4:1  rhythm.  Finally,  complete  block 
may  result,  in  which  no  impulses  pass  from  the  auricles,  but  the  ventri- 
cles beat  with  their  own  inherent  rate,  which  Erlanger  estimates,  from  a 
study  of  cases  of  heart-block  in  my  wards,  to  be  about  23  to  28  beats  to  the 
minute  in  man.  The  explanation  of  the  phenomenon  is  based  upon  one  sug- 
gested by  Gaskell.  The  bundle  of  His,  like  all  muscle  tissue,  becomes  fatigued 
when  it  is  made  to  contract  repeatedly.  Under  normal  circumstances  sufficient 
time  elapses  between  successive  beats  to  permit  the  bundle  to  return  to  its 
normal  state,  but  when  from  injury  or  any  cause  the  irritability  of  the  bundle 
is  greatly  reduced,  it  may  not  react  to  the  auricular  stimulus,  which  thus  fails 
to  reach  the  ventricles.  Occasionally  while  compressing  the  auriculo-ven- 
tricular bundle  in  the  dog,  the  ventricle  alone  may  suddenly  stop  beating  for 


838  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

as  long  as  twenty  seconds.  Tlie  explanation  is  here  to  be  sought  for  the  syn- 
copal attacks  in  Stokes- Adams  disease.  In  this  condition  the  relaxed  ventricles 
are  distended  rhythmically  by  the  beats  of  the  auricles  until  the  distension  may 
be  extreme.  The  veins  become  engorged  and  pulsate  synchronously  with  the 
auricles.  Each  of  the  infrequent  contractions  of  the  ventricles  relieves  the 
condition  temporarily.  When  the  heart-block  is  complete  the  vagi  still  exert 
their  normal  control  over  the  rate  of  the  auricles,  but  they  have  lost  almost 
completely  their  influence  over  the  ventricles,  and  in  Stokes- Adams  disease 
we  find  the  pulse-rate  is  little  influenced  by  conditions  wliich  normally  alter  it, 
as  exercise,  posture,  etc. 

Clinically  Stokes- Adams  disease  presents  these  features:  (a)  slow  pulse, 
usually  permanent,  but  sometimes  paroxysmal,  falling  to  40,  20,  or  even  6 
per  minute;  (h)  cerebral  attacks — vertigo  of  a  transient  character,  syncope, 
pseudo-apoplectiform  attacks  or  epileptiform  seizures;  (c)  visible  auricular 
impulses  in  the  veins  of  the  neck,  as  noted  by  Stokes — ^the  beats  varying 
greatlj^,  a  2 : 1  or  3  :  1  rhytlim  is  the  most  common.  There  are  several  groups 
of  cases.  It  is  usually  a  senile  manifestation  associated  with  arterio-sclerosis. 
The  cases  in  young  adults  and  middle-aged  men  are  often  myocardial  and 
of  s}qDhilitic  origin.  There  is  a  neurotic  group  in  which  all  the  features  may 
be  present,  and  in  which  post  mortem  no  lesions  have  been  found  (Edes  and 
Councilman).  The  outlook  in  this  class  of  cases  is  good;  in  the  others  it  is  a 
serious  disease  and  usually  fatal,  though  it  may  last  for  many  years.  The 
cerebral  attacks  are  due  to  ansmia  of  the  brain  or  of  the  medulla  in  conse- 
quence of  the  imperfect  ventricular  action.  In  one  of  my  cases  Baetjer  could 
see  with  the  fluoroscope  the  more  frequent  contraction  of  the  auricles. 

Treatment  of  Palpitation  and  Arrliytlimia. 

An  important  element  in  many  cases  is  to  get  the  patient's  mind  quieted, 
and  he  can  be  assured  that  there  is  no  actual  danger.  The  mental  element  is 
often  very  strong.  In  palpitation,  before  using  medicines,  it  is  well  to  try 
the  effect  of  Iwgienic  measures.  As  a  rule,  moderate  exercise  may  be  taken 
with  advantage.  Eegular  hours  should  be  kept,  and  at  least  ten  hours  out  of 
the  twenty-four  should  be  spent  in  the  recumbent  posture.  A  tepid  bath  may 
be  taken  in  the  morning,  or,  if  the  patient  is  weakly  and  nervous,  in  the  even- 
ing, followed  by  a  thorough  rubbing.  Hot  baths  and  the  Turkish  bath  should 
be  avoided.  The  dietetic  management  is  most  important.  It  is  best  to  pro- 
hibit absolutely  alcohol,  tea,  and  coffee.  The  diet  should  be  light  and  the 
patient  should  avoid  taking  large  meals.  Articles  of  food  known  to  cause 
fiatulencT  should  not  be  used.  If  a  smoker,  the  patient  should  give  up  tobacco. 
Sexual  excitement  is  particularly  pernicious,  and  the  patient  should  be  warned 
specially  on  this  point.  For  the  distressing  attacks  of  palpitation  which  occur 
with  neurasthenia,  particularly  in  women,  a  rigid  Weir  Mitchell  course  is  the 
most  satisfactory.  It  is  in  these  cases  that  we  find  the  most  distressing  throb- 
bing in  the  abdomen,  which  is  apt  to  come  on  after  meals,  and  is  very  much 
aggravated  by  flatulency.  The  cases  of  palpitation  due  to  excesses  or  to  errors 
in  diet  and  dyspepsia  are  readily  remedied  by  hygienic  measures. 

A  course  of  iron  is  often  useful.  Strychnia  is  particularly  valuable,  and 
is  perhaps  best  administered  as  the  tincture  of  nux  vomica  in  large  doses. 


DISEASES  OF  THE  HEART.  839 

Very  little  good  is  obtained  from  the  smaller  quantities.  It  should  be  given 
freely,  20  minims  three  times  a  day. 

If  there  is  great  rapidity  of  action,  aconite  may  be  tried  or  veratrum  viride. 
There  are  cases  associated  with  sleeplessness  and  restlessness  which  are  greatly 
benefited  by  bromide  of  potassium.  Digitalis  is  very  rarely  indicated,  but  in 
obstinate  cases  it  may  be  tried  with  the  nux  vomica. 

Cases  of  heart  hurry  are  often  extremely  obstinate,  as  may  be  judged  from 
the  ease  of  the  physician  reported  by  H.  C.  Wood,  in  whom  the  condition  per- 
sisted in  spite  of  all  measures  for  fifty  years.  The  bromides  are  sometimes 
useful;  the  general  condition  of  neurasthenia  should  be  treated,  and  during 
the  paroxysm  an  ice-bag  may  be  placed  upon  the  heart,  or  Leiter's  coil, 
through  which  ice-water  may  be  passed.  Electricity,  in  the  form  of  galvan- 
ism, is  sometimes  serviceable,  and  for  its  mental  effect  the  Franklinic  current. 
For  the  condition  of  slow  pulse  but  little  can  be  done.  A  great  majority  of 
the  eases  are  not  dangerous. 

IX.    ANGINA   PECTORIS. 

Stenocardia,  or  the  breast-pang,  described  by  Heberden,  is  not  an  inde- 
pendent affection,  but  a  symptom  associated  with  a  number  of  morbid  condi- 
tions of  the  heart  and  vessels,  more  particularly  with  sclerosis  of  the  root  of 
the  aorta  and  changes  in  the  coronary  arteries.  True  angina  is  characterized 
by  paroxysms  of  agonizing  pain  in  the  region  of  the  heart,  extending  into 
the  arms  and  neck.  In  violent  attacks  there  is  a  sensation  of  impending 
death. 

Etiology. — It  is  a  disease  of  adult  life  and  occurs  almost  exclusively  in 
men.  In  Huchard's  statistics  of  237  cases  only  42  were  in  women.  In  my 
first  series  of  40  cases  there  was  only  one  woman.  It  may  occur  through  sev- 
eral generations,  as  in  the  Arnold  family.  Gout  and  diabetes  are  important 
factors.  A  number  of  cases  of  angina  pectoris  have  followed  influenza.  At- 
tacks are  not  infrequent  in  certain  forms  of  heart-disease,  particularly  aortic 
insufficiency  and  adherent  pericardium.  It  is  much  less  common  in  disease 
of  the  mitral  valve.  Almost  without  exception  the  subjects  of  angina  have 
arterio-sclerosis,  either  general  or  localized  at  the  root  of  the  aorta,  with 
changes  in  the  coronary  arteries  and  in  the  myocardium.  Severe  attacks  may 
occur  in  the  early  period  of  the  growth  of  aortic  aneurism.  In  men  under 
thirty-five  syphilitic  aortitis  is  an  important  factor. 

Phenomena  of  the  Attack. — The  exciting  cause  is  in  a  majority  of  all 
eases  well  defined.  In  only  rare  instances  do  the  patients  have  attacks  when 
quiet.  They  come  on  during  exertion  most  frequently,  as  in  walking  up  hill 
or  doing  something  entailing  sudden  muscular  effort;  occasional^  even  the 
effort  of  dressing  or  of  stooping  to  lace  the  shoes  may  bring  on  a  paroxysm. 
Mental  emotion  is  a  second  very  potent  cause.  John  Hunter  appreciated  this 
when  he  said  that  "  his  life  was  in  the  hands  of  any  rascal  who  chose  to  annoy 
and  tease  him."  In  his  case  a  fatal  attack  occurred  during  a  fit  of  anger. 
A  third,  and  in  many  instances  the  most  important,  factor  is  flatulent  dis- 
tention of  the  stomach.  Another  common  exciting  cause  is  cold;  even  the 
chill  of  getting  out  of  bed  in  the  morning  or  on  bathing  may  bring  on  a 
paroxysm. 


840  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

Usually  diiring  exertion  or  intense  mental  emotion  the  patient  is  seized 
with  an  agonizing  pain  in  the  region  of  the  heart  and  a  sense  of  constriction, 
as  if  the  heart  had  been  seized  in  a  vice.  The  pains  radiate  to  the  neck  and 
down  the  arm,  and  there  may  be  numbness  of  the  fingers  or  in  the  cardiac 
region.  The  face  is  usually  pallid  and  may  assume  an  ashy-gray  tint,  and  not 
infrequently  a  profuse  sweat  breaks  out  over  the  surface.  The  paroxysm  lasts 
from  several  seconds  to  a  minute  or  two,  during  which,  in  severe  attacks,  the 
patient  feels  as  if  death  were  imminent.  As  pointed  out  by  Latham,  there 
are  two  elements  in  it,  the  -psdn— dolor  pectoris — and  the  indescribable  feel- 
ing of  anguish  and  sense  of  imminent  dissolution — an  gar  animi.  There  are 
great  restlessness  and  anxiety,  and  the  patient  may  drop  dead  at  the  height 
of  the  attack  or  faint  and  pass  away  in  sjTicope.  The  condition  of  the  heart 
during  the  attack  is  variable;  the  pulsations  may  be  uniform  and  regular. 
The  pulse  tension,  however,  is  usually  increased,  but  it  is  surprising,  even  in 
cases  of  extreme  severity,  how  slightly  the  character  of  the  pulse  may  be 
altered.  After  the  attack  there  ma}'  be  eructations,  or  the  passage  of  a  large 
quantity  of  clear  urine.  The  patient  usually  feels  exhausted,  and  for  a  day 
or  two  may  be  badly  shaken ;  in  other  instances  in  an  hour  or  two  the  patient 
feels  himself  again.  "WTiile  dyspnoea  is  not  a  constant  feature,  the  paroxysm 
is  not  infrequently  associated  with  a  form  of  asthma;  there  is  wheezing  in 
the  bronchial  tubes,  which  may  come  on  very  rapidly,  and  the  patient  gets 
short  of  breath.  Many  patients  the  subjects  of  angina  die  suddenly  without 
warning  and  not  in  a  paroxysm.  In  other  instances  death  follows  in  the  first 
well-marked  paroxysm,  as  in  the  case  of  Thomas  Arnold.  In  a  third  group 
there  are  recurring  attacks  over  long  periods  of  years,  as  in  John  Hunter's 
case;  while  in  a  fourth  group  of  cases  there  are  rapidly  recurring  attacks  for 
several  days  in  succession,  with  progressive  and  increasing  weakness  of  the 
heart. 

With  reference  to  the  radiation  of  pain  in  angina,  the  studies  of  Mac- 
kenzie and  of  Head  are  of  great  interest.  Head  concludes  that  (1)  in  dis- 
eases of  the  heart,  and  more  particularly  in  aortic  disease,  the  pain  is  referred 
along  the  first,  second,  third,  and  fourth  dorsal  areas ;  ( 2 )  in  angina  pectoris 
the  pain  may  be  referred  in  addition  along  the  fifth,  sixth,  and  seventh,  and 
even  the  eighth  and  ninth  dorsal  areas,  and  is  always  accompanied  by  pain  in 
certain  cervical  areas.  A  remarkable  fact  is  the  early  localization  of  the  pain 
in  distant  parts,  not  infrequently  in  the  left  arm;  in  one  of  my  cases  in  the 
left  testis,  and  in  another  in  the  jaw. 

Theories  of .  An^na  Pectoris. —  (1)  That  it  is  a  neuralgia  of  the  cardiac 
nerves,  but  the  agonizing  cramp-like  character  of  the  pain,  the  suddenness  of 
the  onset,  and  the  associated  features,  are  unlike  any  neuralgic  aff'ection.  The 
pain,  however,  is  undoubtedly  in  the  cardiac  plexus  and  radiates  to  adjacent 
nerves.  It  is  interesting  lo  note,  in  connection  with  the  almost  constant  scle- 
rosis of  the  coronary  arteries  in  angina,  that  Thoma  has  found  marked  sclero- 
sis of  the  temporal  artery  in  migraine  and  Dana  has  met  with  local  thickening 
of  the  arteries  in  some  cases  of  neuralgia.  (2)  Heberden  believed  that  it 
was  a  cramp  of  the  heart-muscle  itself.  Cramp  of  certain  muscular  territories 
would  better  explain  the  attack.  (3)  That  it  is  due  to  the  extreme  tension  of 
the  ventricular  walls,  in  consequence  of  an  acute  dilatation  associated,  in  the 
majority  of  cases,  with  affection  of  the  coronary  arteries.     Traube,  who  sup- 


DISEASES  OF   THE  HEART.  841 

ported  this  view,  held  that  the  agonizing  pain  resulted  from  the  great  stretch- 
ing and  tension  of  the  nerves  in  the  muscular  substance.  A  modified  form 
of  this  view  is  that  there  is  a  spasm  of  the  coronary  arteries  with  great  increase 
of  the  intracardiac  pressure. 

(4)  The  theory  of  Allan  Burns,  revived  by  Potain  and  others,  that  the 
condition  is  one  of  transient  ischasmia  of  the  heart-muscle  in  consequence  of 
disease,  or  spasm,  of  the  coronary  arteries.  The  condition  known  as  intermit- 
tent claudication  illustrates  what  may  take  place.  In  man  (and  in  the  horse), 
in  consequence  of  thrombosis  of  the  abdominal  aorta  or  iliacs,  transient  para- 
plegia and  spasm  may  follow  exertion.  The  collateral  circulation,  ample 
when  the  limbs  are  at  rest,  is  insufficient  after  the  muscles  are  actively  used, 
and  a  state  of  relative  ischgemia  is  induced  with  loss  of  power,  which  disap- 
pears in  a  short  time.  This  "  intermittent  claudication  "  theory  best  explains 
the  angina  paroxysm.  A  heart  the  coronary  arteries  of  which  are  sclerotic 
or  calcified,  is  in  an  analogous  state,  and  any  extra  exertion  is  likely  to  be  fol- 
lowed by  a  relative  ischgemia  and  spasm.  In  Allan  Burns's  work  on  The  Heart 
(1809)  the  theory  is  discussed  at  length,  but  he  does  not  think  that  spasm  is 
a  necessary  accompaniment  of  the  ischsemia. 

In  fatal  cases  of  angina  the  coronary  arteries  are  almost  invariably  dis- 
eased either  in  their  main  divisions,  or  there  is  chronic  endarteritis  with  great 
narrowing  of  the  orifices  at  the  root  of  the  aorta.  Experimentally,  occlusion 
of  the  coronary  arteries  produces  slowing  of  the  heart's  action,  gradual  dila- 
tation, and  death  within  a  very  few  minutes.  Cohnheim  has  shown  that  in  the 
dog  ligation  of  one  of  the  large  coronary  branches  produces  within  a  minute 
a  condition  of  arrhythmia,  and  within  two  minutes  the  heart  ceases  in  diastole. 
These  experiments,  however,  do  not  throw  much  light  upon  the  etiology  of 
angina  pectoris.  Extreme  sclerosis  of  the  coronary  arteries  is  common,  and  a 
large  majority  of  the  cases  present  no  symptoms  of  angina.  Even  in  the  cases 
of  sudden  death  due  to  blocking  of  an  artery,  particularly  the  anterior  branch 
of  the  coronary  artery,  there  is  usually  no  great  pain  either  before  or  during 
the  attack. 

Diagnosis. — There  are  many  grades  of  true  angina.  A  man  may  have 
slight  prascordial  pain,  a  sense  of  distress  and  uneasiness,  and  radiation  of 
the  pains  to  the  arm  and  neck.  Such  attacks  following  slight  exertion,  an 
indiscretion  in  diet,  or  a  disturbing  emotion,  may  alternate  with  attacks  of 
much  greater  severity,  or  they  may  occur  in  connection  with  a  pulse  of  in- 
creased tension  and  signs  of  general  arterio-sclerosis.  In  the  milder  grades 
the  diagnosis  can  not  rest  upon  the  symptoms  of  the  attack  itsglf,  since  they 
may  be  simulated  by  what  is  known  as  the  neurotic  or  functional  variety ;  but 
the  diagnosis  should  be  based  upon  the  examination  of  the  heart  and  arteries 
and  a  careful  consideration  of  the  mode  of  onset  and  symptoms.  The  cases  of 
neurotic  angina  pectoris  in  women  call  for  the  greatest  care  in  the  diagnosis, 
and  attention  to  the  points  given  in  the  table  of  Huchard  will  be  of  the  great- 
est aid.  The  existence  of  a  marked  increase  in  the  blood-pressure  is  con- 
firmatory evidence  of  organic  disease. 

Functional  Angina  Pectoris. — There  are  two  main  groups,  the  neu- 
rotic and  the  toxic.  The  former  embraces  the  hysterical  and  neurasthenic 
cases,  which  are  very  common  in  women.  Huchard  has  given  an  excellent 
differential  table  between  the  two  forms. 


er  symp- 

Associated    T\'itli    nervous    symp- 

toms. 

Agoniz- 

Vaso-motor  form  common.     Pain 

compres- 

less  severe;  sensation  of  distention. 

^ttitude : 

Pain  lasts  one  or  t'wo  hours.    Agi- 

tation and  activity. 

coronary 

Xeuralgia  of  nerves   and  cardio- 

842  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 


TEUE  A^;GINA.  NEUEOTIC   FORM. 

Most  common  between  the  ages  of  At  every  age^  even  six  years, 

forty  and  fifty  years. 

'Move  common  in  men.     Attacks  More   common   in   women.      At- 

hrought  on  by  exertion.  tacks  spontaneous. 

Attacks  rarely  periodical  or  noc-  Often  periodical  and  nocturnal. 

turnal. 

!N'ot  associated  with  otl: 
toms. 

Vaso-motor  form  rare, 
ing  pain  and  sensation  of 
sion  by  a  vice. 

Pain  of  short  duration. 
silence,  immobility. 

Lesions :     sclerosis     of 
artery.  plexus. 

Prognosis  grave,  often  fatal.  Xever  fatal. 

Arterial  medication.  Antineuralgic  medication. 

Notlmagel  has  described  as  vaso-motor  angina  a  form  in  which  the  symp- 
toms set  in  with  coldness  and  nmnbness  in  the  extremities,  followed  by  great 
precordial  pain  and  feelings  of  faintness.  Some  have  recognized  also  a  reflex 
variety. 

Toxic  Angina. — This  embraces  cases  due  to  the  abuse  of  tea,  coffee,  and 
tobacco.  There  are  three  groups  of  cases  of  so-called  tobacco  heart :  First,  the 
irritable  heart  of  smokers,  seen  particularly  in  young  lads,  in  which  the  sjnnp- 
toms  are  palpitation,  irregularit)^,  and  rapid  action;  secondly,  heart  pain  of  a 
sharp,  shooting  character,  which  may  be  very  severe ;  and,  thirdly,  attacks  of 
such  severitv'  that  they  deserve  the  name  of  angina. 

Prognosis. — Cardiac  pain  without  evidence  of  arterio-sclerosis  or  valve- 
disease  is  not  of  much  moment.  Angina  in  men  is  almost  invariably  associ- 
ated with  marked  cardio-vascular  lesions,  in  which  the  prognosis  is  alwa3's 
grave.  With  judicious  treatment  the  attacks,  however,  may  be  long  deferred, 
and  a  few  instances  recover  completel3\  The  prognosis  is  naturally  more 
serious  with  aortic  insufficiency  and  advanced  arterio-sclerosis.  Patients  who 
have  had  well-marked  attacks  may  live  for  many  years,  but  much  depends 
upon  the  care  with  which  they  regulate  their  daily  life. 

Treatment. — Patients  subject  to  this  affection  should  live  a  quiet  life, 
avoiding  particularly  excitement  and  sudden  muscular  exertion.  During  the 
attack  nitrite  of  amyl  should  be  inhaled,  as  advised  by  Lauder  Brunton.  From 
3  to  5  drops  may  be  placed  upon  cotton-wool  in  a  tumbler  or  upon  the  hand- 
kerchief. This  is  frequently  of  great  service  in  the  attack,  relieving  the  ago- 
nizing pain  and  distress.  Subjects  of  the  disease  should  carry  the  perles  of 
the  nitrite  of  am}^  with  them,  and  use  them  on  the  first  indication  of  an 
attack.  In  some  instances  the  nitrite  of  amyl  is  quite  powerless,  though  given 
freely.  If  within  a  minute  or  two  relief  is  not  obtained  in  this  way,  chloro- 
form should  at  once  be  given,    A  few  inhalations  act  promptly  and  give  great 


DISEASES  OF  THE  HEART.  843 

relief.  Should  the  pains  continue,  a  hypodermic  of  morphia  may  be  adminis- 
tered. In  severe  and  repeated  paroxysms  a  patient  may  display  remarkable 
resistance  to  the  action  of  this  drug. 

In  the  intervals,  nitroglycerin  may  be  given  in  full  doses,  as  recom- 
mended by  Murrell,  or  the  nitrite  of  sodium  (Matthew  Hay),  The  nitro- 
glycerin should  be  used  for  a  long  time  and  in  increasing  doses,  beginning 
with  1  minim  three  times  a  day  of  the  1-per-cent  solution,  and  increasing 
the  dose  1  minim  every  five  or  six  days  until  the  patient  complains  of  flush- 
ing or  headache.  The  fluid  extract  of  English  hawthorn — Crategus  oxycantlia 
— has  been  strongly  recommended  by  Jennings,  Clements,  and  others. 

Huchard  recommends  the  iodides,  believing  that  their  prolonged  use  in- 
fluences the  arterio-sclerosis.  Twenty  grains  three  times  a  day  may  be  given 
for  several  years,  omitting  the  medicine  for  about  ten  days  in  each  month. 
In  some  instances  this  treatment  is  most  beneficial,  particularly  in  middle- 
aged  men  with  a  history  of  syphilis. 

For  the  neurotic,  the  treatment  must  be  directed  to  the  general  nervous 
condition.  Electricity  is  sometimes  very  beneficial,  particularly  the  Frank- 
linic  form. 

X.     CONGENITAL   AFFECTIONS    OF    THE    HEART. 

These  have  only  a  limited  clinical  interest,  as  in  a  large  proportion  of  the 
cases  the  anomaly  is  not  compatible  with  life,  and  in  others  nothing  can  be 
done  to  remedy  the  defect  or  even  to  relieve  the  symptoms. 

The  congenital  affections  result  from  interruption  of  the  normal  course 
of  development  or  from  inflammatory  processes — endocarditis;  sometimes 
from  a  combination  of  both. 

{a)  General  Anomalies. — Of  general  anomalies  of  development  the  fol- 
lowing conditions  may  be  mentioned:  Acardia,  absence  of  the  heart,  which 
has  been  met  with  in  the  monstrosity  known  by  the  same  name;  double  heart, 
which  has  occasionally  been  found  in  extreme  grades  of  foetal  deformity; 
dextrocardia,  in  which  the  heart  is  on  the  right  side,  either  alone  or  as  part 
of  a  general  transposition  of  the  viscera ;  ectopia  cordis,  a  condition  associated 
with  fission  of  the  chest  wall  and. of  the  abdomen.  The  heart  may  be  situ- 
ated in  the  cervical,  pectoral,  or  abdominal  regions.  Except  in  the  abdominal 
variety  the  condition  is  very  rarely  compatible  with  extra-uterine  life.  Occa- 
sionally, as  in  a  case  reported  by  Holt,  the  child  lives  for  some  months,  and 
the  heart  may  be  seen  and  felt  beating  beneath  the  skin  in  the  epigastric 
region.    This  infant  was  five  months  old  at  the  date  of  examination. 

( & )  Anomalies  of  the  Cardiac  Septa. — The  septa  of  both  auricles  and  ven- 
tricles may  be  defective,  in  which  case  the  heart  consists  of  but  two  chambers, 
the  cor  hiloculare  or  reptilian  heart.  In  the  septum  of  the  auricles  there  is 
a  very  common  defect,  owing  to  the  fact  that  the  membrane  closing  the  fora- 
men ovale  has  failed  at  one  point  to  become  attached  to  the  ring,  and  leaves 
a  valvular  slit  which  may  be  large  enough  to  admit  the  handle  of  a  scalpel. 
Neither  this  nor  the  small  cribriform  perforations  of  the  membrane  are  of 
any  significance. 

The  foramen  ovale  may  be  patent  without  a  trace  of  membrane  closing 
it.    In  some  instances  this  exists  with  other  serious  defects,  such  as  stenosis 


844  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

of  the  pulmonary  artery,  or  imperfection  of  tlie  ventricular  septum.  In 
others  the  patent  foramen  ovale  is  the  only  anomaly,  and  in  many  instances 
it  does  not  appear  to  have  caused  any  embarrassment,  as  the  condition  has 
been  found  in  persons  who  have  died  of  various  affections.  The  ventricular 
septum  may  be  absent,  the  condition  known  as  trilocular  heart.  Much  more 
frequently  there  is  a  small  defect  in  the  upper  portion  of  the  septum,  either 
in  the  situation  of  the  membranous  portion  known  as  the  "  undefended  space  " 
or  in  the  region  situated  just  anterior  to  this.  The  anomaly  is  very  frequently 
associated  with  narrowing  of  the  pulmonary  orifice  or  of  the  conus  arteriosus 
of  the  right  ventricle. 

(c)  Anomalies  and  Lesions  of  the  Valves. — Numerical  anomalies  of  the 
valves  are  not  uncommon.  The  semilunar  segments  at  the  arterial  orifices 
are  not  infrequently  increased  or  diminished  in  number.  Supernumerary  seg- 
ments are  more  frequent  in  the  pulmonary  artery  than  in  the  aorta.  Four, 
or  sometimes  five,  valves  have  been  found.  The  segments  may  be  of  equal 
size,  but,  as  a  rule,  the  supernumerary  valve  is  small. 

Instead  of  three  there  may  be  only  two  semilunar  valves,  or,  as  it  is 
termed,  the  bicuspid  condition.  In  my  experience,  this  is  more  frequent  in 
the  aortic  valve.  Of  21  instances  only  2  occurred  at  the  pulmonary  orifice. 
Two  of  the  valves  have  united,  and  from  the  ventricular  face  show  either  no 
trace  of  division  or  else  a  slight  depression  indicating  where  the  union  has 
occurred.  From  the  aortic  side  there  is  usually  to  be  seen  some  trace  of  divi- 
sion into  two  sinuses  of  Valsalva.  There  has  been  a  discussion  as  to  the  origin 
of  this  condition,  whether  it  is  really  an  anomaly  or  whether  it  is  not  due  to 
endocarditis,  foetal  or  post-natal.  The  combined  segment  is  usually  thickened, 
but  the  fact  that  this  anomaly  is  met  with  in  the  foetus  without  a  trace  of 
sclerosis  or  endocarditis  shows  that  it  may,  in  some  cases  at  least,  result  from 
a  developmental  error. 

Clinically  this  is  a  very  important  congenital  defect,  owing  to  the  liability 
of  the  combined  valve  to  sclerotic  changes.  Except  two  foetal  specimens  all 
of  my  cases  showed  thickening  and  deformity,  and  in  15  of  those  which  I 
have  reported  death  resulted  directly  or  indirectly  from  the  lesion. 

The  little  fenestrations  at  the  margins  of  the  sigmoid  valves  have  no  sig- 
nificance ;  they  occur  in  a  considerable  proportion  of  all  bodies. 

Anomalies  of  the  auriculo- ventricular  valves  are  not  often  met  with. 

FcETAL  ENDOCARDITIS  may  occur  either  at  the  arterial  or  aurieulo-ven- 
tricular  orifices.  It  is  nearl}^  alwaj^s  of  the  chronic  or  sclerotic  variety.  Very 
rarely  indeed  is  it  of  the  warty  or  verrueose  form.  There  are  little  nodular 
bodies,  sometimes  six  or  eight  in  number,  on  the  mitral  and  tricuspid  seg- 
ments— ^the  nodules  of  Albini — ^which  represent  the  remains  of  foetal  struc- 
tures, and  must  not  be  mistaken  for  endocardial  outgrowths.  The  little 
rounded,  bead-like  hsemorrhages  of  a  deep  purple  color,  which  are  very  com- 
mon on  the  heart  valves  of  children,  are  also  not  to  be  mistaken  for  the  prod- 
ucts of  endocarditis.  In  foetal  endocarditis  the  segments  are  usually  tliickened 
at  the  edges,  shrunken,  and  smooth.  In  the  mitral  and  tricuspid  valves  the 
cusps  are  found  united  and  the  chordge  tendinese  are  thickened  and  shortened. 
In  the  semilunar  valves  all  trace  of  the  segments  has  disappeared,  leaving  a 
stiff  membranous  diaphragm  perforated  by  an  oval  or  rounded  orifice.  It 
is  sometimes  very  difficult  to  say  whether  this  condition  has  resulted  from 


DISEASES  OF  THE  HEART.  845 

foetal  endocarditis  or  whether  it  is  an  error  in  development.  In  very  many 
instances  the  processes  are  combined;  an  anomalous  valve  becomes  the  seat 
of  chronic  sclerotic  changes,  and,  according  to  Rauchfuss,  endocarditis  is  more 
common  on  the  right  side  of  the  heart  only  because  the  valves  are  here  more 
often  the  seat  of  developmental  errors. 

Lesions  at  the  Pulmonary  Orifice. — Stenosis  of  this  orifice  is  one  of 
the  commonest  and  most  important  of  congenital  heart  affections.  A  slow 
endocarditis  causes  gradual  union  of  the  segments  and  narrowing  of  the  orifice 
to  such  a  degree  that  it  admits  only  the  smallest-sized  probe.  In  some  of  the 
cases  the  smooth  membranous  condition  of  the  combined  segments  is  such  that 
it  would  appear  to  be  the  result  of  faulty  development.  In  some  instances 
vegetations  occur.  The  condition  is  compatible  with  life  for  many  years, 
and  in  a  considerable  proportion  of  the  cases  of  heart-disease  above  the  tenth 
year  this  lesion  is  present.  With  it  there  may  be  defect  of  the  ventricular 
septum.  Pulmonary  tuberculosis  is  a  very  common  cause  of  death.  Oblitera- 
tion or  atresia  of  the  pulmonary  orifice  is  a  less  frequent  but  more  serious 
condition  than  stenosis.  It  is  associated  with  persistence  of  the  ductus  arte- 
riosus, together  with  patency  of  the  foramen  ovale  or  defect  of  the  ventricular 
septum  with  hypertrophy  of  the  right  heart.  Stenosis  of  the  conus  arteriosus 
of  the  right  ventricle  exists  in  a  considerable  proportion  of  the  cases  of  obstruc- 
tion at  the  pulmonary  orifice.  At  the  outset  a  developmental  error,  it  may  be 
combined  with  sclerotic  changes.  The  ventricular  septum  is  imperfect,  the 
foramen  ovale  is  usually  open,  and  the  ductus  arteriosus  patent.  These  three 
lesions  at  the  pulmonary  orifice  constitute  the  most  important  group  of  all  con- 
genital cardiac  affections.  Of  181  instances  of  various  congenital  anomalies 
collected  by  Peacock,  119  cases  came  under  this  category,  and,  according  to  this 
author,  in  86  per  cent  of  the  patients  living  beyond  the  twelfth  year  the  lesion 
is  at  this  orifice. 

Congenital  lesions  of  the  aortic  orifice  are  not  very  frequent.,  Eauchfuss 
has  collected  24  cases  of  stenosis  and  atresia ;  stenosis  of  the'  left  conus  arterio- 
sus may  also  occur,  a  condition  which  is  not  incompatible  with  prolonged  life. 
Ten  of  the  16  cases  tabulated  by  Dilg  were  over  thirty  years  of  age. 

Transposition  of  the  large  arterial  trunlcs  is  a  not  uncommon  anomaly. 
There  may  be  neither  hypertrophy,  cyanosis,  nor  heart  murmur. 

Symptoms  of  Congenital  Heart-disease. — Cyanosis  occurs  in  over  90  per 
cent  of  the  cases,  and  forms  so  distinctive  a  feature  that  the  terms  "  blue  dis- 
ease "  and  "  morbus  CEeruleus  "  are  practically  synonyms  for  congenital  heart- 
disease.  The  lividity  in  a  majority  of  cases  appears  early,  within  the  first 
week  of  life,  and  may  be  general  or  confined  to  the  lips,  nose,  and  ears,  and 
to  the  fingers  and  toes.  In  some  instances  there  is  in  addition  a  general  dusky 
suffusion,  and  in  the  most  extreme  grades  the  skin  is  almost  purple.  It  may 
vary  a  good  deal  and  may  be  intense  only  on  exertion.  The  external  temper- 
ature is  low.  Dyspnoea  on  exertion  and  cough  are  common  symptoms.  A 
great  increase  in  the  number  of  the  red  corpuscles  has  been  noted  by  Gibson 
and  by  Vaquez.  In  a  case  of  Gibson's  there  were  above  eight  millions  of  red 
blood-corpuscles  to  the  cubic  millimetre.  The  children  rarely  thrive,  and  often 
display  a  lethargy  of  both  mind  and  body.  The  fingers  and  toes  are  clubbed 
to  a  degree  rarely  met  with  in  any  other  affection.  The  cause  of  the  cyanosis 
has  been  much  discussed.    Morgagni  referred  it  to  the  general  congestion  of 


846  DISEASES  OE   THE   CIRCULATORY  SYSTEM. 

fhe  venous  system  due  to  obstruction,  and  this  view  was  supported  in  a  paper, 
one  of  the  ablest  tbat  bas  been  written  on  the  subject,  by  Moreton  Stille. 
Morrisons  analysis  of  75  cases  of  congenital  heart-disease  shows  that  closure 
of  the  pulmonary  orifice  with  patency  of  the  foramen  ovale  and  the  ventricular 
septum  is  the  condition  most  frequently  associated  with  cyanosis,  and  he  con- 
cludes that  the  deficient  aeration  of  the  blood  owing  to  diminished  lung  func- 
tion is  the  most  important  factor.  Another  view,  often  attributed  erroneously 
to  William  Hunter,  was  that  the  discoloration  was  due  to  the  admixture  in  the 
heart  of  venous  and  arterial  blood ;  but  lesions  may  exist  which  permit  of  very 
free  mixture  without  producing  cyanosis.  The  question  of  the  cause  of  cyano- 
sis really  can  not  be  considered  as  settled.  Yariot  has  recently  made  the  sug- 
gestion that  the  cause  is  not  entirely  cardiac,  but  is  associated  with  disturbance 
throughout  the  whole  circulatory  system,  and  particularly  a  vaso-motor  paresis 
and  malaeration  of  the  red  blood-corpuscles. 

Dia^osis. — In  the  case  of  children,  cyanosis,  with  or  without  enlargement 
of  the  heart,  and  the  existence  of  a  mui'mur  are  sufficient,  as  a  rule,  to  deter- 
mine the  presence  of  a  congenital  heart-lesion.  The  cyanosis  gives  us  no  clew 
to  the  precise  nature  of  the  trouble,  as  it  is  a  symptom  common  to  many 
lesions  and  it  may  be  absent  in  certain  conditions.  The  murmur  is  usually 
systolic  in  character.  It  is,  however,  not  always  present,  and  there  are  in- 
stances on  record  of  complicated  congenital  lesions  in  which  the  examination 
showed  normal  heart-sounds.  In  two  or  three  instances  foetal  endocarditis  has 
been  diagnosed  i?i  gravida  by  the  presence  of  a  rough  systolic  murmur,  and  the 
condition  has  been  corroborated  subsequent  to  the  birth  of  the  child.  H}^er- 
trophy  is  jsresent  in  a  majority  of  the  cases  of  congenital  defect.  The  fatal 
event  may  be  caused  by  abscess  of  the  brain.  For  a  full  discussion  of  the  sub- 
ject the  senior  student  is  referred  to  the  exhaustive  monograph  of  Dr.  Maude 
Abbott  in  Vol.  IT  of  my  "  System  of  Medicine."  I  here  abstract  the  conclu- 
sions of  Hochsinger: 

"  (1)  In  childhood,  loud,  rough,  musical  heart-murmrtrs,  with  normal  or 
only  slight  increase  in  the  heart-dulness,  occur  only  in  congenital  heart-disease. 
The  acquired  endocardial  defects  with  loud  heart-murmurs  in  young  children 
are  almost  always  associated  with  great  increase  in  the  heart-dulness.  In  the 
transposition  of  the  large  arterial  trunks  there  may  be  no  cyanosis,  no  heart- 
mtirmur,  and  an  absence  of  hypertrophy. 

"  (2)  In  young  children  heart-murmurs  with  great  increase  in  the  car- 
diac dulness  and  feeble  apex  beat  suggest  congenital  changes.  The  increased 
dulness  is  chiefly  of  the  right  heart,  whereas  the  left  is  only  slightly  altered. 
On  the  other  hand,  in  the  acquired  endocarditis  in  children,  the  left  heart  is 
chiefly  affected  and  the  apex  beat  is  visible;  the  dilatation  of  the  right  heart 
comes  late  and  does  not  materially  change  the  increased  strength  of  the  apex 
beat. 

*'  (3)  The  entire  absence  of  munnurs  at  the  apex,  with  their  evident  pres- 
ence in  the  region  of  the  auricles  and  over  the  pulmonary  orifice,  is  always  an 
important  element  in  differential  diagnosis,  and  points  rather  to  septum  defect 
or  pulmonary  stenosis  than  to  endocarditis. 

*''  (4)  An  abnormally  weak  second  pulmonic  sound  associated  with  a  dis- 
tinct systolic  murmur  is  a  symptom  which  in  earh^  childliood  is  onl}'^  to  be 
explained  by  the  assumption  of  a  congenital  ptdmonary  stenosis,  and  possesses 


DISEASES  OF  THE  ARTERIES.  847 

therefore  an  importance  from  a  point  of  differential  diagnosis  which  is  not  to 
be  underestimated. 

"  (5)  Absence  of  a  palpable  thrill,  despite  loud  murmurs  which  are  heard 
over  the  whole  prsecordial  region,  is  rare  except  with  congenital  defects  in 
the  septum,  and  it  speaks  therefore  against  an  acquired  cardiac  affection. 

"  (6)  Loud,  especially  vibratory,  systolic  murmurs,  with  the  point  of 
maximum  intensity  over  the  upper  third  of  the  sternum,  associated  with  a 
lack  of  marked  sjmiptoms  of  hypertrophy  of  the  left  ventricle,  are  very  impor- 
tant for  the  diagnosis  of  a  persistence  of  the  ductus  Botalli,  and  can  not  be 
explained  by  the  assumption  of  an  endocarditis  of  the  aortic  valve." 

Escherich  suggests  that  the  systolic  basic  murmur  heard  sometimes  in  the 
newborn,  particularly  if  premature,  may  originate  in  the  ductus  Botalli  before 
its  closure. 

Treatment. — The  child  should  be  warmly  clad  and  guarded  from  all  cir- 
cumstances liable  to  excite  bronchitis.  In  the  attacks  of  urgent  dyspnoea 
with  lividity  blood  should  be  freely  let.  Saline  cathartics  are  also  useful. 
Digitalis  must  be  used  with  care ;  it  is  sometimes  beneficial  in  the  later  stages. 
When  the  compensation  fails,  the  indications  for  treatment  are  those  of  valvu- 
lar disease  in  adults. 


C.    DISEASES   OF  THE  ABTERIES. 

I.     DEGENERATIONS. 

Fatty  degeneration  of  the  intima  is  extremely  common,  and  is  seen  in 
the  form  of  yellowish-white  spots  in  the  aorta  and  larger  vessels.  Calcifica- 
iion  of  the  arterial  wall  follows  fatty  degeneration  and  sclerosis,  and  is  asso- 
ciated with  atheromatous  changes.  It  occurs  in  the  intima  and  the  media. 
In  the  latter  it  produces  what  is  sometimes  known  as  annular  calcification, 
which  occurs  particularly  in  the  middle  coat  of  medium-sized  vessels  and 
may  convert  them  into  firm  tubes.    It  is  by  no  means  always  a  senile  change. 

Hyaline  degeneration  may  attack  either  the  larger  or  the  smaller  vessels. 
In  the  former  the  intima  is  converted  into  a  smooth,  homogeneous  sub- 
stance; this  is  commonly  an  initial  stage  of  arterio-sclerosis ;  here  it  is  a 
transformation  of  the  endotheliaj  lining.  Of  the  smaller  arteries  and  capil- 
laries hyaline  metamorphosis  is  oftenest  seen  in  the  glomeruli  of  the  kidneys. 
It  is  not  to  be  confounded  with  the  amjdoid  change  which  is  prone  to  occur 
in  the  same  situation.  The  condition  is  variously  regarded  as  due  to  coagula- 
tion of  an  albuminous  fluid  and  h3^aline  metamorphosis  of  leucocytes  or  of 
fibrin.    This  substance  reacts  like  the  last  with  Weigert's  fibrin  stain. 

II.    ARTERIO-SCLEROSIS    (Arterio-capillary  Fibrosis). 

The  conception  of  arterio-sclerosis  as  an  independent  affection — a  general 
disease  of  the  vascular  system — is  due  to  Gull  and  Sutton. 

Definition. — A  condition  of  thickening,  diffuse  or  circumscribed,  begin- 
ning in  the  intima,  consequent  upon  primary  changes  in  the  media  and  adven- 
titia,  but  later  involving  the  latter  two  coats.    The  process  leads^  in  the  larger 


848  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

arteries,  to  what  is  known  as  atheroma  and  to  endarteritis  deformans,  and 
seriously  interferes  with  the  normal  functions  of  various  organs. 

Etiolog-y. — Among  the  important  factors  in  causing  arterio-sclerosis  the 
following  ma}^  be  considered : 

(1)  Hypertension. — The  degree  of  pressure  maintained  in  the  cardio- 
vascular system,  with  its  periodic  increase  with  each  systole,  has  an  im- 
portant influence  in  the  production  of  organic  changes  in  its  walls.  The 
blood-pressure  varies  greatly  in  different  individuals,  and  in  the  same 
individual  under  varying  conditions.  There  are  persons  with  chronic  hypo- 
tension, perhaps  associated  with  lowered  resistance  and  an  increased  sus- 
ceptibility to  infectious  disease.  In  asthenia  from  any  cause,  in  the  toxaemias 
of  t}rphoid  fever,  tuberculosis,  and  many  infectious  diseases  the  vascular  ten- 
sion is  low.  An  increase  in  the  tension  is  found  in  certain  chronic  diseases, 
such  as  gout,  and  in  the  various  forms  of  cardiac  and  renal  disease.  Much 
diversity  of  opinion  exists  as  to  the  relation  of  the  hypertension  to  the  struc- 
tural changes;  some  think  that  the  hypertension  is  secondary,  others,  notably 
Allbutt,  contend  that  it  not  infrequently  exists  jDrimarily,  a  view  substantiated 
by  the  recent  studies  in  pulse  tension.  There  are  persons  who  show  a  rise  in 
blood-pressure  at  or  about  middle  life  without  discoverable  organic  disease,  and 
who  subsequently  become  subject  to  arterio-sclerosis  and  renal  disease. 

(2)  As  an  involution  process  arterio-sclerosis  is  an  accompaniment  of  old 
age,  and  is  the  expression  of  the  natural  wear  and  tear  to  which  the  tubes  are 
subjected.  Longevity  is  a  vascular  question,  which  has  been  well  expressed  in 
the  axiom  that  "  a  man  is  only  as  old  as  his  arteries."  To  a  majority  of  men 
death  comes  primarily  or  secondarily  through  this  portal.  The  onset  of  what 
may  be  called  physiological  arterio-sclerosis  depends,  in  the  first  place,  upon  the 
quality  of  arterial  tissue  (vital  rubber)  which  the  individual  has  inherited, 
and  secondly  upon  the  amount  of  wear  and  tear  to  which  he  has  subjected  it. 
That  the  former  plays  a  most  important  role  is  shown  in  the  cases  in  which 
arterio-sclerosis  sets  in  early  in  life  in  individuals  in  whom  none  of  the  recog- 
nized etiological  factors  can  be  found.  Thus,  for  instance,  a  inan  of  twenty- 
eight  or  twenty-nine  may  have  the  arteries  of  a  man  of  sixty,  and  a  man  of 
forty  may  present  vessels  as  much  degenerated  as  they  should  be  at  eighty. 
Entire  families  sometimes  show  this  tendency  to  early  arterio-sclerosis — a 
tendency  which  can  not  be  explained  in  any  other  way  than  that  in  the  make- 
up of  the  machine  bad  material  was  used  for  the  tubing.  More  commonly 
the  arterio-sclerosis  results  from  the  bad  use  of  good  vessels. 

(3)  Chronic  Intoxications. — Alcohol,  lead,  and  gout  play  an  important 
role  in  the  causation  of  arterio-sclerosis,  although  the  precise  mode  of  their 
action  is  not  yet  very  clear.  They  may  act,  as  Traube  suggests,  by  increasing 
the  peripheral  resistance  in  the  smaller  vessels  and  in  this  way  raising  the 
blood  tension,  or  possibly,  as  Bright  taught,  they  alter  the  quality  of  the  blood 
and  render  more  difficult  its  passage  through  the  capillaries.  The  observations 
of  Cabot  have  thrown  doubt  on  the  importance  of  alcohol  as  a  factor. 

The  poisons  of  the  acute  infections  may  produce  degenerative  changes  in 
the  media  and  adventitia.  Thayer  has  recently  called  attention  to  the  fre- 
quency of  arterial  changes  as  a  sequence  of  typhoid  fever. 

(4)  Syphilis  is  one  of  the  most  important  single  causes.  There  is  a  local 
syphilitic  arteritis  most  commonly  seen  in  the  aorta — a  mesaortitis — ^which 


DISEASES  OF  THE  ARTERIES.  849 

is  a  prime  factor  in  the  production  of  aneurism ;  and  there  is  a  late  diffiise 
change,  comparable  to  the  parasyphilitic  lesions  in  the  nervous  system. 

(5)  Overeating. — I  am  more  and  more  impressed  with  the  part  played  by 
overeating  in  inducing  arterio-sclerosis.  There  are  many  cases  in  which  there 
is  no  other  factor.  George  Cheyne's  advice,  which  I  quote  at  page  463,  was 
never  more  needed  than  by  the  present  generation. 

(6)  The  stress  and  strain  of  modern  life. — There  are  men  in  the  fifth 
decade  who  have  not  had  syphilis  or  gout,  who  have  eaten  and  drunk  with 
discretion,  and  in  whom  none  of  the  ordinary  factors  are  present — ^men  in 
whom  the  arterio-sclerosis  seems  to  come  on  as  a  direct  result  of  a  high-pres- 
sure life. 

(7)  Overwork  of  the  muscles,  which  acts  by  increasing  the  peripheral  re- 
sistance and  by  raising  the  blood-pressure. 

(8)  Renal  Disease. — The  relation  between  the  arterial  and  kidney  lesions 
has  been  much  discussed,  some  regarding  the  arterial  degeneration  as  sec- 
ondary, others  as  primary.  There  are  two  groups  of  cases,  one  in  which  the 
arterio-sclerosis  is  the  first  change,  and  the  other  in  which  it  is  secondary  to 
a  primary  affection  of  the  kidneys. 

Morbid  Anatomy. — Thoma  divides  the  cases  into  primary  arterio-sclerosis, 
in  which  there  are  local  changes  in  the  arteries  leading  to  dilatation  and  a 
compensatory  increase  of  the  connective  tissue  of  the  intima;  secondary 
arterio-sclerosis,  due  to  changes  in  the  arteries  which  follow  increased  resist- 
ance to  the  blood-flow  in  the  peripheral  vessels.  This  increased  tension  leads 
to  dilatation  and  to  slowing  of  the  blood-stream  and  a  secondary  compensa- 
tory growth  of  the  intima. 

In  a  study  of  41  autopsies  upon  arterio-sclerotic  cases  from  my  wards. 
Councilman  follows  the  useful  division  into  nodular,  senile,  and  diffuse  forms. 

(a)  jSTodulae  Form. — In  the  circumscribed  or  nodular  variety  the  mac- 
roscopic changes  are  very  characteristic.  The  aorta  presents,  in  the  early 
stages,  from  the  ring  to  bifurcation,  numerous  flat  projections,  yellowish  or 
yellowish-white  in  color,  and  situated  particularly  about  the  orifices  of  the 
branches.  In  the  early  stage  these  patches  are  scattered  and  do  not  involve 
the  entire  intima.  In  more  advanced  grades  the  patches  undergo  atheromatous 
changes.  The  material  constituting  the  button  undergoes  softening  and  breaks 
up  into  granular  material,  consisting  of  molecular  debris — the  so-called 
atheromatous  abscess. 

In  the  circumscribed  or  nodular  arterio-sclerosis  the  primary  alteration 
consists  in  a  degeneration  or  a  local  infiltration  in  the  media  and  adven- 
titia,  chiefly  about  the  vasa  vasorum.  The  affection  is  really  a  mesarteritis 
and  a  periarteritis.  These  changes  lead  to  the  weakening  of  the  wall  in  the 
affected  area,  at  which  spot  the  proliferative  changes  commence  in  the  intima, 
particularly  in  the  subendothelial  structures,  with  gradual  thickening  and  the 
formation  of  an  atheromatous  button  or  a  patch  of  nodular  arterio-sclerosis. 
The  researches  of  Thoma  have  shown  that  this  is  really  a  compensatory  proc- 
ess, and  that  before  its  degeneration  the  nodular  button,  which  post  mortem 
projects  beyond  the  lumen,  during  life  fills  up  and  obliterates  what  would 
otherwise  be  a  depression  of  the  wall  in  consequence  of  the  weakening  of  the 
media.  A  similar  process  goes  on  in  the  smaller  vessels,  and  in  any  one  of 
the  smaller  branches  it  can  be  readily  seen  on  section  that  each  patch  of  endar- 
55 


850  DISEASES  OF   THE  CIRCULATORY  SY STEAL 

teritis  corresponds  to  a  defect  in  the  media  and  often  to  changes  in  the  adven- 
titia.  The  condition  is  one  which  may  lead  to  rapid  dilatation  or  to  the 
production  of  an  aneurism,  particularly  in  the  early  stage,  before  the  weak- 
ened spot  is  thickened  and  strengthened  by  the  intimal  changes. 

(&)  Sexlle  Aeteeio-scleeosis. — The  larger  arteries  are  dilated  and  tor- 
tuous, the  walls  thin  but  stiff,  and  often  converted  into  rigid  tubes.  The 
sub  endothelial  tissue  undergoes  degeneration  and  in  spots  breaks  down,  form- 
ing the  so-called  atheromatous  abscesses,  the  contents  of  which  consist  of  a 
molecular  debris.  They  may  open  into  the  lumen,  when  they  are  known  as 
atheromatous  ulcers.  The  greater  portion  of  the  intima  may  be  occupied  by 
rough  calcareous  plates,  with  here  and  there  fissures  and  losses  of  substance, 
upon  which  not  infrequently  white  thrombi  are  deposited.  Microscopically 
there  is  extreme  degeneration  of  the  coats,  particularly  of  the  media.  Senile 
atrophy  of  the  liver  and  kidneys  usually  accompanies  these  changes.  Senile 
changes  are  common  in  other  organs.  The  heart  may  be  small  and  is  not 
necessarily  hypertrophied.  In  7  of  1-i  cases  of  Councilman's  series  there  was 
no  enlargement.    Brown  atrophy  is  common. 

(c)  Diffuse  Aeteeio-scleeosis. — The  process  is  wide-spread  throughout 
the  aorta  and  its  branches,  in  the  former  usually,  but  not  necessarily,  asso- 
ciated with  the  nodular  form.  The  subjects  of  this  variety  are  usually  middle- 
aged  men,  but  it  may  occur  early.  Of  the  27  in  Councilman's  series  belong- 
ing to  this  group  the  majority  were  between  the  ages  of  forty  and  fifty-five. 
The  youngest  was  a  negro  of  twenty-three  and  the  oldest  a  man  of  sixty. 
The  affection  is  very  prevalent  among  negroes;  less  than  50  per  cent  were  in 
whites,  whereas  the  ratio  of  colored  to  white  patients  in  the  wards  is  one  to 
seven.  The  affection  is  met  with  in  strongly  built,  muscular  men  and,  as 
Councilman  remarks,  they  rarely  present  on  the  autopsy  table  signs  of  general 
anasarca  or,  if  cedema  exists,  it  has  come  on  during  the  last  few  days  of  life. 
The  aorta  and  its  branches  are  more  or  less  dilated,  the  branches  sometimes 
more  than  the  trunk.  The  intima  may  be  smooth  and  show  very  slight  changes 
to  the  naked  eye;  more  commonly  there  are  scattered  elevated  areas  of  an 
opaque  white  color,  some  of  which  may  have  undergone  atheromatous  changes 
as  in  the  senile  form. 

Microscopically  in  the  several  forms  the  media  shows  necrotic  and  hya- 
line changes,  involving  in  the  larger  arteries  both  muscular  and  elastic 
elements,  and  the  intima  presents  a  great  increase  in  the  subendothelial  con- 
nective tissue,  which  is  particularly  marked  opposite  areas  of  advanced  degen- 
eration in  the  media.  The  small  arteries — those  in  the  kidneys,  for  exam- 
ple— show  "  a  thickening  of  the  wall,  due  to  the  formation  of  a  homogeneous 
hyaline  tissue  vrithin  the  muscular  coat.  This  tissue  contains  but  few  cells, 
is  faintly  striated,  and  stains  a  light  brown  in  the  osmic  acid  used  in  the  hard- 
ening solution.  In  many  of  the  smallest  vessels  nothing  can  be  seen  of  the 
elastic  lamina,  in  others  only  fragments  can  be  made  out,  in  others  it  is  pre- 
served. .  .  .  The  muscular  fibres  of  the  media  show  marked  atrophic  changes. 
Fatty  degeneration  of  the  cells  can  be  made  out  both  in  fresh  sections  and 
after  hardening  in  Flemming's  solution.  The  nuclei  are  thin  and  atrophic 
and  vacuoles  are  sometimes  seen  in  them.  In  some  arteries  the  muscle-fibres 
have  almost  disappeared  and  the  media  is  changed  into  a  homogeneous  tissue, 
similar  to  that  in  the  thickened  intima "  (Councilman).    The  degeneration  of 


DISEASES  OF  THE  ARTERIES.  851 

the  media  is  most  marked  in  the  smaller  arteries.  The  capillaries  are  thick- 
ened, particularly  those  of  the  glomeruli  of  the  kidneys,  which  are  often  oblit- 
erated and  involved  in  extensive  hyaline  degeneration. 

It  is  in  this  group  of  cases  that  the  heart  shows  the  most  important 
changes.  The  average  weight  in  the  cases  referred  to  was  over  450  grammes, 
and  there  were  two  cases  in  which  without  valvular  disease  the  weight  was 
over  800  grammes.  Fibrous  myocarditis  is  often  present,  particularly  when 
the  coronary  arteries  are  involved.  The  semilunar  valves  are  sometimes 
opaque  and  sclerotic,  and  may  be  incompetent.  The  kidneys  may  show  ex- 
tensive sclerosis,  but  in  many  cases  the  changes  are  so  slight  that  macroscop- 
ically  they  might  be  overlooked.  They  may  be  increased  in  size.  The  capsule 
is  usually  adherent,  the  surface  a  little  rough,  and  very  often  presents  atrophic, 
depressed  areas,  deep-red  in  color.    Increased  consistence  is  always  present. 

Sclerosis  of  the  pulmonary  artery  is  met  with  in  all  conditions  which  for 
a  long  time  increase  the  tension  in  the  lesser  circulation,  particularly  in  mitral 
valve  disease  and  in  emphysema.  Sometimes  the  sclerosis  reaches  a  high  grade 
and  is  accompanied  with  aneurismal  dilatation  of  the  primary  and  secondary 
branches,  more  rarely  with  insufficiency  of  the  pulmonary  valve.  Leonard 
Eogers  has  shown  that  in  India  it  is  not  uncommon  as  a  primary  affection. 
In  a  remarkable  case  of  a  young  man  of  twenty-four,  reported  by  Komberg 
from  Curschmann's  clinic,  the  pulmonary  arteries  were  involved  in  most  ex- 
tensive arterio-sclerosis ;  the  main  branches  were  dilated,  and  the  smaller 
branches  were  the  seat  of  the  most  extreme  sclerotic  changes.  On  the  other 
hand,  the  aorta  and  its  branches  were  normal. 

In  many  cases  of  arterio-sclerosis  the  condition  is  not  confined  to  the 
arteries,  but  extends  not  only  to  the  capillariog  but  also  to  the  veins,  and  may 
properly  be  termed  an  angio-sclerosis. 

Sclerosis  of  the  veins — phleho-sclerosis — is  not  at  all  an  uncommon  accom- 
paniment of  arterio-sclerosis.  It  is  seen  in  conditions  of  heightened  blood- 
pressure,  as  in  the  portal  system  in  cirrhosis  of  the  liver  and  in  the  pulmonary 
veins  in  mitral  stenosis.  The  afEected  vessels  are  usually  dilated,  and  the 
intima  shows,  as  in  the  arteries,  a  compensatory  thickening,  which  is  particu- 
larly marked  in  those  regions  in  which  the  media  is  thinned.  The  new- 
formed  tissue  in  the  endophlebitis  may  undergo  hyaline  degeneration,  and  is 
sometimes  extensively  calcified.  In  a  case  of  fibroid  obliteration  of  the  portal 
vein  of  long  standing,  I  found  the  intima  of  the  greatly  dilated  gastric,  splenic, 
and  mesenteric  veins  extensively  calcified.  Without  existing  arterio-sclerosis 
the  peripheral  veins  may  be  sclerotic,  usually  in  conditions  of  debility,  but  not 
infrequently  in  young  persons. 

Symptoms. — Increased  Tension. — The  pressure  with  which  the  blood 
flows  in  the  arteries  depends  upon  the  degree  of  peripheral  resistance  and  the 
force  of  the  ventricular  contraction.  A  high-tension  pulse  may  exist  with 
very  little  arterio-sclerosis;  but,  as  a  rule,  when  the  condition  has  been  per- 
sistent, the  sclerosis  and  high  tension  are  found  together.  On  the  other  hand  a 
very  low  or  normal  tension  may  be  present  in  extremely  sclerotic  vessels.  The 
recent  introduction  of  clinical  instruments  for  measuring  blood-pressure  has 
been  most  useful.     (Consult  the  work  of  T.  Janeway  on  Blood-Pressure.) 

Hypeetrophy  of  the  Heart. — In  consequence  of  the  peripheral  resist- 
ance and  increased  work  the  left  ventricle  increases  in  size,  and  some  of  the 


852  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

purest  examples  of  simple  hypertrophy  occur  in  this  condition.  The  cham- 
ber may  be  little,  if  at  all,  dilated.  The  apex  beat  is  dislocated  in  advanced 
cases  an  inch  or  more  beyond  the  nipple  line.  The  impulse  is  heaving  and 
forcible.     The  aortic  second  sound  is  clear,  ringing,  and  accentuated. 

The  early  s}Tnptoms  are  interesting.  Stengel  has  called  attention  to  the 
pallor,  and  there  may  be  dyspeptic  symptoms.  It  is  remarkable  with  what 
rapidity  the  disease  may  progress.  I  have  knoT^Ti  the  peripheral  arteries  to 
stiffen  and  grow  old  in  a  couple  of  years. 

The  combination  of  heightened  blood-pressure,  a  palpable  thickening  of 
the  arteries,  hypertrophy  of  the  left  ventricle,  and  accentuation  of  the  aortic 
second  sound  are  signs  pathognomonic  of  arterio-sclerosis.  From  this  period 
of  establishment  the  course  of  the  disease  may  be  very  varied.  For  years 
the  patient  may  have  good  health,  and  be  in  a  condition  analogous  to  that 
of  a  person  with  a  well-compensated  valvular  lesion.  There  may  be  no  renal 
SAinptoms.  or  there  may  be  the  passage  of  a  larger  amount  of  urine  than 
normal,  with  transient  albuminuria,  and  now  and  then  hyaline  tube-casts. 
The  subsequent  historj^  is  extraordinarily  diverse,  depending  upon  the  vas- 
cular territory  in  which  the  sclerosis  is  most  advanced,  or  upon  the  accidents 
which  are  so  liable  to  happen,  and  the  symptoms  may  be  cardiac,  cerebral, 
renal,  etc. 

(1)  Cardiac. — The  involvement  of  the  coronary  arteries  may  lead  to  the 
various  symptoms  already  referred  to  under  that  section — ^thrombosis  with 
sudden  death,  fibroid  degeneration  of  the  heart,  aneurism  of  the  heart,  rup- 
ture, and  angina  pectoris.  Angina  pectoris  is  not  uncommon,  and  the  organic 
variety  is  almost  always  associated  with  arterio-sclerosis.  A  second  impor- 
tant group  of  cardiac  s}Tnptoms  results  from  the  dilatation  which  finally  gets 
the  better  of  the  hj^Dertrophy.  The  patient  then  presents  all  the  symptoms 
of  cardiac  insufficiencT — dyspnoea,  scant}^  urine,  and  very  often  serous  effu- 
sions. If  the  case  has  come  under  observation  for  the  first  time  the  clinical 
picture  is  that  of  chronic  valvular  disease,  and  the  existence  of  a  loud  blowing 
murmur  at  the  apex  may  throw  the  practitioner  off  his  guard.  Many  cases 
terminate  in  this  way. 

(2)  The  cerebral  symptoms  of  arterio-sclerosis  are  varied  and  important, 
and  embrace  those  of  many  degenerative  diseases,  acute  and  chronic  (which 
follow  sclerosis  of  the  smaller  branches),  and  cerebral  hsemorrhage. 

Transient  hemiplegia,  monoplegia,  or  aphasia  may  occur  in  advanced  ar- 
terio-sclerosis. The  attacks  are  very  characteristic,  often  brief,  lasting  twent}^- 
four  hours  or  less.  Eecovery  may  be  perfect.  Eecurrence  is  the  rule,  and  a 
patient  may  have  a  score  or  more  attacks  of  aphasia,  or  in  the  course  of  a 
couple  of  years  there  may  be  half  a  dozen  transient  hemiplegic  attacks  or  one 
or  two  monoplegias,  or  paraplegia  for  a  day  or  two.  It  is  difficult  to  say  upon 
what  these  attacks  depend.  Spasm  of  the  arteries  has  been  suggested,  but 
the  condition  of  the  smallest  arteries  is  not  very  favorable  to  this  view.  Pea- 
body  has  called  attention  to  these  cases,  which  are  more  common  than  is 
indicated  in  the  literature.  Vertigo  occurs  frequently,  and  may  be  either 
simple,  or  is  associated  with  slow  pulse  and  syncopal  or  epileptiform  attacks 
— the  Stokes- Adams  syndrome. 

(3)  Renal  s}Tnptdms  supervene  in  a  large  number  of  the  cases.  A  sclero- 
sis, patchy  or  diffuse,  is  present  in  a  majority  of  the  cases  at  the  time  of 


DISEASES  OF  THE  ARTERIES.  853 

autopsy,  and  the  condition  is  practically  that  of  contracted  kidney.  It  is  seen 
in  a  typical  manner  in  the  senile  form,  and  not  infrequently  develops  early  in 
life  as  a  direct  sequence  of  the  diffuse  variety.  It  is  often  difficult  to  decide 
clinically  (and  the  question  is  one  upon  which  good  observers  might  not  agree 
in  a  given  case)  whether  the  arterial  or  the  renal  disease  has  been  primary. 

(4)  Among  other  events  in  arterio-sclerosis  may  be  mentioned  gangrene 
of  the  extremities,  due  either  directly  to  endarteritis  or  to  the  dislodgment  of 
thrombi.     Sudden  transient  paralysis  may  occur. 

(5)  Iniermittent  lameness  or  claudication,  the  dysbasia  angio-sclerotica  of 
Erb,  the  crural  angina  of  Walton,  is  seen  most  frequently  in  connection  with 
arterio-sclerosis.  In  the  horse,  in  which  the  intermittent  lameness  was  first 
described  b}^  Bouley,  verminous  aneurisms  are  present  in  the  iliac  arteries.  In 
man  Charcot  described  the  condition  in  1856  in  an  old  soldier  who  was  not 
able  to  walk  for  more  than  a  quarter  of  an  hour  without  severe  cramps  in  the 
legs.  The  post  mortem  showed  a  traumatic  aneurism  of  one  iliac  artery.  The 
loss  of  function  and  the  pain  in  the  muscles  were  due  to  the  relative  ischemia. 
Erb  has  shown  that  intermittent  lameness  is  not  at  all  infrequent,  particularly 

,  among  private  patients,  only  3  of  his  45  cases  not  coming  in  this  class.  Of 
127  cases  there  were  only  7  in  women.  Hebrews  seem  more  frequently  affected. 
Sj^philis,  alcohol,  and  tobacco  are  common  factors.  Muscular  weakness  after 
exertion  or  complete  disability,  numbness,  tingling,  and  paresthesia  of  various 
forms  are  the  common  symptoms.  Pulsation  may  be  absent  in  the  dorsal 
arteries  of  the  feet  and  the  vessels  are  sclerotic.  Vaso-motor  changes  may  be 
present,  and  in  the  dependent  position  the  feet  and  legs  become  deeply 
congested. 

Treatment. — In  the  late  stages  the  conditions  must  be  treated  as  they 
arise  in  connection  with  the  various  viscera.  In  the  early  stages,  before  any 
local  symptoms  are  manifest,  the  patient  should  be  enjoined  to  live  a  quiet, 
well-regulated  life,  avoiding  excesses  in  food  and  drink.  It  is  usually  best  to 
explain  frankly  the  condition  of  affairs,  and  so  gain  his  intelligent  co-opera- 
tion. Special  attention  should  be  paid  to  the  state  of  the  bowels  and  urine, 
and  the  secretion  of  the  skin  should  be  kept  active  by  daily  baths.  Alcohol 
in  all  forms  should  be  prohibited,  and  the  food  should  be  restricted  to  plain, 
wholesome  articles.  The  use  of  mineral  waters  or  a  residence  every  year  at 
one  of  the  mineral  springs  is  usually  serviceable.  If  there  has  been  a  syphilitic 
history  an  occasional  course  of  iodide  of  potassium  is  indicated,  indeed,  even 
in  the  non-syphilitic  cases  it  seems  to  do  good,  and  whenever  the  blood-pres- 
sure is  high  nitroglycerin  or  the  sodium  nitrite  may  be  given. 

In  cases  which  come  under  observation  for  the  first  time  with  dyspnoea, 
slight  lividity,  and  signs  of  cardiac  insufficiency,  venesection  is  indicated.  In 
some  instances,  with  very  high  tension,  striking  relief  is  afforded  by  the 
abstraction  of  20  ounces  of  blood. 

III.    ANEURISM. 

The  following  forms  of  aneurism  are  usually  recognized: 
(a)  The  true,  in  which  the  sac  is  formed  of  one  or  more  of  the  arterial 
coats.     This  may  be  fusiform,  cylindrical,  or  cirsoid  (in  which  the  dilatation 
is  in  an  artery  and  its  branches),  or  it  may  be  circumscribed  or  sacculated. 


854  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

Aneurisms  are  usuall}"  fusiform,  resulting  from  uniform  dilatation  of  the 
vessel,  or  saccular. 

(&)  The  false  aneurism,  in  which  there  is  rupture  of  all  the  coats,  and 
the  blood  is  free  (or  circumscribed)  in  the  tissues. 

(c)  The  dissecting  aneurism,  which  results  from  injur}''  or  laceration  of 
the  internal  coat.  The  blood  dissects  between  the  layers;  hence  the  name, 
dissecting  aneurism.  This  occurs  usually  in  the  aorta,  and  may  last  for  years, 
forming  when  complete  a  double  tube — the  so-called  double  aorta. 

(d)  Arterio-venous  aneurism  results  when  a  communication  is  established 
between  an  artery  and  a  vein,  A  sac  may  intervene,  in  which  case  we  have 
what  is  called  a  varicose  aneurism;  but  in  many  cases  the  communication  is 
direct  and  the  chief  change  is  in  the  vein,  which  is  dilated,  tortuous,  and  pul- 
sating, the  condition  being  termed  an  aneurismal  varix. 

Etiology  and  Pathology. — An  aneurism  is  an  accident  in  connection  with 
disease  of  the  vessel  wall  leading  to  weakness  and  consequent  dilatation,  or 
to  rupture.  While  the  ordinary  arterio-sclerosis  may  lead  to  aneurism,  the 
great  majority  of  the  cases  result  from  the  aortitis  associated  with  s}^hilis, 
which  leads  to  loss  of  elasticity  and  local  rupture.  The  incidence  of  aortic 
aneurism  is  in  the  third  and  fourth  decades,  earlier  than  the  common  forms 
of  arterio-sclerosis.  Aneurisms  arise  then:  (a)  By  the  gradual  diffuse  dis- 
tention of  the  arterial  coats,  which  have  been  weakened  by  arterio-sclerosis, 
particularly  in  its  early  stages,  before  compensatory  endarteritis  develops.  The 
arch  of  the  aorta  is  often  dilated  in  this  way  so  as  to  form  an  irregular 
aneurism. 

(&)  In  consequence  of  circumscribed  loss  of  resisting  power  in  the  media 
and  adventitia,  there  is  a  laceration  or  rupture  of  the  intima.  If  small  this 
leads  to  a  local  bulging  and  the  gradual  production  of  a  sac;  if  large  it  may 
form  a  dissecting  aneurism,  splitting  the  coats;  or  the  transverse  tear  may 
heal  completely,  leaving  a  large  scar.  In  a  case  of  Daland's  there  was  just 
above  the  aortic  valves  an  old  transverse  tear  of  the  intima,  extending  almost 
the  entire  circumference  of  the  vessel.  Sclerosis  of  the  media  and  adventitia 
had  taken  place  and  the  process  was  evidently  of  some  standing.  An  inch 
or  more  above  it  was  a  fresh  transverse  tear  (or  rather  cut,  as  the  edges  were 
as  sharp  as  if  cut  with  a  razor)  which  had  produced  a  dissecting  aneurism. 
This  process  is  by  no  means  uncommon,  and  occurs  chiefly  in  the  aortic  arch, 
very  often  in  vessels  with  smooth  intima. 

(c)  Embolic  Aneurism. — When  an  embolus  has  lodged  in  a  vessel  and 
permanently  plugged  it,  aneurismal  dilatation  may  follow  on  the  proximal  side. 
The  embolus  itself,  if  a  calcified  fragment  from  a  valve,  may  lacerate  the  wall, 
or  if  infected  may  produce  inflammation  and  softening. 

{d)'  Mycotic  Aneurism. — The  importance  of  this  form  has  been  specially 
considered  by  Eppinger  in  his  exhaustive  monograph.  The  occurrence  of 
multiple  aneurisms  in  malignant  endocarditis  has  been  observed  by  several 
writers.  Probably  the  first  case  in  which  the  mycotic  nature  was  recognized 
was  one  which  occurred  at  the  Montreal  General  Hospital  and  is  reported  in 
full  in  my  lectures  on  malignant  endocarditis.  In  addition  to  the  ulceration 
of  the  valves  there  were  four  aneurisms  of  the  arch,  of  which  one  was  large  and 
saccular,  and  three  were  not  bigger  than  cherries.  An  extensive  growth  of 
micrococci  was  present. 


DISEASES  OF  THE  ARTERIES.  855 

A  form  of  parasitic  aneurism  very  commonly  affecting  the  mesenteric 
arteries  of  the  horse  is  due  to  the  development  of  the  Strongylus  armatus. 

Thoma  has  described  a  "  traction  "  aneurism  of  the  concavity  of  the  arch 
at  the  point  of  insertion  of  the  remnant  of  the  ductus  Botalli  (Virchow's 
Archiv,  Bd.  122). 

And,  lastly,  there  are  cases  in  which  without  any  definite  cause  there  is 
a  tendency  to  the  occurrence  of  aneurisms  in  various  parts  of  the  body.  A 
remarkable  instance  of  it  in  our  profession  was  afforded  by  the  brilliant 
Thomas  King  Chambers,  who  first  had  an  aneurism  in  the  left  popliteal  artery, 
eleven  years  subsequently  an  aneurism  in  the  right  leg  which  was  cured  by 
pressure,  and  finally  aneurisms  of  the  carotid  arteries. 

Incidence  of  Aneurism. — The  disease  is  more  common  in  Great  Britain 
and  in  America  than  on  the  continent  of  Europe.  The  greater  freqiiency  in 
the  British  army  than  in  those  of  continental  countries  is  associated  with  the 
greater  incidence  of  syphilis.  The  negroes  are  more  affected  than  the  whites 
in  the  United  States. 

Aneurism  of  the  Thoracic  Aorta. 

The  causes  which  favor  arterio-sclerosis  prevail  in  aortic  aneurism,  par- 
ticularly syphilis  and  overwork.  The  greatest  danger  probably  is  in  strong 
muscular  men  with  commencing  degenerative  processes  in  the  arteries,  the 
result  of  aortitis,  who  during  a  sudden  muscular  exertion  are  liable  to  lacerate 
the  coats,  the  intima  not  yet  being  strengthened  by  compensatory  thickening 
over  a  spot  of  mesarteritis.  Aneurisms  of  the  thoracic  aorta  are  of  two  main 
types — the  diffuse  dilatation  and  the  saccular.  The  former  is  most  common 
in  the  arch,  but  the  entire  tube  may  be  involved.  The  saccular  variety  is  the 
most  frequent  clinically;  the  diffuse  form  is  often  overlooked.  The  saccular 
aneurism  may  be  small  and  situated  just  above  the  aortic  ring.  Others  form 
large  tumors  which  project  externally  and  occupy  a  large  portion  of  the  upper 
thorax.  Small  sacs  from  the  descending  portion  of  the  arch  may  compress  the 
trachea  or  the  bronchi.  In  the  thoracic  portion  the  sac  may  erode  the  vertebrae 
or  grow  into  the  pleural  cavity  and  compress  the  lung.  It  may  grow  through 
the  ribs  and  appear  in  the  back. 

The  chief  influence  of  an  aneurism  is  manifested  in  what  are  known  as 
pressure  effects.  In  the  absence  of  these  an  aneurism  may  attain  a  large  size 
without  producing  symptoms  or  seriously  interfering  with  the  circulation. 
Indeed,  a  useful  clinical  subdivision  as  given  by  Bramwell  is  into  three  groups 
— aneurisms  which  are  entirely  latent  and  give  no  physical  signs;  aneurisms 
which  present  signs  of  intrathoracic  pressure,  although  it  is  difficult  or  impos- 
sible to  determine  the  nature  of  the  lesion  producing  the  pressure ;  and,  lastly, 
aneurisms  which  produce  distinct  tumors  with  well-marked  pressure  symp- 
toms and  external  signs.  Broadbent  makes  another  useful  division  into 
aneurism  of  symptoms  and  aneurism  of  physical  signs.  It  is  perhaps  best 
to  consider  aneurisms  of  the  aorta  according  to  the  situation  of  the  tumor. 

(a)  Aneurisms  of  the  Ascending  Portion  of  the  Arch. — Just  above 
the  sinuses  of  Valsalva  they  are  often  small,  latent,  and  due  to  syphilis. 
Eupture  usually  takes  place  into  the  pericardium,  causing  instant  death. 
Along  the  convex  border  of  the  ascending  part,  aneurism  frequently  arises, 


856  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

and  may  grow  to  a  large  size^  either  passing  out  into  the  right  pleura  or 
forvard^  pointing  at  the  second  or  third  interspace^  eroding  the  ribs  and  ster- 
num, and  producing  large  external  tumors.  In  this  situation  the  sac  is  liable, 
indeed,  to  compress  the  superior  vena  cava,  causing  engorgement  of  the  ves- 
sels of  the  head  and  arm,  sometimes  compressing  only  the  subclavian  vein,  and 
causing  enlargement  and  oedema  of  the  right  arm.  Perforation  may  take  place 
into  the  superior  vena  cava,  of  which  accident  Pepper  and  Griffith  have  col- 
lected 29  cases.  In  rare  instances,  when  the  aneurism  springs  from  the  con- 
cave side  of  the  vessels,  the  tumor  may  appear  to  the  left  of  the  sternum. 
Large  aneurisms  in  this  situation  may  cause  much  dislocation  of  the  heart, 
pushing  it  down  and  to  the  left,  and  sometimes  compressing  the  inferior  vena 
cava,  and  causing  swelling  of  the  feet  and  ascites.  The  right  recurrent  laryn- 
geal nerve  is  often  compressed.  The  innominate  artery  is  rarely  involved. 
Death  commonly  follows  from  rupture  into  the  pericardium,  the  pleura,  or 
into  the  superior  cava;  less  commonly  from  rupture  externally,  sometimes 
from  s}Ticope. 

(h)  AxEURisMs  OF  THE  TRANSVERSE  Arch. — The  direction  of  their 
growth  is  most  commonly  backward,  but  they  may  grow  forward,  erode  the 
sternum,  and  produce  large  tumors.  The  tumor  presents  in  the  middle  line 
and  to  the  right  of  the  sternum  much  more  often  than  to  the  left,  which 
occurred  in  only  -i  of  35  aneurisms  in  this  situation  (0.  A.  Browne).  Even 
when  small  and  producing  no  external  tumor  they  may  cause  marked  pressure 
signs  in  their  growth  backward  toward  the  spine,  involving  the  trachea  and 
the  oesophagus,  and  giving  rise  to  cough,  which  is  often  of  a  paroxysmal  char- 
acter, and  dysphagia.  The  left  recurrent  lar3mgeal  is  often  involved  in  its 
course  round  the  arch.  A  small  aneurism  from  the  lower  or  posterior  wall 
of  the  arch  may  compress  a  bronchus,  inducing  bronchorrhoea,  gradual  bron- 
chiectasy,  and  suppuration  in  the  lung — a  process  which  by  no  means  infre- 
quently causes  death  in  aneurism,  and  a  condition  which  at  the  Montreal  Gen- 
eral Hospital  we  were  in  the  habit  of  terming  aneurismal  phthisis.  Occa- 
sionally enormous  aneurisms  arise  in  this  situation,  and  grow  into  both  pleurse, 
extending  between  the  manubrium  and  the  vetebrte ;  they  may  persist  for  years. 
The  sac  may  be  evident  at  the  sternal  notch.  The  innominate  artery,  less  com- 
monly the  left  carotid  and  subclavian,  may  be  involved  in  the  sac,  and  the 
radial  or  carotid  pulse  may  be  absent  or  retarded.  Pressure  on  the  sym- 
pathetic may  at  first  cause  dilatation  and  subsequently  contraction  of  the 
pupil.     Sometimes  the  thoracic  duct  is  compressed. 

The  ascending  and  transverse  portions  of  the  arch  are  not  infrequently 
involved  together,  usually  without  the  branches;  the  tumor  grows  upward, 
or  upward  and  to  the  right. 

(c)  Aneurisms  of  the  Descending  Portion  of  the  Arch. — It  is  not 
infrequently  the  traction  aneurism  of  Thoma.  The  sac  projects  to  the  left 
and  backward,  and  often  erodes  the  vertebrse  from  the  third  to  the  sixth 
dorsal,  causing  great  pain  and  sometimes  compression  of  the  spinal  cord. 
Dysphagia  is  common.  Pressure  on  the  bronchi  ma}^  induce  bronchiectasy, 
with  retention  of  secretions,  and  fever.  A  tumor  may  appear  externall)^  in 
the  region  of  the  scapula,  and  here  attain  an  enormous  size.  Death  not  infre- 
quently occurs  from  rupture  into  the  pleura,  or  the  sac  may  grow  into  the 
lung  and  caujse  haemoptysis. 


DISEASES  OF  THE  ARTERIES.  857 

(d)  Aneurisms  of  the  Descending  Thoracic  Aorta. — The  larger  num- 
ber occur  close  to  the  diaphragm^  the  sac  lying  upon  or  to  the  left  of  the  bodies 
of  the  lower  dorsal  vertebra,  which  are  often  eroded.  They  are  frequently 
latent,  and  are  often  overlooked;  pulmonary  and  pleural  symptoms  are 
common.  Pain  in  the  back  is  severe;  dysphagia  is  not  infrequent.  The 
sac  may  reach  an  enormous  size  and  form  a  subcutaneous  tumor  in' the 
left  back. 

Physical  Signs. — Inspection. — A  good  light  is  essential;  cases  are  often 
overlooked  owing  to  a  hasty  inspection.  The  face  is  often  suffused,  the  con- 
junctiva injected,  and  veins  of  the  chest  and  of  one  arm  engorged.  One 
pupil  may  be  enlarged.  In  many  instances  inspection  is  negative.  On  either 
side  of  the  sternum  there  may  be  abnormal  pulsation,  due  to  dislocation  of  the 
heart,  to  deformity  of  the  thorax,  or  to  retraction  of  the  lung.  The  aneurismal 
pulsation  is  usually  above  the  level  of  the  third  rib  and  most  commonly  to  the 
right  of  the  sternum,  either  in  the  first  or  second  interspace.  It  may  be  only  a 
diffuse  heaving  impulse  without  any  external  tumor.  Often  the  impulse  is 
noticed  only  when  the  chest  is  looked  at  obliquely  in  a  favorable  light.  When 
the  innominate  is  involved  the  throbbing  may  pass  into  the  neck  or  be  appar- 
ent at  the  sternal  notch.  Posteriorly,  when  pulsation  occurs,  it  is  most  com- 
monly found  to  the  left  of  the  spine.  An  external  tumor  is  present  in  many 
cases,  projecting  either  through  the  upper  part  of  the  sternum  or  to  the 
right,  sometimes  involving  the  sternum  and  costal  cartilages  on  both  sides, 
forming  a  swelling  the  size  of  a  cocoa-nut  or  even  larger.  The  skin  is  thin, 
often  blood-stained,  or  it  may  have  ruptured,  exposing  the  lamina  of  the  sac. 
The  apex  beat  may  be  much  dislocated,  particularly  when  the  sac  is  large. 
It  is  more  commonly  a  dislocation  from  pressure  than  from  enlargement  of 
the  heart  itself. 

Palpation. — The  area  and  degree  of  pulsation  are  best  determined  by  pal- 
pation. When  the  aneurism  is  deep-seated  and  not  apparent  externally,  the 
bimanual  method  should  be  used,  one  hand  upon  the  spine  and  the  other  on 
the  sternum.  There  may  be  only  a  diffuse  impulse.  When  the  sac  has  per- 
forated the  chest  wall  the  impulse  is,  as  a  rule,  forcible,  slow,  heaving,  and 
expansile,  and  has  the  same  qualities  as  a  forcible  apex  beat.  The  resistance 
may  be  very  great  if  there  are  thick  laminge  beneath  the  skin;  more  rarely 
the  sac  is  soft  and  fluctuating.  The  hand  upon  the  sac,  or  on  the  region  in 
which  it  is  in  contact  with  the  chest  wall,  may  feel  a  diastolic  shock,  often 
of  great  intensity,  which  forms  one  of  the  valuable  physical  signs  of  aneurism. 
A  systolic  thrill  is  sometimes  present,  not  so  often  in  saccular  aneurisms  as 
in  the  dilatation  of  the  arch.  The  pulsation  may  sometimes  be  felt  in  the 
suprasternal  notch. 

Percussion. — The  small  and  deep-seated  aneurisms  are  in  this  respect  nega- 
tive. In  the  larger  tumors,  as  soon  as  the  sac  reaches  the  chest  wall,  there  is 
produced  an  area  of  abnormal  dulness,  the  position  of  which  depends  upon 
the  part  of  the  aorta  affected.  Aneurisms  of  the  ascending  arch  grow  forward 
and  to  the  right,  producing  dulness  on  one  side  of  the  manubrium ;  those  from 
the  transverse  arch  produce  dulness  in  the  middle  line,  extending  toward  the 
left  of  the  sternum,  while  aneurisms  of  the  descending  portion  most  com- 
monly produce  dulness  in  the  left  interscapular  and  scapular  regions.  The 
percussion  note  is  flat  and  gives  a  feeling  of  increased  resistance. 


858  DISEASES  OF   THE  CIRCULATORY  SYSTEM. 

Auscultation. — Adventitious  sounds  are  not  always  to  be  heard.  Even  in 
a  large  sac  there  may  be  no  murmur.  Much  depends  upon  the  thickness  of  the 
laminaj  of  fibrin.  An  important  sign,  particularly  if  heard  over  a  dull  region, 
is  a  ringing,  accentuated  second  sound,  a  phenomenon  rarely  missed  in  large 
aneurisms  of  the  aortic  arch.  A  systolic  murmur  may  be  present;  sometimes 
a  double  murmur,  in  which  case  the  diastolic  bruit  is  usually  due  to  asso- 
ciated aortic  insuificiency.  The  systolic  murmur  alone  is  of  little  moment  in 
the  diagnosis  of  an  aneurismal  sac.  A  continuous  humming-top  murmur  with 
systolic  intensification  is  heard  when  the  aneurism  communicates  with  the 
vena  cava  or  the  pulmonary  artery.  With  the  single  stethoscope  the  shock  of 
the  impulse  with  the  first  sound  is  sometimes  very  marked. 

Among  other  physical  signs  of  importance  are  retardation  of  the  pulse 
in  the  arteries  beyond  the  aneurism,  or  in  those  involved  in  the  sac.  There 
may,  for  instance,  be  a  marked  difference  between  the  right  and  left  radial, 
both  in  volume  and  time.  A  physical  sign  of  large  thoracic  aneurism,  which 
I  have  not  seen  referred  to,  is  obliteration  of  the  pulse  in  the  abdominal  aorta 
and  its  branches.  ^Lj  attention  was  called  to  this  in  a  patient  who  was 
stated  to  have  aortic  insufficiency.  There  was  a  well-marked  diastolic  murmur, 
but  in  the  femorals  and  in  the  aorta  I  was  surprised  to  find  no  trace  of  pul- 
sation, and  not  the  slightest  throbbing  in  the  aljdominal  aorta  or  in  the  per- 
ipheral arteries  of  the  leg.  The  circulation  was,  however,  unimpaired  in  them 
and  there  was  no  dilatation  of  the  veins.  Attracted  by  this,  I  then  made  a 
careful  examination  of  the  patient's  back,  when  the  circumstance  was  dis- 
covered, which  neither  the  patient  himself  nor  any  of  his  physicians  had 
noticed,  that  he  had  a  very  large  area  of  pulsation  in  the  left  scapular  region. 
The  sac  probably  was  large  enough  to  act  as  a  reservoir  annihilating  the  ven- 
tricular systole,  and  converting  the  intermittent  into  a  continuous  stream. 

The  tracheal  tugging,  a  valuable  sign  in  deep-seated  aneurisms,  was  de- 
scribed by  Surgeon-Major  Oliver,  and  was  specially  studied  by  my  colleagues 
Eoss  and  MacDonnell  at  the  Montreal  General  Hospital.  Oliver  gives  the 
following  directions :  "  Place  the  patient  in  the  erect  position,  and  direct  him 
to  close  his  mouth  and  elevate  his  chin  to  almost  the  full  extent;  then  grasp 
the  cricoid  cartilage  between  the  finger  and  thumb,  and  use  stead}^  and  gentle 
upward  pressure  on  it,  when,  if  dilatation  or  aneurism  exists,  the  pulsation 
of  the  aorta  will  be  distinctly  felt  transmitted  through  the  trachea  to  the 
hand."  This  is  a  sign  of  great  value  in  the  diagnosis  of  deep-seated  aneu- 
risms, though  it  may  occasionally  be  felt  in  tumors  and  in  the  extreme 
dynamic  dilatation  of  aortic  insufficiency.  It  may  be  visible  in  the  thyroid 
cartilage.     The  trachea  may  be  pushed  to  one  side. 

Occasionally  a  systolic  murmur  may  be  heard  in  the  trachea,  as  pointed 
out  by  David  Drummond,  or  even  at  the  patient's  mouth,  when  opened.  This 
is  either  the  sound  conveyed  from  the  sac,  or  is  produced  by  the  air  as  it  is 
driven  out  of  the  wind-pipe  during  the  systole.  Feeble  respiration  in  one 
lung  is  a  common  effect  of  pressure.  ) 

Symptoms. — There  ma}^  be  no  symptoms.  A  man  may  present  a  tumor 
which  has  eroded  the  chest  wall  without  pain  or  any  discomfort.  Every  phys- 
ical sign  may  be  present  without  a  single  s^inptom. 

An  important  but  variable  feature  in  thoracic  aneurism  is  paiji,  which  is 
particularly  marked  in  deep-seated  tumors.     It  is  usually  paroxysmal,  sharp, 


DISEASES  OF  THE  ARTERIES.  859 

and  lancinating,  often  ver}^  severe  when  the  tumor  is  eroding  the  vertehrge,  or 
perforating  the  chest  wall.  In  the  latter  case,  after  perforation  the  pain  may- 
cease.  Anginal  attacks  are  not  uncommon,  particularly  in  aneurisms  at  the 
root  of  the  aorta.  Frequently  the  pain  radiates  down  the  left  arm  or  up  the 
neck,  sometimes  along  the  upper  intercostal  nerves.  Superficial  tenderness 
may  be  felt  in  the  skin  over  the  heart  or  over  the  left  sternomastoid  muscle. 
Cough  results  either  from  the  direct  pressure  on  the  wind-pipe,  or  is  associated 
with  bronchitis.  The  expectoration  in  these  instances  is  abundant,  thin,  and 
watery;  subsequently  it  becomes  thick  and  turbid.  Paroxysmal  cough  of  a 
peculiar  brazen,  ringing  character  is  a  characteristic  symptom  in  some  cases, 
particularly  when  there  is  pressure  on  the  recurrent  laryngeal  nerves,  or  the 
cough  may  have  a  peculiar  wheezy  quality — the  "  goose  cough." 

Dyspnoea,  which  is  common  in  cases  of  aneurism  of  the  transverse  por- 
tion, is  not  necessarily  associated  with  pressure  on  the  recurrent  laryngeal 
nerves,  but  may  be  due  directly  to  compression  of  the  trachea  or  the  left 
bronchus.  It  may  occur  with  marked  stridor.  Loss  of  voice  and  hoarseness 
are  consequences  of  pressure  on  the  recurrent  laryngeal,  usually  the  left, 
inducing  either  a  spasm  in  the  muscles  of  the  left  vocal  cord  or  paralysis. 

Paralysis  of  an  abductor  on  one  side  may  be  present  without  any  symp- 
toms. It  is  more  particularly,  as  Semon  states,  when  the  paralytic  contrac- 
tures supervene  that  the  attention  is  called  to  laryngeal  symptoms. 

HcBmorrliage  in  thoracic  aneurism  may  come  from  (a)  the  soft  granula- 
tions in  the  trachea  at  the  point  of  compression,  in  which  case  the  sputa  are 
blood-tinged,  hut  large  quantities  of  blood  are  not  lost;  (&)  from  rupture 
of  the  sac  into  the  trachea  or  a  bronchus;  (c)  from  perforation  into  the  lung 
or  erosion  of  the  lung  tissue.  The  bleeding  may  be  profuse,  rapidly  proving 
fatal,  and  is  a  common  cause  of  death.  It  may  persist  for  weeks  or  months, 
in  which  case  it  is  simply  hemorrhagic  weeping  through  the  s'ac,  which  is 
exposed  in  the  trachea.  In  some  instances,  even  after  a  very  profuse  haemor- 
rhage, the  patient  recovers  and  may  live  for  years,  A  man  with  well-marked 
thoracic  aneurism,  whom  I  showed  to  my  class  at  the  University  of  Pennsyl- 
vania and  who  had  had  several  brisk  hgemorrhages,  died  four  years  after, 
having  in  the  meantime  enjoyed  average  health.  Death  from  hemorrhage  is 
relatively  more  common  in  aneurism  of  the  third  portion  of  the  arch  and  of 
the  descending  aorta. 

Difficulty  of  swallowing  is  a  comparatively  rare  symptom,  and  may  be 
due  either  to  spasm  or  to  direct  compression.  The  sound  should  never  be 
passed  in  these  cases,  as  the  oesophagus  may  be  almost  eroded  and  perforation 
of  the  sac  has  taken  place. 

Heart  Symptoms. — Pain  has  been  referred  to;  it  is  often  anginal  in  char- 
acter, and  is  most  common  when  the  root  of  the  aorta  is  involved.  The  heart 
is  hypertrophied  in  less  than  one-half  the  cases.  The  aortic  valves  are  some- 
times incompetent,  either  from  disease  of  the  segment's  or  from  stretching  of 
the  aortic  ring. 

Among  other  signs  and  symptoms,  venous  compression,  which  has  already 
been  mentioned,  may  involve  one  subclavian  or  the  superior  vena  cava.  A 
curious  phenomenon  in  intrathoracic  aneurism  is  the  clubbing  of  the  fingers 
and  incurving  of  the  nails  of  one  hand,  of  which  two  examples  have  been 
under   my   care,   both   without   any   special   distention   or   signs   of   venous 


860.  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

engorgement.  Tumors  of  the  arch  may  involve  the  pulmonary  arterj^,  pro- 
ducing comjjression,  or  in  some  instances  adhesion  of  the  pulmonary  segments 
and  insufficiency  of  the  valve;  or  the  sac  may  rupture  into  the  artery,  an 
accident  which  happened  in  two  of  my  cases,  producing  instantaneous  death. 

Pupil  Symptoms. — These  may  be  due  to,  first,  pressure  on  the  sympa- 
thetic, which  may  cause  dilatation  of  one  pupil  when  the  cord  is  irritated, 
contraction  when  the  nerve  is  paralyzed.  Flushing  of  the  side  of  the  face 
and  ear,  increased  temperature  and  sweating,  ma}^  be  present.  Secondly,  as 
Ainley  Walker  and  Wall  have  shown,  the  anisocoria  is  most  frequently  due  to 
vascular  conditions — with  low  blood-pressure  in  one  carotid  the  pupil  on  that 
side  is  dilated,  with  high  pressure  contracted,  and  in  26  cases  of  aneurism 
they  found  a  relation  between  the  state  of  the  ]3upil  and  the  arteries  on  the 
same  side.  Thirdly,  in  a  few  cases  the  anisocoria  is  a  parasyphilitic  manifesta- 
tion associated  with  the  Argyll-Eobertson  phenomenon  and  absent  knee-jerks 
— the  Babinski  s3Tidrome. 

An  X-ray  examination  should  be  made  in  all  doubtful  cases.  The  fiuoro- 
scope  gives  an  accurate  picture  of  the  situation,  the  size,  and  the  relation  to 
the  heart.  Even  a  small  sac  may  be  seen.  In  several  cases  I  have  known  the 
diagnosis  to  rest  upon  it  alone  in  cases  in  which  scarcely  a  physical  sign  was 
present.  Sailer  and  Pfahler  have  shown  that  a  condition  of  tortuosity  of  the 
aorta,  due  to  arterio-sclerosis,  may  exist,  suggesting  very  strongly  the  pres- 
ence of  aneurism,  particularly  on  examination  with  the  fluoroscope. 

The  clinical  picture  of  aneurism  of  the  aorta  is  extremely  varied.  Many 
cases  present  characteristic  symptoms  and  no  physical  signs,  while  others  have 
well-marked  physical  signs  and  no  symptoms.  As  Broadbent  remarks,  the 
aneurism  of  physical  signs  springs  from  the  ascending  portion  of  the  aorta; 
the  aneurism  of  symptoms  grows  from  the  transverse  arch. 

Diagnosis. — Aneurism  of  the  aorta  may  be  confounded  with:  (a)  The  vio- 
lent throbbing  impulse  of  the  arch  in  aortic  insufficiency.  I  have  already 
referred  to  a  case  of  this  kind  in  which  the  diagnosis  of  aneurism  was  made 
by  several  good  observers. 

(&)  Simple  Dynamic  Pulsation. — This  is  common  in  the  abdominal  aorta, 
but  is  rare  in  the  arch.  A  case  which  came  under  the  care  of  William  Mur- 
ray and  Bramwell  presented,  without  any  pain  or  pressure  symptoms,  pulsa- 
tion and  dulness  over  the  aorta.  The  condition  gradually  disappeared  and 
was  thought  to  be  neurotic. 

(c)  Dislocation  of  the  heart  in  curvature  of  the  spine  may  cause  great 
displacement  of  the  aorta,  so  that  it  has  been  known  to  pulsate  forcibly  to 
the  right  of  the  sternum. 

{d)  Solid  Tumors. — When  the  tumor  projects  externally  and  pulsates  the 
difficulty  may  be  considerable.  In  tumor  the  heaving,  expansile  pulsation  is 
absent,  and  there  is  not  that  sense  of  force  and  power  which  is  so  striking 
in  the  throbbing  of  a  perforating  aneurism.  There  is  not  to  be  felt  as  in 
aortic  aneurism  the  shock  of  the  heart-sounds,  particularly  the  diastolic  shock. 
Auscultatory  sounds  are  less  definite,  as  large  aneurisms  may  occur  without 
murmurs ;  and,  on  the  other  hand,  murmurs  may  be  heard  over  tumors.  The 
greatest  difficulty  is  in  the  deep-seated  thoracic  tumors,  and  here  the  diagnosis 
may  be  impossible.  I  have  already  referred  to  the  case  which  was  regarded 
'by  Skoda  as  tumor  and  by  Oppolzer  as  aneurism.    The  physical  signs  may  be 


DISEASES  OF  THE  ARTERIES.  861 

indefinite.  The  ringing  aortic  second  sound  is  of  great  importance  and  is 
rarely,  if  ever,  heard  over  tumor.  Tracheal  tugging  is  here  a  valuable  sign. 
Pressure  phenomena  are  less  common  in  tumor,  whereas  pain  is  more  frequent. 
The  general  appearance  of  the  patient  in  aneurism  is  much  better  than  in 
tumor,  in  which  there  may  be  cachexia  and  enlargement  of  the  glands  in  the 
axilla  or  in  the  neck.  Healthy,  strong  males  who  have  worked  hard  and  have 
had  syphilis  are  the  most  common  subjects  of  aneurism.  Occasionally  cancer 
of  the  oesophagus  may  simulate  aneurism,  producing  pressure  on  the  left 
bronchus. 

(e)  Pulsating  Pleurisy. — In  cases  of  empyema  necessitatis,  if  the  pro- 
jecting tumor  is  in  the  neighborhood  of  the  heart  and  pulsates,  the  condition 
may  readily  be  mistaken  for  aneurism.  The  absence  of  the  heaving,  firm  dis- 
tention and  of  the  diastolic  shock  would,  together  with  the  history  and  the 
existence  of  pleural  effusion,  determine  the  nature  of  the  case.  If  necessary, 
puncture  may  be  made  with  a  fine  hypodermic  needle.  In  a  majority  of  the 
cases  of  pulsating  pleurisy  the  throbbing  is  diffuse  and  wide-spread,  moving 
the  whole  side. 

Prognosis. — The  outlook  in  thoracic  aneurism  is  always  grave.  Life  may 
be  prolonged  for  some  years,  but  the  patients  are  in  constant  jeopardy.  Spon- 
taneous cure  is  not  very  infrequent  in  the  small  sacculated  tumors  of  the 
ascending  and  thoracic  portions.  The  cavity  becomes  filled  with  laminae  of 
firm  fibrin,  which  become  more  and  more  dense  and  hard,  the  sac  shrinks 
considerably,  and  finally  lime  salts  are  deposited  in  the  old  fibrin.  The  laminae 
of  fibrin  may  be  on  a  level  with  the  lumen  of  the  vessel,  causing  complete 
obliteration  of  the  sac.  The  cases  which  rupture  externally,  as  a  rule  run  a 
rapid  course,  although  to  this  there  are  exceptions;  the  sac  may  contract, 
become  firm  and  hard,  and  the  patient  may  live  for  five,  or  even  for  ten  or 
twenty  years.  The  cases  which  have  lasted  longest  in  my  experience  have 
been  those  in  which  a  saccular  aneurism  has  projected  from  the  ascending 
arch.  One  patient  in  Montreal  had  been  known  to  have  aneurism  for  eleven 
years.  The  aneurism  may  be  enormous,  occupying  a  large  area  of  the  chest, 
and  yet  life  be  prolonged  for  many  years,  as  in  the  case  mentioned  as  under 
the  care  of  Skoda  and  Oppolzer.  One  of  the  most  remarkable  instances  is  the 
case  of  dissecting  aneurism  reported  by  Graham.  The  patient  was  invalided 
after  the  Crimean  War  with  aneurism  of  the  aorta,  and  for  years  was  under 
the  observation  of  J,  H.  Eichardson,  of  Toronto,  under  whose  care  he  died  in 
1885.  The  autopsy  showed  a  healed  aneurism  of  the  arch,  with  a  dissecting 
aneurism  extending  the  whole  length  of  the  aorta,  which  formed  a  double  tube. 

Treatment. — In  a  large  proportion  of  the  cases  this  can  only  be  palliative. 
Still  in  every  instance  measures  should  be  taken  which  are  known  to  promote 
clotting  and  consolidation  within  the  sac.  In  any  large  series  of  cured 
aneurisms  a  considerable  majority  of  the  patients  have  not  been  known  to  be 
subjects  of  the  disease,  but  the  obliterated  sac  has  been  found  accidentally  at 
the  post  mortem. 

The  most  satisfactory  plan  in  early  cases,  when  it  can  be  carried  oiit  thor- 
oughly, is  the  modified  Valsalva  method  advised  by  the  late  Mr.  Tufnell,  of 
Dublin,  the  essentials  of  which  are  rest  and  a  restricted  diet.  The  rest 
should,  as  far  as  possible,  be  absolute.  The  reduction  of  the  daily  number  of 
heart-beats,  when  a  patient  is  recumbent  and  without  exertion,  amounts  to 


862  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

many  thousands,  and  is  one  of  the  principal  advantages  of  this  plan.  Mental 
quiet  should  also  be  enjoined.  The  diet  advised  by  Tufnell  is  extremely  rigid 
— for  breakfast,  2  ounces  of  bread  and  butter  and  2  ounces  of  milk  or  tea; 
dinner,  3  ounces  of  mutton  and  3  of  potatoes  or  bread  and  4  ounces  of  claret ; 
supper,  2  ounces  of  bread  and  butter  and  2  ounces  of  tea.  This  low  diet 
diminishes  the  blood-volume  and  is  thought  also  to  render  the  blood  more 
fibrinous.  "  Total  per  diem,  10  ounces  of  solid  food  and  8  ounces  of  fluid, 
and  no  more."  This  treatment  should  be  pursued  for  several  months,  but, 
except  in  persons  of  a  good  deal  of  mental  stamina,  it  is  impossible  to  carry 
it  out  for  more  than  a  few  weeks  at  a  time.  It  is  a  form  of  treatment  adapted 
only  to  the  saccular  form  of  aneurism,  and  in  cases  of  large  sacs  communi- 
cating with  the  aorta  by  a  comparatively  small  orifice  the  chances  of  consoli- 
dation are  fairly  good.  Unquestionably  rest  and  the  restriction  of  the  liquids 
are  the  important  parts  of  the  treatment,  and  a  greater  variety  and  quantity 
of  food  may  be  allowed  with  advantage.  If  this  plan  can  not  be  thoroughly 
carried  out,  the  patient  should  at  any  rate  be  advised  to  live  a  very  quiet  life, 
moving  alwut  with  deliberation  and  avoiding  all  sudden  mental  or  bodily 
excitement.  The  bowels  should  be  kept  regular,  and  constipation  and  strain- 
ing should  be  carefully  avoided.  Of  medicines,  iodide  of  potassium,  as  advised 
by  Balfour,  is  of  great  value.  It  may  be  given  in  doses  of  from  10  to  15  or 
20  grains  three  times  a  da}'.  Larger  doses  are  not  necessary.  The  mode  of 
action  is  not  well  understood.  It  may  act  by  increasing  the  secretions  and  so 
inspissating  the  blood,  by  lowering  the  blood-pressure,  or,  as  Balfour  thinks, 
by  causing  thickening  and  contraction  of  the  sac.  The  most  striking  effect 
of  the  iodide  in  my  experience  has  been  the  relief  of  the  pain.  The  evi- 
dence is  conclusive  that  the  syphilitic  cases  are  more  benefited  by  it  than  the 
non-syphilitic.  All  these  measures  have  little  value  unless  the  sac  is  of  a 
suitable  form  and  size.  The  large  tumors  with  ynde  mouths  communicating 
with  the  ascending  portion  of  the  aorta  may  be  treated  on  the  most  approved 
plans  for  months  without  the  slightest  influence  other  than  reduction  in  the 
intensity  of  the  throbbing.  A  patient  with  a  tumor  projecting  into  the  right 
pleura  remained  on  the  most  rigid  Tufnell  treatment  for  more  than  one  hun- 
dred days,  during  which  time  he  also  took  iodide  of  potassium  faithfully.  The 
pulsations  were  greatly  reduced  and  the  area  of  dulness  diminished,  and  we 
congratulated  ourselves  that  the  sac  was  probably  consolidating.  Sudden 
death  followed  rupture  into  the  pleura,  and  the  sac  contained  only  fluid  blood, 
not  a  shred  of  fibrin.  In  cases  in  which  the  tumor  is  large,  or  in  which  there 
seems  to  be  very  little  prospect  of  consolidation,  it  is  perhaps  better  to  advise 
a  man  to  go  on  quietly  with  his  occupation,  avoiding  excitement  and  worry. 
Our  profession  has  offered  many  examples  of  good  work,  thoroughly  and  con- 
scientiously carried  out,  by  men  with  aneurism  of  the  aorta,  who  wisely,  I 
think,  preferred,  as  did  the  late  Hilton  Fagge,  to  die  in  harness. 

ScEGiCAL  Measures. — In  a  few  cases  consolidation  may  be  promoted  in 
the  sac  by  the  introduction  of  a  foreign  body,  such  as  wire,  horse-hair,  or 
by  the  combination  of  wiring  and  electrolysis.  Moore,  in  1864,  first  wired 
a  sac,  putting  in  78  feet  of  fine  wire.  Death  occurred  on  the  fifth  day. 
Corradi  proposed  the  combined  method  of  wiring  with  electrolysis,  which 
was  first  used  by  Burresi  in  1879.  His  patient  lived  for  three  and  a  half 
months.     Horse-hair,  watch-spring  wire,  catgut,  and  Florence  silk  have  been 


DISEASES  OF  THE  ARTERIES.  863 

used.  Hiinner  reports  the  statistical  results  of  both  methods  up  to  October, 
1900.  With  Moore's  method  (wiring)  14  cases  were  treated,  8  of  thoracic 
aneurism,  all  fatal;  6  aneurisms  of  the  abdominal  aorta,  3  of  which  were 
successful.  Of  23  cases  treated  by  wiring  and  electrolysis  (Moore-Corradi 
method),  17  were  thoracic  and  6  abdominal.  The  thoracic  cases  of  Eosen- 
stirn,  Stewart,  and  Kerr,  and  the  abdominal  cases  of  Noble  and  Finney 
(Case  V),  were  successful.  In  8  of  the  23  cases  there  were  amelioration  of 
sj^mptoms  and  probable  prolongation  of  life.  The  most  favorable  cases  are 
those  in  which  the  aneurism  is  sacculated,  but  this  is  a  point  not  easily  deter- 
mined, and  often  from  a  sac  particularly  favorable  for  wiring  there  may  be 
secondary  projections  of  great  thinness.  The  sudden  filling  by  clot  of  an 
aneurism  of  the  coeliac  axis  or  of  the  superior  mesenteric  artery  may  result 
fatally  from  infarct  of  the  intestine. 

Other  Conditions  requiring  Treatment. — Pressure  on  veins  causing  en- 
gorgement, particularly  of  the  head  and  arms,  is  sometimes  promptly  relieved 
by  free  venesection,  and  at  any  time  during  the  course  of  a  thoracic  aneurism, 
if  attacks  of  dyspnoea  with  lividity  supervene,  bleeding  may  be  resorted  to  with 
great  benefit.  It  has  the  advantage  also  of  promptly  checking  the  pain,  for 
which  symptom,  as  already  mentioned,  the  iodide  of  potassium  often  gives 
relief.  In  the  final  stages  morphia  is,  as  a  rule,  necessary.  Dyspnoea,  if 
associated  with  cyanosis,  is  best  relieved  by  bleeding.  Chloroform  inhalations 
may  be  necessary.  The  question  sometimes  comes  up  with  reference  to  trache- 
otomy in  these  cases  of  urgent  dyspnoea.  If  it  can  be  shown  by  laryngoscopic 
examination  that  it  is  due  to  bilateral  abductor  paralysis  the  trachea  may 
be  opened,  but  this  is  extremely  rare,  and  in  nearly  every  instance  the  urgent 
dyspnoea  is  caused  by  pressure  about  the  bifurcation.  When  the  sac  appears 
externally  and  grows  large,  an  ice-cap  may  be  applied  upon  it,  or  a  bella- 
donna plaster  to  allay  the  pain.  In  some  instances  an  elastic  support  may  be 
used  with  advantage,  and  I  saw  a  physician  with  an  enormous  external  aneu- 
rism in  the  right  mammary  region  who  for  many  months  had  obtained  great 
relief  by  the  elastic  support,  passing  over  the  shoulder  and  under  the  arm  of 
the  opposite  side. 

Digitalis,  ergot,  aconite,  and  veratrum  viride  are  rarely,  if  ever,  of  service 
in  thoracic  aneurism. 

Aneurism  of  the  Abdominal  Aorta. 

The  sac  is  most  common  just  below  the  diaphragm  in  the  neighborhood 
of  the  coeliac  axis.  This  variety  is  rare  in  comparison  with  thoracic  aneurism. 
Of  the  468  cases  of  aortic  aneurism  at  St.  Bartholomew's  Hospital,  23  involved 
the  abdominal  aorta.  Seventeen  cases  occurred  in  my  wards  in  the  Johns 
Hopkins  Hospital  in  sixteen  years.  The  tumor  may  be  fusiform  or  sacculated, 
and  it  is  sometimes  multiple.  Projecting  backward,  it  erodes  the  vertebrae 
and  may  cause  numbness  and  tingling  in  the  legs  and  finally  paraplegia,  or 
it  may  pass  into  the  thorax  and  burst  into  the  pleura.  More  commonly  the 
sac  is  on  the  anterior  wall  and  projects  forward  as  a  definite  tumor,  which 
may  be  either  in  the  middle  line  or  a  little  to  the  left.  The  tumor  may  project 
in  the  epigastric  region  (which  is  most  common),  in  the  left  hypochondrium, 
in  the  left  flank,  or  in  the  lumbar  region.  When  high  up  beneath  the  pillar 
of  the  diaphragm  it  may  attain  considerable  size  without  being  very  apparent 


864  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

on  palpation.  Wlien  it  ruptures  into  the  retro-peritoneal  tissues  tliere  may 
be  formed  gradually  a  tumor  in  the  flank,  which  enlarges  with  very  little 
pulsation.  It  may  be  mistaken  for  a  rapidly  growing  sarcoma  or  for  appendi- 
citis, and  an  operation  may  be  performed. 

The  symptoms  are  chiefly  pain,  very  often  of  a  neuralgic  nature,  passing 
round  to  the  sides  or  localized  in  the  back,  and  more  persistent  and  intense 
than  in  any  other  variety  of  aneurism.  Gastric  symptoms,  particularly  vomit- 
ing, may  be  early  and  deceptive  features.  Eetardation  of  the  pulse  in  the 
femoral  is  a  very  common  symptom. 

Diagnosis  and  Physical  Signs. — Inspection  may  show  marked  pulsation  in 
the  epigastric  region,  sometimes  a  definite  tumor.  A  thrill  is  not  uncommon. 
The  pulsation  is  forcible,  expansile,  and  sometimes  double  when  the  sac  is 
large  and  in  contact  with  the  pericardium.  On  palpation  a  definite  tumor 
can  he  felt.  If  large,  there  is  some  degree  of  dulness  on  percussion  which 
usually  merges  with  that  of  the  left  lobe  of  the  liver.  On  auscultation,  a 
systolic  murmur  is,  as  a  rule,  audible,  and  is  sometimes  best  heard  at  the 
back.  A  diastolic  murmur  is  occasionally  present,  usually  very  soft  in  quality. 
One  of  the  commonest  of  clinical  errors  is  to  mistake  a  throbbing  aorta  for 
an  aneurism.  It  is  to  be  remembered  that  no  pulsation,  however  forcible,  or 
the  presence  of  a  thrill  or  a  systolic  murmur  justifies  the  diagnosis  of  abdomi- 
nal aneurism  unless  there  is  a  definite  tumor  which  can  he  grasped  and  which 
has  an  expansile  pulsation.  Attention  to  this  rule  will  save  many  errors.  The 
throbbing  aorta — the  "  preternatural  pulsation  in  the  epigastrium,"  as  Allan 
Burns  calls  it — is  met  with  in  all  neurasthenic  conditions,  particularly  in 
women.  In  anaemia,  particularly  in  some  instances  of  traumatic  angemia, 
the  throbbing  may  be  very  great.  In  the  case  of  a  large,  stout  man  with  severe 
hsemorrhages  from  a  duodenal  ulcer  the  throbbing  of  the  abdominal  aorta  not 
only  shook  violently  the  whole  abdomen,  but  communicated  a  pulsation  to 
the  bed,  the  shock  of  which  was  distinctly  perceptible  to  any  one  sitting  upon 
it.  Very  frequently  a  tumor  of  the  pylorus,  of  the  pancreas,  or  of  the' left 
lobe  of  the  liver  is  lifted  with  each  impulse  of  the  aorta  and  may  be  con- 
founded with  aneurism.  .The  absence  of  the  forcible  expansile  impulse  and 
the  examination  in  the  knee-elbow  position,  in  which  the  tumor,  as  a  rule, 
.falls  forward,  and  the  pulsation  is  not  then  communicated,  suffice  for  differ- 
entiation. The  tumor  of  abdominal  aneurism,  though  usually  fixed,  may  be 
very  freely  movable. 

The  outlook  in  abdominal  aneurism  is  bad.  A  few  cases  heal  spontane- 
ously. Death  may  result  from  (a)  complete  obliteration  of  the  lumen  by 
clots;  (&)  compression  paraplegia;  (c)  rupture  (which  is  almost  the  rule) 
either  into  the  pleura,  retroperitoneal  tissues,  peritonaeum,  or  the  intestines, 
very  commonly  the  duodenum;  (d)  embolism  of  the  superior  mesenteric 
artery,  producing  infarction  of  the  intestines. 

The  treatment  is  such  as  already  advised  in  thoracic  aneurism.  When  the 
aneurism  is  low  down  pressure  has  been  successfully  applied  in  a  case  by  Mur- 
ray, of  Newcastle.  It  must  be  kept  up  for  many  hours  under  chloroform. 
The  plan  is  not  without  risk,  as  patients  have  died  from  bruising  and  injury 
of  the  sac.  Nine  cases  in  my  series  were  treated  surgically.  In  two  the 
wiring  and  electrolysis  were  followed  by  great  improvement;  one  man  lived 
for  three  years. 


DISEASES  OF  THE  ARTERIES,  865 


Aneurism  of  the  Bkanches  of  the  Abdominal  Aorta. 

The  cwliac  axis  is  itself  not  infrequently  involved  in  aneurism  of  the 
first  portion  of  the  abdominal  aorta.  Of  its  branches,  the  splenic  artery  is 
occasionally  the  seat  of  aneurism.  This  rarely  causes  a  tumor  large  enough 
to  be  felt;  sometimes,  however,  the  tumor  is  of  large  size.  I  have  reported 
a  case  in  a  man,  aged  thirty,  who  had  an  illness  of  several  months'  dura- 
tion, severe  epigastric  pain  and  vomiting,  which  led  his  physicians  in  New 
York  to  diagnose  gastric  ulcer.  There  was  a  deep-seated  tumor  in  the  left 
hypochondriac  region,  the  dulness  of  which  merged  with  that  of  the  spleen. 
There  was  no  pulsation,  but  it  was  thought  on  one  occasion  that  a  bruit  was 
heard.  The  chief  symptoms  while  under  observation  were  vomiting,  severe 
epigastric  pain,  occasional  haematemesis,  and  finally  severe  haemorrhage  from 
the  bowels.  An  aneurism  of  the  splenic  artery  the  size  of  a  cocoa-nut  was 
situated  between  the  stomach  above  and  the  transverse  colon  below,  and 
extended  to  the  right  as  far  as  the  level  of  the  navel.  The  sac  contained 
densely  laminated  fibrin.  It  had  perforated  the  colon.  I  have  twice  seen 
small  aneurisms  on  the  splenic  artery.  Of  39  instances  of  aneurism  on  the 
branches  of  the  abdominal  aorta  collected  by  Lebert,  10  were  of  the  splenic 
artery. 

Of  aneurism  of  the  hepatic  artery  Rolland  has  collected  40  cases  (1908), 
of  which  24  were  extra-hepatic.  In  Eolland's  case  there  were  three  sacs — all 
intra-hepatic.  Eupture  took  place  in  32  cases — in  16  into  the  peritoneal  cav- 
ity, in  13  into  the  bile  passages.  The  sac  is  rarely  large,  but  in  the  case  of 
Wollmann's  it  was  as  large  as  a  child's  liead.  .  No  case  has  been  diagnosed. 
Cholelithiasis  and  duodenal  ulcer  are  the  conditions  for  which  it  is  most  likely 
to  be  mistaken.  In  Eoss  and  Osier's  case  the  liver  was  enlarged,  with  symp- 
toms of  pyaemia. 

Aneurism  of  the  superior  mesenteric  artery  is  not  very  uncommon.  The 
diagnosis  is  scarcely  possible  from  aneurism  of  the  arch.  Plugging  of  the 
branches  or  of  the  main  stem  may  cause  the  symptoms  of  infarction  of  the 
bowels  which  have  already  been  considered. 

Renal  Artery. — Henry  Morris  has  collected  21  instances  of  aneurism,  12 
of  which  arose  from  injury.  Many  of  them  were  false.  Pulsation  and  a  bruit 
are  not  always  present.  Four  cases  were  operated  upon;  three  recovered.  In 
a  case  of  Keen's  the  tumor  and  the  kidney  were  removed  together, 

Arterio-venous  Aneurism. 

In  this  form,  known  to  Galen,  but  first  accurately  described  by  the  great 
William  Hunter,  there  is  abnormal  communication  between  an  artery  and  a 
vein.  When  a  tumor  lies  between  the  two  it  is  known  as  varicose  aneurism; 
when  there  is  a  direct  communication  without  tumor  the  vein  is  chiefly  dis- 
tended and  the  condition  is  known  as  aneurismal  varix. 

While  it  may  occur  in  the  aorta,  it  is  much  more  common  in  the  peripheral 
arteries  as  a  result  of  stab  or  gunshot  wounds. 

An  aneurism  of  the  ascending  portion  of  the  arch  may  open  directly  into 
the  vena  cava.  Twenty-nine  cases  of  this  lesion  have  been  analyzed  by  Pepper 
and  Griffith.  Cyanosis,  oedema,  and  great  distention  of  the  veins  of  the  upper 
56 


866  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

part  of  the  body  are  the  most  frequent  symptoms,  and  develop,  as  a  rule, 
with  suddenness.  Of  the  physical  signs  a  thrill  is  present  in  some  cases.  A 
continuous  murmur  with  systolic  intensification  is  of  great  diagnostic  value. 
Thurnam  (Medico-Chirurgical  Transactions,  1840)  gave  the  first  accurate 
account  of  this  murmur  and  of  this  characteristic  type  of  cyanosis.  There  is 
only  one  condition  with  which  it  could  be  confounded,  viz.,  the  remarkable 
cyanosis  of  the  upper  part  of  the  body  which  follows  crushing  accidents  to 
the  thorax.  Perforation  between  the  aorta  and  pulmonary  artery  causes  very 
much  the  same  symptoms.  In  a  few  cases  an  aneurism  of  the  abdominal  aorta 
perforates  the  inferior  vena  cava — oedema  and  cyanosis  of  the  legs  and  lower 
half  of  the  body,  and  the  distinctive  thrill  and  murmur  are  present. 

In  the  arterio-venous  aneurisms  which  follow  stab  and  bullet  wounds  of 
the  subclavian,  axillary,  carotid,  femoral  and  popliteal  arteries,  the  clinical 
features  are  most  characteristic.  First,  the  veins  enlarge  as  the  arterial  blood 
flows  under  higher  pressure  into  them.  The  affected  limb  may  be  greatly 
swollen  and  in  a  young  person  may  lengthen,  and  the  growth  of  hair  is  in- 
creased. Secondly,  a  strong  thrill  is  felt,  of  maximum  intensity  at  the  site  of 
the  aneurism,  but  sometimes  to  be  felt  at  the  most  distant  parts  of  a  limb. 
Thirdly,  the  characteristic  continuous  murmur  with  systolic  intensification  is 
heard.  In  the  external  arteries  the  condition  may  persist  for  years  before  dis- 
ability is  caused  by  enlargement  of  the  veins  and  swelling  of  the  limb. 

PoLTAETEEiTis  AcuTA  jSToDOSA  {Periarteritis  Nodosa). 

A  series  of  cases  has  been  described  in  which  small  aneurisms  occur  on 
the  arteries  of  the  muscles  and  viscera.  The  first  case  was  reported  by  Kuss- 
maul  and  Maier,  and  about  19  cases  in  all  have  been  described  (Dickson). 
A  case,  agreeing  clinically  with  the  others,  has  occurred  in  my  wards.  No 
autopsy  was  permitted,  but  the  nodules  were  felt  in  the  abdominal  wall  before 
death.  ,The  case  is  reported  by  Sabin  (J.  H.  H.  Bulletin,  1901).  There  are 
marked  thickening  of  the  intima  and  infiltration  of  the  other  coats,  with  a 
nuclear  growth  almost  sarcomatous.  There  are  two  theories:  one  that  the 
nodules  are  aneurisms  due  to  syphilis  or  to  congenital  weakening  of  the 
arteries;  the  other  that  they  are  aneurisms  secondary  to  an  infiammatory 
process  like  the  infectious  granulomata. 

The  cases  have  occurred  chiefly  in  men  between  the  ages  of  twenty-seven 
and  fifty-two;  the  course  is  from  eight  to  twelve  weeks.  The  patients  com- 
plain of  weakness.  The  symptoms  correspond  with  the  situation  of  the  lesions ; 
thus,  their  presence  in  the  muscles  is  associated  with  pain,  weakness,  and 
sometimes  paralysis  and  atrophy.  The  nodules  are  abundant  in  the  alimentary 
tract.  The  severest  symptom  is  epigastric  pain;  there  is  loss  of  appetite, 
thirst,  vomiting,  constipation,  or  diarrhoea.  The  disease  is  febrile  at  first,  but 
the  temperature  sinks  to  subnormal,  while  the  pulse  remains  rapid.  "Wlien 
the  cerebral  vessels  are  involved  there  are  headache,  excitement,  convulsions, 
and  optic  neuritis,  and  the  diagnosis  of  meningitis  is  made.  The  ansemia 
is  extreme.  In  our  case  the  haemoglobin  was  21  per  cent,  the  red  blood-cells 
1,704,000.  The  leucocytes  reached  116,000,  of  which  91  per  cent  were  poly- 
morphonuclear forms.  The  urine  is  scanty,  of  low  specific  gravity,  with  albu- 
min and  casts.    Urea  is  excreted  in  small  quantities,  but  the  mind  is  clear. 


SECTION    X. 
DISEASES   OF   THE   JSTEEYOUS   SYSTEM. 


A.    GENERAL  INTRODTJCTIOK 

In"  diseases  of  the  nervous  system  it  is  of  the  greatest  importance  to  know 
accurately  the  position  of  the  morbid  process,  and  here,  even  more  than  in  the 
other  departments  of  medicine,  a  thorough  knowledge  of  anatomy  and  physi- 
ology is  essential.  As  it  is  not  possible  to  do  more  than  touch  on  the  subject 
in  this  place,  for  further  details  the  student  is  referred  to  the  text-books  of 
anatomy,  physiology,  and  neurology. 

The  nervous  system  arises  from  two  kinds  of  embryonic  cells:  one  forms 
the  supporting  elements  or  neuroglia,  and  the  other  the  nerve  cells  proper 
or  neurones.  The  latter  represent  the  cell  units  of  the  nervous  system,  and 
are  the  only  elements  that  discharge  or  carry  impulses. 

The  Neurone. — Its  Structure. — We  think  of  the  nervous  system  as  a 
combination  of  an  immense  number  of  these  units,  all  having  an  essentially 
similar  structure.  Each  neurone  is  composed  of  a  receptive  cell  body  and  of 
conducting  elements — namely,  the  protoplasmic  processes  or  dendrites,  and 
the  axis-cylinder  process  or  axone.  In  general,  it  may  be  stated  that  the 
dendrites  conduct  impulses  toward  the  cell  body  (cellulipetal  conduction)  and 
the  axones  conduct  them  away  from  the  cell  (cellulifugal  conduction).  De- 
pending upon  whether  the  axones  conduct  impulses  in  a  direction  away  from 
or  toward  the  cerebrum  they  are  called  efferent  or  afferent.  The  axis-cylinder 
process,  after  leaving  the  cell,  gives  off  at  varying  intervals  lateral  branches 
called  collaterals,  which  run  at  right  angles  to  the  process.  These  collaterals, 
and  finally  the  axis-cylinder  process  itself,  split  up  at  their  terminations  into 
many  fine  fibres,  forming  the  end  brushes.  These,  known  as  arborizations, 
surround  the  body  of  one  or  more  of  the  many  other  cells,  or  interlace  with 
their  protoplasmic  processes.  Thus  the  terminals  of  the  axone  of  one  neu- 
rone are  related  to  the  dendrites  and  cell  bodies  of  other  neurones  by  contact 
(Eamon  y  Cajal)  or  by  concrescence  (Held).  Whether  or  not  the  neurones 
are  organically  connected  with  one  another  is  still  in  dispute.  The  weight 
of  evidence  is  in  favor  of  complete  anatomical  and  relative  physiological  inde- 
pendence. The  studies  of  Apathy,  Bethe,  and  others  speak  in  favor  of  a  gen- 
eral interconnection  by  means  of  neurofibrils  and  protoplasmic  bridges.  These 
neurofibrils  traverse  the  dendrites  and  the  cell  body  in  bundles  of  fine  fibres, 
the  majority  of  which  do  not  anastomose,  but  pass  through  the  cell  body  from 
dendrite  to  dendrite  or  to  axone,  in  which  process  they  reach  their  clearest 

867 


868  DISEASES  OF  THE  NERVOUS  SYSTEM. 

expression,  for  it  consists  of  a  bundle  of  closely  packed  fibrillsB.  In  the  inter- 
stices of  the  mesh  of  neurofibrils  in  the  cell  body  proper  there  exist  under 
normal  conditions  islands  of  granular  protoplasm  possessing  a  staining  reac- 
tion that  differs  from  that  of  the  fibres  themselves — the  so-called  "tigroid" 
or  Nissl  bodies.  The  disposition  of  these  bodies,  as  brought  out  by  the  methy- 
lene-blue  reaction,  is  largely  useful  as  an  index  of  the  effect  of  morbid  condi- 
tions upon  the  nerve  cell. 

Function  of  the  Neurone'. — As  already  stated,  the  function  of  the  neu- 
rone is  to  conduct  nervous  impulses.  Their  mode  of  action,  reduced  to  its 
simplest  form,  may  be  represented  by  two  cells,  one  of  which,  reacting  to  the 
environment,  conducts  impulses  inward,  whereas  the  other,  awakened  by  this 
afferent  impulse,  conducts  an  impulse  outward.  This  reflex  response  Marshall 
Hall  showed  to  be  the  fundamental  principle  of  action  of  the  nervous  system. 
The  environment  acts  on  the  afferent  neurones  through  special  sense  organs, 
so  that  a  variety  of  afferent  impulses,  olfactory,  visual,  auditory,  gustatory, 
tactile,  painful,  thermic,  muscular,  visceral,  and  vascular,  may  be  origi- 
nated. The  efferent  neurones  convey  impulses  outward  to  non-nervous  tis- 
sues, to  the  skeletal,  visceral,  and  vascular  muscles  and  to  the  secretory  glands, 
whose  activities  may  thus  be  augmented  or  inhibited.  The  more  important 
reflex  centres  lie  in  the  bulbo-spinal  axis.  The  situation  of  the  vascular  and 
respiratory  centres  in  the  bulb  make  it  the  vital  centre  of  the  body.  In  the 
spinal  cord  the  location  of  many  reflex  centres,  particularly  those  for  the  mus- 
cle tendons  and  for  some  of  the  viscera,  is  represented  in  the  table  on  page 
871.  The  visceral  mechanism  is  almost  wholly  regulated  by  the  bulbo- 
spinal axis,  and  its  reactions  are  usually  unpereeived.  Only  in  conditions  of 
disease  do  the  visceral  reflexes  "  rise  into  consciousness,''  and  it  is  at  such 
times  that  the  referred  pains  and  areas  of  tenderness  (Henry  Head)  are  pro- 
duced in  the  skin-fields  of  the  spinal  segments  corresponding  to  the  centre 
for  registration  of  the  visceral  reflex. 

Degeneration  and  Eegeneration  oe  the  Neurone. — The  nutrition  of 
the  neurone  depends  in  large  part  upon  the  condition  of  the  cell  body,  and 
this  in  turn  in  all  probability  upon  the  activity  of  the  nucleus.  If  the  cell  is 
injured  in  any  manner  the  processes  degenerate,  or  if  the  processes  are  sepa- 
rated from  the  cell  they  degenerate.  Though  the  nerve  cells  cease  to  multiply 
soon  after  birth,  they  nevertheless  retain  remarkable  powers  of  growth  and 
repair.  Injury  to  the  cell  body  may  not  be  recovered  from,  but  if  the  axone 
be  severed  and  degeneration  take  place  in  consequence,  it  may  under  favorable 
circumstances  be  replaced  by  sprouts  from  the  central  stump,  and  its  function 
be  regained.  Bethe  and  others  believe  that  the  peripheral  section,  independ- 
ently of  the  cell  body,  has  the  power  of  regeneration.  It  is  probable,  however, 
that  both  factors  play  a  part  in  the  regeneration — ^namely,  the  down  growth 
of  the  axone  from  the  central  end  of  the  divided  nerve  as  well  as  the  changes 
in  the  periphery,  which  are  most  marked  in  the  cells  of  the  sheath  of  Schwann. 

Cell  Systems. — The  cell  bodies  of  the  neurones  are  collected  more  or  less 
closely  together  in  the  gray  matter  of  the  brain  and  spinal  cord  and  in  the 
ganglia  of  the  peripheral  nerves.  Their  processes,  especially  the  axis-cylinder 
processes,  run  for  the  most  part  in  the  white  tracts  of  the  brain  and  spinal 
cord  and  in  the  peripheral  nerves.  In  this  way  the  different  parts  of  the 
central  nervous  system  are  brought  into  relation  with  each  other  and  with  the 


GENERAL  INTRODUCTION. 


869 


rest  of  the  body.     Furthermore,  the  axis-cylinder  processes  arising  from  cells 
subserving  similar  functions  are  apt  to  be  collected  together  into  bundles  or 


\>E  G 


Fig, 


1. — Diagram  of  motor  path  from  left  brain.  The  upper  segment  is  black,  the  lower  red. 
The  nuclei  of  the  motor  cerebral  nerves  are  shown  in  red  on  the  right  side  ;  on  the  left 
side  the  cerebral  nerves  of  that  side  are  indicated.  A  lesion  at  1  would  cause  upper  seg- 
ment paralysis  in  the  arm  of  the  opposite  side — cerebral  monoplegia ;  at  3,  upper  segment 
paralysis  of  the  whole  opposite  side  of  the  body — hemiplegia ;  at  3,  upper  segment  paral- 
ysis of  the  opposite  face,  arm,  and  leg,  and  lower  segment  paralysis  of  the  eye  muscles 
on  the  same  side — crossed  paralysis ;  at  4,  upper  segment  paralysis  of  opposite  arm  and 
leg,  and  lower  segment  paralysis  of  the  face  and  the  external  rectus  on  the  same  side — 
crossed  paralysis ;  at  5,  upper  segment  paralysis  of  all  muscles  below  lesion,  and  lower 
segment  paralysis  of  muscles  represented  at  level  of  lesion — spinal  paraplegia ;  at  6,  lower 
segment  paralysis  of  muscles  localized  at  seat  of  lesion — anterior  poliomyelitis.  (Van 
Gehuchten,  modified.) 


870 


DISEASES  OF   THE  NERVOUS  SYSTEM. 


tracts,  and  though  in  many  cases  the  course  of  these  tracts  and  the  functions 
which  they  possess  are  extremely  complicated  and  as  yet  have  not  been  com- 
pletely unravelled,  nevertheless  some  of  them  are  simple  and  fairly  well  under- 
stood. Particularly  by  the  study  of  the  degenerations,  that  may  have  resulted 
from  injury  or  from  the  toxins  of  certain  diseases  which  possess  an  aflfinity 
for  one  or  another  of  these  individual  tracts  or  systems,  has  it  been  possible 
to  trace  the  course  of  certain  of  them  through  the  nervous  system.  Fortu- 
nately for  the  clinician  the  best  understood  and  the  simplest  system  in  its 
arrangement  is  that  which  conveys  motor  impulses  from  the  cortex  to  the  per- 
iphery— the  so-called  pyramidal  tract. 

The  Motor  System. — Motor  impulses  starting  in  the  left  side  of  the  brain 
cause  contractions  of  muscles  on  the  right  side  of  the  bod}',  and  those  from 

the  right  side  of  the  brain  in  muscles  of  the 
left  side  of  the  body.  Leaving  out  of  consid- 
eration some  few  exceptions,  it  may  be  stated 
as  a  general  rule  that  the  motor  path  is  crossed, 
and  that  the  crossing  takes  place  in  the  upper 
segment  (Figs.  1  and  2).  Every  muscular 
movement,  even  the  simplest,  requires  the  ac- 
tivity of  many  neurones.  In  the  production 
of  each  movement  special  neurones  are  brought 
into  play  in  a  definite  combination,  and  when- 
ever these  neurones  act  in  this  combination 
that  specific  movement  is  the  result.  In  other 
words,  all  the  movements  of  the  body  are  rep- 
resented in  the  central  nervous  system  by  com- 
binations of  neurones — ^that  is,  they  are  local- 
ized. Muscular  movements  are  localized  in 
every  part  of  the  motor  path,  so  that  in  cases 
of  disease  of  the  nervous  system  a  study  of  the 
motor  defect  often  enables  one  to  fix  upon  the 
site  of  the  process,  and  it  would  be  hard  to 
over-estimate  the  importance  of  a  thorough 
knowledge  of  such  localization.  A  voluntary 
motor  impulse  starting  from  the  brain  cortex 
must  pass  through  at  least  two  neurones  be- 
fore it  can  reach  the  muscles,  and  we  there- 
fore speak  of  the  motor  tract  as  being  com- 
posed of  two  segments  —  an  upper  and  a 
lower. 

The  Lower  Motor  Segment. — The  neurones  of  the  lower  segment  have 
the  cell  bodies  and  their  protoplasmic  processes  in  the  different  levels  of  the 
ventral  horns  of  the  spinal  cord  and  in  the  motor  nuclei  of  the  cerebral  nerves. 
The  axis-cylinder  processes  of  the  lower  motor  neurones  leave  the  spinal  cord 
in  the  ventral  roots  and  run  in  the  peripheral  nerves,  to  be  distributed  to  all 
the  muscles  of  the  body,  where  they  end  in  arborizations  in  the  motor  end 
plates.  These  neurones  are  direct — that  is,  their  cell  bodies,  their  processes, 
and  the  muscles  in  which  they  end  are  all  on  the  same  side  of  the  body. 

The  ventral  roots  of  the  spinal  cord  are  collected,  from  above  down,  into 


Fig.  2. — Diagram  of  motor  path 
from  each  hemisphere,  show- 
ing the  crossing  of  the 
path,  which  takes  place  in 
the  upper  segment  both  for 
the  cranial  and  spinal  nerves. 
(Van  Grehuchten,  colored.) 


GENERAL  INTRODUCTION. 


871 


small  groups,  which,  after  joining  with  the  dorsal  roots  of  the  same  level 
of  the  cord,  leave  the  spinal  canal  between  the  vertebrae  as  the  spinal 
nerves.  That  part  of  the  cord  from  which  the  roots  forming  a  single 
spinal  nerve  arise  is  called  a  segment,  and  corresponds  to  the  nerve  which 
arises  from  it  and  not  to  the  vertebra  to  which  it  may  be  opposite.  With 
the  exception  of  the  cervical  region,  in  which  all  the  nerve  roots  but  the 
eighth  emerge  from  above  the  vertebrae,  the  roots  of  each  segment  for  the 
remainder  of  the  cord  leave  the  spinal  canal  below  the  vertebra  of  corre- 
sponding number,  and  consequently,  owing  to  the  fact  that  during  growth 
the  bony  canal  lengthens  much  more  than  the  cord  itself,  the  more  tailwards 
one  goes  the  greater  is  the  discrepancy  in  position  between  each  spinal  segment 
and  its  particular  vertebra.  This  must  be  borne  in  mind  when  determining 
upon  the  site  of  a  lesion  known  to  occupy  a  given  segment,  for  it  may  lie 
far  above  the  vertebra  of  like  number  and  name.  A  chart  has  been  prepared 
from  numerous  measurements  by  Eeid  showing  the  level  of  the  various  seg- 
ments of  the  cord  in  relation  to  the  spines  of  the  vertebrae.  The  axis-cylinder 
processes  which  go  to  make  up  any  one  peripheral  nerve  do  not  necessarily 
arise  from  the  same  segment  of  the  spinal  cord ;  in  fact,  most  peripheral 
nerves  contain  processes  from  several  often  quite  widely  separated  segments. 
Most  of  the  long  striped  muscles,  furthermore,  having  originated  in  the 
embryo  from  more  than  one  myatome,  are  innervated  from  more  than  one 
,  segment. 

Our  knowledge  of  the  localization  of  the  muscular  movements  in  the  gray 
matter  of  the  lower  motor  segment  is  far  from  complete,  but  enough  is  known 
to  aid  materially  in  determining  the  site  of  a  spinal  lesion.  A  number  of 
tables  have  been  prepared  by  different  observers  to  represent  our  present  knowl- 
edge of  this  subject.  They  differ  from  each  other  in  minor  details,  but  agree 
in  the  main.  The  following  table,  in  which  is  included  for  each  of  the  spinal 
segments  the  centres  of  representation  for  the  more  important  skeletal  muscles, 
the  main  reflex  centres,  and  the  main  location  of  the  segmental  skin-field,  has 
been  prepared  from  the  studies  of  Starr,  Edinger,  Wichmann,  Sherrington, 
Bolk,  and  others : 


LOCALIZATION  OF  THE  FUNCTIONS  IN  THE  SEGMENTS  OF  THE 

SPINAL  CORD. 


Segment. 

Striped  Muscles. 

Reflex. 

Skin-Fields  (cp.  Figs. 

7, AND  8). 

I.  II  and 
IIIC. 

Splenius  capitis. 

Hyoid  muscles. 

Sterno-mastoid. 

Trapezius. 

Diaphragm  (C  III-V)  . 

Levator  scapulae  (C  III-V). 

Hypoehondrium  ("?). 

Sudden   inspiration  pro- 
duced by  sudden  press- 
ure beneath  the  lower 
border    of    ribs    (dia- 
phragmatic). 

Back  of  head  to  ver- 
tex. 
Neck  (upper  part). 

JVC. 

Trapezius. 
Diaphragm. 
Levatot  scapulae. 
Scaleni  (C  IV-T  I). 
Teres  minor. 
Supraspinatus. 
Rhomboid. 

Dilatation  of  the  pupil 
produced  by  irritation 
of  neck.     Reflex 
through  the  sympathe- 
tic (C  IV-T  I). 

Neck  (lower  part  to 

second  rib). 
Upper  shoulder. 

872 


DISEASES  OF   THE  NERVOUS  SYSTEM. 


LOCALIZATION  OF  THE  FUNCTIONS  IN  THE   SEGMENTS  OP  THE 
SPINAL   CORD  {Continued). 


Segment. 

Striped  Muscles. 

Reflex. 

Skin-Fields  (cf.  Figs. 

7   AND   8). 

V  c. 

Diaphragm 

Scapular  (C  V-T  I). 

Outer  side  of  shoul- 

Teres minor. 

Irritation  of  skin  over  the 

der  and  upper  arm 

Supra    and   infra    spinatus    (C 

scapula  produces  con- 

over    deltoid     re- 

V-VI). 

traction  of  the  scapular 

gion. 

Rhomboid. 

muscles. 

Subscapularis. 

Supinator    longus    and 

Deltoid. 

biceps. 

Biceps. 

Tapping    their     tendons 

Brachialis  anticus. 

produces   flexion    of 

Supinator  longus  (C  V-VII). 

forearm. 

Supinator  brevis  (C  V-VII). 

Pectoralis  (clavicular  part). 

Serratus  magnus. 

VI  c. 

Teres  minor  and  major. 

Triceps.     Tapping  elbow 

Outer   side   of   fore- 

Infraspinatus. 

tendon  produces  exten- 

arm,    front      and 

Deltoid. 

sion  of  forearm. 

back. 

Biceps. 

Posterior     wrist.       Tap- 

Outer half  of  hand  (?). 

Brachialis  anticus. 

ping  tendons  causes  ex- 

Supinator longus. 

tension  of  hand  (C  VI- 

Supinator  brevis. 

VII). 

Pectoralis  (clavicular  part). 

Serratus  magnus  (C  V-VIII). 

Coraco-brachialis. 

Pronator  teres. 

Triceps  (outer  and  long  heads). 

Extensors  of  wrist  (C  VI- VIII). 

.vn  c. 

Teres  major. 

Scapulo-humeral.      Tap- 

Inner side  and  back 

Subscapularis. 

ping  the   inner   lower 

of   arm   and  fore- 

Deltoid (posterior  part). 

edge  of  scapula  causes 

arm. 

Pectoralis  major  (costal  part). 

adduction  of  the  arm. 

Radial  half    of    the 

Pectoralis  minor. 

Anterior     wrist.       Tap- 

hand. 

Serratus  magnus. 

ping   anterior  tendons 

Pronators  of  wrist. 

causes  flexion  of  wrist 

Triceps. 

(C  VII-VIII). 

Extensors  of  wrist  and  fingers. 

Flexors  of  wrist. 

Latissimus  dorsi  (C  VI-VIII). 

VIII  c. 

Pectoralis  major  (costal  part). 

Palmar.     Stroking  palm 

Forearm   and   hand. 

Pronator  quadratus. 

causes  closure   of  fin- 

inner half. 

Flexors  of  wrist  and  fingers. 

gers. 

Latissimus. 

Radial  lumbricales  and    inter- 
ossei. 

I  T. 

Lumbricales  and  interossei. 

Upper    arm,    inner 

Thenar    and    hvpothenar    emi- 

half. 

nences  (C  VII-T  I). 

II  to 

Muscles  of  back  and  abdomen. 

Epigastric.     Tickling 

Skin    of    chest    and 

XII  T. 

Ereetores  spmae  (T  I-LV)'. 

ma  mmary  region 

abdomen     in    ob- 

Intercostals (T  I-T  XII). 

causes     retraction     of 

lique  dorso-ventral 

Rectus  abdominis  (T  V-T  XII). 

epigastrium     (T     IV- 

zones.    The  nipple 

External  oblique  (T  V-XII). 

VII). 

lies    between    the 

Internal  oblique  (T  VII-L  I). 

Abdominal.     Stroking 

zone  of  T  IV  and 

Transversalis  (T  VII-L  I). 

side  of  abdomen  causes 

T  V.     The  umbil- 

retraction  of    belly   (T 

licus    lies    in    the 

IX-XII). 

field  of  T  X. 

GENERAL  INTRODUCTION. 


873 


LOCALIZATION   OF  THE   FUNCTIONS  IN  THE  SEGMENTS  OP  THE 
SPINAL   CORD  (Continued). 


Segment. 

Striped  Muscles. 

Reflex. 

Skin-Fields  (cf.  Figs. 

7  AND   8). 

XL. 

Lower  part  of  external  and  in- 
ternal oblique  and   transver- 
salis. 

Quadratus  lumborum  (L  I-II). 

Creinaster. 

Psoas  major  and  minor  (1). 

Cremasteric.        Stroking 
inner  thigh  causes  re- 
traction    of     scrotum 
(L  I-II). 

Skin  over  lowest  ab- 
dominal zone  and 
groin. 

II  L. 

Psoas  major  and  minor. 

Iliacus. 

Pectinens. 

Sartorius  (lower  part). 

Flexors  of  knee  (Kemak). 

Adductor  longus  and  brevis. 

Front  of  thigh. 

Ill  L. 

Sartorius  (lower  part). 
Adductors  of  thigh. 
Quadriceps  femoris  (L  II-L  IV). 
Inner  rotators  of  thigh. 
Abductors  of  thigh. 

Patellar    tendon.      Tap- 
ping tendon  causes  ex- 
tension of  leg.  "  Knee- 
jerk." 

Front  and  inner  side 
of  thigh. 

IV  L. 

Plexors  of  knee  (Perrier). 
Quadriceps  femoris. 
Adductors  of  thigh. 
Abductors  of  thigh. 
Extensors  of  ankle  (tibialis  anti- 

cus). 
Glutei  (medius  and  minor). 

Gluteal.      Stroking  but- 
tock causes    dimpling 
in     fold     of     buttock 
(L  IV-V). 

Mainly  inner  side  of 
thigh   and   leg    to 
ankle. 

V  L. 

Flexors    of     knee     (ham-string 

muscles)  (L  IV-S  II). 
Outward  rotators  of  thigh. 
Glutei. 
Plexors  of  ankle  (gastrocnemius 

and  soleus)  (L  IV-S  II). 
Extensors  of  toes  (L  IV-S  I). 
Peronsei. 

Back  of  leg,  and  part 
of  foot. 

I  to 

II  S. 

Flexors  of  ankle  (L  V-S  II). 

Long  flexor  of  toes  (L  V-S  II). 

Peronsei. 

Intrinsic  muscles  of  foot. 

Foot   reflex.      Extension 
of   Achilles    tendon 
causes  flexion  of  ankle 
(S  I-II).  Ankle-clonus. 

Plantar.      Tickling    sole 
of   foot  causes  flexion 
of  toes  or  extension  of 
great   toe   and   flexion 
of  others. 

Back   of  thigh,  leg, 
and     foot ;     outer 
side. 

Ill  to 

V  s. 

Perineal  muscles. 
Levator  and  sphincter  ani  (S  I- 
III). 

Vesical  and  anal  reflexes. 

Skin     over     sacrum 

and  buttock. 
Anus. 
Perinaeum.  Genitals. 

The  Upper  Motor  Segment  and  Motor  Areas  of  the  Cortex. — The 
cell  bodies  of  the  upper  motor  neurones  are  found  in  the  brain  cortex  lying 
for  the  rriost  part  in  a  strip  anterior  to  the  fissure  of  Eolando,  and  it  is  in 
this  region  that  we  find  the  movements  of  the  body  again  represented. 

The  clinical  studies  of  Hughlings  Jackson,  the  experiments  of  Hitzig  and 
Fritsch  and  of  Ferrier,  and  the  anatomical  studies  of  tract  myelinization  by 


874 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


Flechsig,  laid  the  foundation  for  the  great  mass  of  most  excellent  work  which 
has  been  done  upon  this  subject.  We  owe  much  to  Victor  Horsley  and  his  asso- 
ciates for  their  careful  researches  in  this  direction.  More  recently  the  experi- 
mental work  of  Sherrington  and  Griinbaum  on  the  higher  apes  has  somewhat 
modified  the  observations  of  preceding  investigators,  and  with  the  result  of 
more  accurately  delineating  the  motor  territor}'.  They  have  shown  that  true 
motor  responses  are  elicited  only  by  stimulation  anterior  to  the  Eolandic  fissure; 
that  practically  no  point,  over  the  ascending  frontal  convolution,  fails  to  re- 


FiG.  3. — Diagrammatic  representation  of  cortical  localization  in  the  left  hemisphere,  showing 
the  speech  centres.  The  motor  areas  determined  by  unipolar  faradic  excitation  of  the 
anthropoid  cortex  (Sherrington  and  G-riinbaum)  are  here  shown  stippled  in  red  and  lie 
anterior  to  the  Rolandic  fissure.  The  sensory  areas  presumably  lie  posterior  to  this  fis- 
sure and  are  roughly  indicated  in  blue  without  accurate  delineation.  Lying  as  it  does 
on  the  upper  surface  of  the  hemisphere,  the  leg  area  should  not  be  visible  on  a  lateral 
view  such  as  is  given  here. 


spend  to  stimulation :  that  there  is  but  slight  extension  of  the  motor  cortex  on 
to  the  paracentral  lobule  of  the  mesial  surface  of  the  brain;  that  movements 
are  obtainable  not  only  from  the  exposed  part  of  the  convolution,  but  also  from 
its  hidden  surface  to  the  very  depths  of  the  Rolandic  sulcus;  that  there  is  an 
area  of  representation  for  the  trunk  between  the  centres  for  the  leg  and  arm, 
and  also  for  the  neck  between  those  of  the  arm  and  face;  that  the  superior 
and  inferior  genua  are  the  landmarks  which  indicate  the  situation  of  these 
small  areas  of  representation  for  trunk  and  neck.    These  results  .have  in  large 


GENERAL  INTRODUCTION, 


875 


measure  been  confirmed  by  Gushing  by  unipolar  electrical  stimulation  of 
the  human  cortex  in  a  number  of  brain  cases  that  have  been  operated  upon 
from  my  clinic.  From  above  down  the  motor  areas  occur  in  the  following 
order :  leg,  trunk,  arm,  neck,  head  ( Fig.  3 ) .  Those  of  the  leg  and  arm  occupy 
the  upper  half  of  the  convolution,  and  that  for  the  head,  including  movements 
of  the  face,  jaws,  tongue,  and  larynx,  the  lower  half. 

The  speech  centres  are  indicated  in  the  diagram  (Fig.  3)  in  accordance 
with  the  generally  accepted  views :  that  for  motor  speech  occupies  the  posterior 
part  of  the  left  third  frontal  or  Broca's  convolution.  It  is  a  disputed  point 
whether  or  not  there  is  a  separate  centre  presiding  over  the  movements  em- 
ploj^ed  in  writing.  Some  have  assumed  such 
a  centre  to  be  present  in  the  second  frontal 
convolution  as  indicated  on  the  diagram. 
The  conjugate  movement  of  head  and  eyes 
to  the  opposite  side  has  commonly  been  found 
in  apes  to  follow  stimulation  of  the  external 
surface  of  the  frontal  lobe.  Similarly  move- 
ments of  the  eyes  may  be  elicited  from  the 
occipital  cortex,  but  probably  none  of  these 
reactions  are  comparable  to  the  more  simple 
movements  through  the  pyramidal  tract  which 
follow  stimulation  of  the  ascending  frontal 
convolution. 

The  axis-cylinder  processes  of  the  upper 
motor  neurones  after  leaving  the  gray  matter 
of  the  motor  cortex  pass  into  the  white  mat- 
ter of  the  brain  and  form  part  of  the  corona 
radiata.  They  converge  and  pass  between  the 
basal  ganglia  in  the  internal  capsule.  Here 
the  motor  axis-cylinders  are  collected  into  a 
compact  bundle — the  pyramidal  tract — occu- 
pying the  knee  and  anterior  two-thirds  of  the 
posterior  limb  of  the  internal  capsule.  The 
■order  in  which  the  movements  of  the  oppo- 
site side  of  the  body  are  represented  at  this 
level,  as  learned  from  experimental  observa- 
tions on  apes,  is  given  in  Fig.  4. 

After  passing  through  the  internal  cap- 
sule the  fibres  of  the  pyramidal  tract  leave  the  hemisphere  by  the  crus,  of 
which  they  occupy  about  the  middle  three-fifths  (Fig.  5).     The  movements 
of  the  tongue  and  lips  are  represented  nearest  the  middle  line. 

As  soon  as  the  tract  enters  the  crus,  some  of  its  axis-cylinder  processes 
leave  it  and  cross  the  middle  line  to  end  in  arborizations  about  the  ganglion 
•cells  in  the  nucleus  of  the  third  nerve  on  the  opposite  side;  and  in  this  way, 
as  the  pyramidal  tract  passes  down,  it  gives  ojff  at  different  levels  fibres  which 
end  in  the  nuclei  of  all  the  motor  cerebral  nerves  on  the  opposite  side  of  the 
body.  Some  fibres,  however,  go  to  the  nuclei  of  the  same  side  (Hoche). 
From  the  crus,  the  pyramidal  tract  runs  through  the  pons  and  forms  in  the 
medulla  oblongata  the  pyramid,  which, gives  its  name  to  the  tract.    At  the 


Fig.  4. — Diagram  of  motor  and  sen- 
sory representation  in  the  inter- 
nal capsule.  NL.,  Lenticular 
nucleus.  NC,  Caudate  nucleus, 
THO.,  Optic  thalamus.  The  mo- 
tor paths  are  red  and  black,  the 
sensory  are  blue. 


876 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


Fig.  5. — Diagram  of  motor  and  sensory  paths  in  Crura. 


lower  part  of  the  medulla,  after  the  fibres  going  to  the  cerebral  nerves  have 
crossed  the  middle  line,  a  large  proportion  of  the  remaining  fibres  cross, 
decussating  with  those  from  the  opposite  p3'ramid.  and  pass  into  the  opposite 
side  of  the  spinal  cord,  forming  the  crossed  p3Tamidal  tract  of  the  lateral 

column  (fasciculus  cerebro- 
spinalis  lateralis)  (Fig.  6, 
1 ) .  The  smaller  number  of 
fibres  which  do  not  at  this 
time  cross,  descend  in  the 
ventral  column  of  the  same 
side,  forming  the  direct 
pyramidal  tract,  or  Tiirck's 
column  (fasciculus  cerebro- 
spinalis  ventralis)    (Fig.  6, 

At  every  level  of  the 
spinal  cord  axis-cylinder 
processes  leave  the  crossed 
pyramidal  tract  to  enter  the 
ventral  horns  and  end  about 
the  cell  bodies  of  the  lower  motor  neurones.  The  tract  diminishes  in  size 
from  above  downward.  The  fibres  of  the  direct  pyramidal  tract  cross  at 
different  levels  in  the  ventral  white  commissure,  and  also,  it  is  believed,  end 
about  cells  in  the  ventral 
horns  on  the  opposite  side  of 
the  cord.  This  tract  usually 
ends  about  the  middle  of  the 
thoracic  region  of  the  cord. 

The  Sensory  System. — 
The  path  for  sensory  conduc- 
tion is  more  complicated  than 
the  motor  path,  and  in  its 
simplest  form  is  composed  of 
at  least  three  sets  of  neu- 
rones, one  above  the  other. 
The  cell  bodies  of  the  lowest 
neurones  are  in  the  ganglia, 
on  the  dorsal  roots  of  the 
spinal  nerves,  and  the  gan- 
glia of  the  sensory  cerebral 
nerves.  These  ganglion  cells 
have  a  special  form,  having 
apparently  but  a.  single  proc- 
ess, which,  soon  after  leav- 
ing the  cell,  divides  in  a  T- 

shaped  manner,  one  portion  running  into  the  central  nervous  system  and 
the  ot]ier  to  the  periphery  of  the  body.  Embryological  and  comparative 
anatomical  studies  have  made  it  seem  probable  that  the  peripheral  sensory 
fibre,  the  process  which  conducts  toward  the  cell,  represents  the  protoplasmic 


Fig.  6. — Diagram  of  cross-section  of  spinal  cord,  show- 
ing motor,  red,  and  sensory,  blue  paths.  1,  Lateral 
pyramidal  tract.  2,  "Ventral  pyramidal  tract.  3, 
Dorsal  columns.  4,  Direct  cerebellar  tract.  5 
Ventro-lateral  ground  bundles.  6,  Ventro-lateral 
ascending  tract  of  Gowers.  (Van  Gehuchten, 
colored.) 


GENERAL  INTRODUCTION.  877 

processes,  while  that  which  conducts  away  from  the  cell  is  the  axis-cylinder 
process.  In  the  peripheral  sensory  nerves  we  have,  then,  the  dendrites  of  the 
lower  sensory  neurones.  These  start  in  the  periphery  of  the  body  from  their 
various  specialized  end  organs.  The  axis-cylinder  processes  leave  the  ganglia 
and  enter  the  spinal  cord  by  the  dorsal  roots  of  the  spinal  nerves.  After  enter- 
ing the  cord  each  axis-cylinder  process  divides  into  an  ascending  and  a 
descending  branch,  which  run  in  the  dorsal  fasciculi.  The  descending  branch 
runs  but  a  short  distance,  and  ends  in  the  gray  matter  of  the  same  side  of 
the  cord.  It  gives  off  a  number  of  collaterals,  which  also  end  in  the  gray 
matter.  The  ascending  branch  may  end  in  the  gray  matter  soon  after  enter- 
ing, or  it  may  run  in  the  dorsal  fasciculi  as  far  as  the  medulla  to  end  about 
the  nuclei  there.  In  any  case  it  does  not  cross  the  middle  line.  The  lower 
sensory  neurone  is  direct. 

The  cells  about  which  the  axis-cylinder  processes  and  their  collaterals  of 
the  lower  sensory  neurone  end  are  of  various  kinds.  They  are  known  as  sen- 
sory neurones  of  the  second  order.  In  the  first  place,  some  of  them  end  about 
the  cell  bodies  of  the  lower  motor  neurones,  forming  the  path  for  reflexes. 
They  also  end  about  cells  whose  axis-cylinder  processes  cross  the  middle  line 
and  run  to  the  opposite  side  of  the  brain.  In  the  spinal  cord  these  cells  are 
found  in  the  different  parts  of  the  gray  matter,  and  their  axis-cylinder  proc- 
esses run  in  the  opposite  ventro-lateral  ascending  tract  of  Gowers  (Fig.  6,  6) 
and  in  the  ground  bundles  (fasciculus  lateralis  proprius  and  fasciculus  ven- 
tralis  proprius). 

In  the  medulla  the  nuclei  of  the  dorsal  fasciculi  (nucleus  fasciculi  gra- 
cilis (Golli)  and  nucleus  fasciculi  cuneati  (Burdachi))  contain  for  the  most 
part  cells  of  this  character.  Their  axis-cylinder  processes,  after  crossing,  run 
toward  the  brain  in  the  medial  lemniscus  or  bundle  of  the  fillet;  certain  of 
the  longitudinal  bundles  in  the  formatio  reticularis  also  represent  sensory 
paths  from  the  spinal  cord  and  medulla  toward  higher  centres.  The  fibres 
of  the  medial  lemniscus  or  fillet  do  not,  however,  run  directly  to  the  cere- 
bral cortex.  They  end  about  cells  in  the  ventro-lateral  portion  of  the  optic 
thalamus,  and  the  tract  is  continued  on  by  way  of  another  set  of  neurones, 
which  send  processes  to  end  in  the  cortex  of  the  posterior  central  and  parietal 
convolutions.  This  is  the  most  direct  path  of  sensory  conduction,  but  by  no 
means  the  only  one.  The  peripheral  sensory  neurones  may  also  end  about 
cells  in  the  cord  whose  axones  run  but  a  short  distance  toward  the  brain  before 
ending  again  in  the  gray  matter,  and  the  path,  if  path  it  can  be  called,  is 
made  up  of  a  series  of  these  superimposed  neurones.  The  gray  matter  of 
the  cord  itself  is  also  believed  to  offer  paths  of  sensory  conduction.  All  these 
paths  reach  the  tegmentum  and  optic  thalamus,  and  thence  are  distributed 
to  the  cortex  along  with  the  other  sensory  paths.  There  may  also  be  paths 
of  sensory  conduction  through  the  cerebellum  by  way  of  the  direct  cerebellar 
tract  and  Gowers'  bundle. 

From  this  short  summary  it  is  evident  that  the  possible  paths  for  the 
conduction  of  afferent  impulses  are  many,  and  become  more  complex  as  the 
various  tracts  approach  the  brain  where  our  knowledge  of  them  is  somewhat 
indefinite.  The  anatomical  arrangement  of  the  two  lower  orders  of  sensory 
neurones  is,  however,  sufficiently  well  understood  to  be  of  great  clinical  value. 
We  have  seen  in  the  case  of  the  motor  neurones  that  the  distribution  of  the 


878 


DISEASES  OF   THE  NERVOUS  SYSTEM. 


Fig.  7.— Anterior  aspect  of  the  segmental  skin-fields  of  the  body,  combined  from  the  studies 
of  Head,  Kocher,  Starr,  Thorburn,  Edinger,  Sherrington,  Wichmann,  Seiffer,  Bolk, 
Cashing,  and  others.  Heavy  lines  represent  levels  of  fusion  of  dermatomes  and  the  pre- 
axial  and  postaxial  lines  of  the  limbs. 


GENERAL  INTRODUCTION. 


879 


YiQ.  8.— Posterior  aspect  of  the  segmental  skin-fields  of  the  body. 


880  DISEASES  OF   THE  NERVOUS  SYSTEM. 

peripheral  nerves  to  the  muscles,  owing  largely  to  the  interlacing  into  plexuses 
of  the  neurones  from  the  yarious  spinal  units,  is  quite  different  from  that  of 
the  ventral  roots  themselves,  and  the  same  rule  holds  true  for  the  peripheral 
nerve  and  dorsal  root  distribution  for  the  cutaneous  areas.  The  cutaneous 
fields  corresponding  to  the  peripheral  nerves  are  well  known,  and  although 
our  knowledge  of  the  exact  site  and  outline  of  some  of  the  segmental  skin- 
fields,  represented  by  the  dorsal  roots,  is  less  accurately  established,  neverthe- 
less they  are  sufficiently  well  understood  to  be  of  aid  in  determining  the 
segmental  level  of  spinal  cord  and  of  dorsal  root  lesions.  Information  con- 
cerning the  topography  in  the  adult  of  these  skin  units  or  dermatomes  has 
been  obtained  from  various  sources;  from  morphological  studies;  from  ana- 
tomical dissections;  from  physiological  experimentation,  particularly  in  Sher- 
rington's hands;  from  the  study  of  anesthesias  in  clinical  cases  after  trau- 
matic injuries  to  the  cord,  by  Starr,  Thorburn.  Kocher,  and  many  others ; 
and  lastly  from  Head's  studies  of  the  distribution  of  the  cutaneous  lesions  in 
herpes  zoster,  and  of  the  areas  of  referred  pain  and  tenderness  in  visceral 
disease.  The  diagrams  on  pages  878  and  879  embody  the  results  of  many 
of  these  observations. 

The  cutaneous  sensory  impressions  are  in  man  conducted  toward  the  brain, 
probably  on  the  opposite  side  of  the  cord — that  is,  the  path  crosses  to  the 
opposite  side  soon  after  entering  the  cord.  Muscular  sense,  on  the  other  hand, 
is  conducted  on  the  same  side  of  the  cord  in  the  fasciculus  of  Goll.  to  cross 
above  by  means  of  the  axones  of  sensory  neurones  of  the  second  order  in  the 
medulla. 

Sensory  Areas  of  the  Cortex. — The  localization  of  sensory  impressions 
in  the  cortex  of  the  brain  is  not  definitely  determined,  but  it  is  believed  to  be 
posterior  to  the  motor  representation.  Sensation  seems,  however,  to  be  more 
widely  represented  than  motion,  and  to  occupy  most  of  the  parietal  lobe  as 
well  as  the  posterior  central  convolutions  (Fig.  3). 

The  paths  for  the  conduction  of  the  stimuli  which  underlie  the  special 
senses  are  given  in  the  section  upon  the  cerebral  nerves,  and  it  is  only  neces- 
sary here  to  refer  to  what  is  known  of  the  cortical  representation  of  these 
senses. 

Visual  impressions  are  localized  in  the  occipital  lobes.  The  primarv  visual 
centre  is  on  the  mesial  surface  in  the  cuneus,  especially  about  the  calcarine 
fissure,  and  here  are  represented  the  opposite  visual  half -fields.  Some  authors 
believe  that  there  is  another  higher  centre  on  the  outer  surface  of  the  occipital 
lobe,  in  which  the  vision  of  the  opposite  eye  is  chiefly  represented.  However 
this  may  be,  most  authors  hold  that  the  angular  gyrus  of  the  left  hemisphere 
is  a  part  of  the  brain  in  which  are  stored  the  memories  of  the  meaning  of 
letters,  words,  figures,  and  indeed  of  all  seen  objects.  This  is  designated  as 
the  visual  speech  centre  on  the  diagram  (Fig.  3).  Flechsig  and  Monakow 
do  not  admit  this. 

Auditory  impressions  are  localized  for  the  most  part  in  the  first  temporal 
convolution  and  the  transverse  temporal  gyri,  and  it  is  in  this  region  in  the 
left  hemisphere  that  the  memories  of  the  meanings  of  heard  words  and  sounds 
are  stored.  Musical  memories  are  localized  somewhat  in  front  of  those  for 
words.  The  cortical  centres  for  smell  include  a  part  of  the  base  of  the  frontal 
lobe,  the  iincus,  and  perhaps  the  gyrus  hippocampi.     The  centres  for  taste 


GENERAL  INTRODUCTION.  881 

are  supposed  to  be  situated  near  those  for  smell,  but  we  possess  as  yet  no 
definite  information  about  them. 

Topical  Diagnosis. — The  successful  diagnosis  of  the  position  of  a  lesion 
in  the  nervous  system  depends  upon  a  careful  and  exhaustive  examination  into 
all  the  symptoms  that  are  present,  and  then  endeavoring  with  the  help  of 
anatomy  and  physiology  to  determine  the  place,  a  disturbance  at  which  might 
produce  these  symptoms. 

The  abnormalities  of  motion  are  usually  the  most  important  localizing 
symptoms,  both  on  account  of  the  ease  with  which  they  can  be  demonstrated, 
and  also  because  of  the  comparative  accuracy  of  our  knowledge  of  the  motor 
path. 

Lesions  in  any  part  of  the  motor  path  cause  disturbances  of  motion.  If 
destructive,  the  function  of  the  part  is  abolished,  and  as  the  result  there  is 
paralysis.  If,  on  the  other  hand,  the  lesion  is  an  irritative  one,  the  structures 
are  thrown  into  abnormal  activity,  which  produces  abnormal  muscular  con- 
traction. The  character  of  the  paralysis  or  of  the  abnormal  muscular  contrac- 
tion varies  with  lesions  of  the  upper  and  lower  segment,  the  variations 
depending,  first,  upon  the  anatomical  position  of  the  two  segments;  and,  sec- 
ondly, upon  the  symptoms  which  are  the  result  of  secondary  degeneration  in 
each  of  the  segments. 

(a)  Lesions  of  the  Lower  or  Spino-muscular  Segment. — Destructive 
Lesions. — It  has  been  stated  above  that  the  nutrition  of  all  parts  of  a  neurone 
depends  upon  their  connection  with  its  healthy  cell  body;  and  if  the  cell  body 
be  injured,  its  processes  undergo  degeneration,  or  if  a  portion  of  a  process  be 
separated  from  the  cell  body,  that  part  degenerates  along  its  whole  length. 
This  so-called  secondary  degeneration  plays  a  very  important  role  in  the 
symptomatology. 

In  the  lower  motor  segment  the  degeneration  not  only  affects  the  axis- 
cylinder  processes  which  run  in  the  peripheral  nerves,  but  also  the  muscle 
fibres  in  which  the  axis-cylinder  processes  end.  The  degeneration  of  the  nerves 
and  muscles  is  made  evident,  first,  by  the  muscles  becoming  smaller  and  flabby, 
and,  secondly,  by  change  in  their  reaction  to  electrical  stimulation.  The 
degenerated  nerve  gives  no  response  to  either  the  galvanic  or  the  faradic  cur- 
rent, and  the  muscle  does  not  respond  to  faradic  stimulation,  but  reacts  in 
a  characteristic  manner  to  the  galvanic  current.  The  contraction,  instead 
of  being  sharp,  quick,  lightning-like,  as  in  that  of  a  normal  muscle,  is  slow 
and  lazy,  and  is  often  produced  by  a  weaker  current,  and  the  anode-closing 
contraction  may  be  greater  than  the  cathode-closing  contraction.  This  is  the 
reaction  of  degeneration,  but  it  is  not  always  present  in  the  classical  form! 
The  essential  feature  is  the  slow,  lazy  contraction  of  the  muscle  to  the  galvanic 
current,  and  when  this  is  present  the  muscle  is  degenerated. 

The  myotatic  irritability,  or  muscle  reflex,  and  the  muscle  tonus  depend 
upon  the  integrity  of  the  reflex  arc,  of  which  the  lower  motor  segment  is  the 
efferent  limb,  and  in  a  paralysis  due  to  lesion  of  this  segment  the  muscle 
reflexes  (tendon  reflexes)  are  abolished  and  there  is  a  diminished  muscular 
tension. 

Lower  segment  paralyses  have  for  their  characteristics  degenerative  atrophy 
with  the  reaction  of  degeneration  in  the  affected  muscles,  loss  of  their  reflex 
excitability,  and  a  diminished  muscular  tension.  These  are  the  general  char- 
57 


882  DISEASES  OF  THE  NERVOUS  SYSTEM. 

acteristics,  but  the  anatomical  relations  of  this  segment  also  give  certain 
peculiarities  in  the  distribution  of  the  paralyses  which  help  to  distinguish 
them  from  those  which  follow  lesions  of  the  upper  segment,  and  which  also 
aid  in  determining  the  site  of  the  lesion  in  the  lower  segment  itself.  The 
cell  bodies  of  this  segment  are  distributed  in  groups,  from  the  level  of  the 
peduncles  of  the  brain  throughout  the  whole  extent  of  the  spinal  cord  to  its 
termination  opposite  the  second  lumbar  vertebra,  and  their  axis-cj^inder  proc- 
esses run  in  the  peripheral  nerves  to  every  muscle  in  the  body;  so  that  the 
component  parts  are  more  or  less  widely  separated  from  each  other,  and  a 
local  lesion  causes  paralysis  of  only  a  few  muscles  or  groups  of  muscles,  and 
not  of  a  whole  section  of  the  body,  as  is  the  case  where  lesions  afEect  the  upper 
segment.  The  muscles  which  are  paralyzed  indicate  whether  the  disease  is  in 
the  peripheral  nerves  or  spinal  cord;  for,  as  we  have  seen  above,  the  muscles 
are  represented  differently  in  the  peripheral  nerves  and  in  the  spinal  cord. 
Sensory  symptoms,  which  may  accompany  the  paralysis,  are  often  of  great 
assistance  in  making  a  local  diagnosis.  Thus,  in  a  paralysis  with  the  char- 
acteristics of  a  lesion  of  the  lower  motor  segment,  if  the  paralyzed  muscles  are 
all  supplied  by  one  nerve,  and  the  ansesthetic  area  of  the  skin  is  supplied  by 
that  nerve,  it  is  evident  that  the  lesion  must  be  in  the  nerve  itself.  On  the 
other  hand,  if  the  muscles  paralyzed  are  not  supplied  by  a  single  nerve,  but 
are  represented  close  together  in  the  spinal  cord,  and  the  anaesthetic  area 
corresponds  to  that  section  of  the  cord  (see  table),  it  is  equally  clear  that  the 
lesion  must  be  in  the  cord  itself  or  in  its  nerve  roots. 

Ieritative  Lesions  of  the  Lower  Motor  Segment. — Lesions  of  this 
segment  cause  comparatively  few  symptoms  of  irritation,  and  our  knowledge  on 
this  point  is  neither  extensive  nor  accurate.  The  fibrillary  contractions  which 
are  so  common  in  muscles  undergoing  degeneration  are  probably  due  to  stimu- 
lation of  the  cell  bodies  in  their  slow  degeneration,  as  in  progressive  muscular 
atrophy,  or  to  irritation  of  the  axis-cylinder  processes  in  the  peripheral  nerves, 
as  in  neuritis.  Lesions  which  affect  the  motor  roots  as  they  leave  the  central 
nervous  system  may  cause  spasmodic  contractions  in  the  muscles  supplied  by 
them.  Certain  convulsive  paroxysms,  of  which  laryngismus  stridulus  is  a 
type,  and  to  which  the  spasms  of  tetany  also  belong,  are  believed  to  be  due  to 
abnormal  activity  in  the  lower  motor  centres.  These  are  the  "  lowest  level  fits  " 
of  Hughlings  Jackson.  Certain  poisons,  as  strychnia  and  that  of  tetanus,  act 
particularly  upon  these  centres. 

The  principal  diseases  in  which  the  lower  motor  segment  may  be  involved 
are :  all  diseases  involving  the  peripheral  nerves,  cerebral  and  spinal  meningitis, 
injuries,  hgemorrhages  and  tumors  of  the  medulla  and  cord  or  their  membranes, 
lesions  of  the  gray  matter  of  the  segment,  anterior  poliomyelitis,  progressive 
muscular  atrophy,  bulbar  paralysis,  ophthalmoplegia,  syringomyelia,  etc. 

(&)  Lesions  op  the  Upper  Motor  Segment. — Destructive  lesions  cause 
paralysis,  as  in  the  lower  motor  segment,  and  here  again  the  secondary  degen- 
eration which  follows  the  lesion  gives  to  the  paralysis  its  distinctive  character- 
istics. In  this  case  the  paralysis  is  accompanied  by  a  spastic  condition, 
shown  in  an  exaggeration  of  muscle  reflex  and  an  increase  in  the  tension  of 
the  muscle.  It  is  not  accurately  known  how  the  degeneration  of  the  pyramidal 
fibres  causes  this  excess  of  the  muscle  reflex.  The  usual  explanation  is,  that 
under  normal  circumstances  the  upper  motor  centres  are  constantly  exerting 


GENERAL  INTRODUCTION.  883 

a  restraining  influence  upon  the  activity  of  the  lower  centres,  and  that  when 
the  influence  ceases  to  act,  on  account  of  disease  of  the  pyramidal  fibres,  the 
lower  centres  take  on  increased  activity,  which  is  made  manifest  by  an  exag- 
geration of  the  muscle  reflex. 

We  have  seen  that  the  neurones  composing  each  segment  of  the  motor  path 
are  to  be  considered  as  nutritional  units,  and  therefore  the  secondary  degen- 
eration in  the  upper  segment  stops  at  the  beginning  of  the  lower.  For  this 
reason  the  muscles  paralyzed  from  lesions  in  the  upper  segment  do  not  undergo 
degenerative  atrophy,  nor  do  they  show  any  marked  change  in  their  electrical 
reactions. 

The  separate  parts  of  the  upper  motor  segment  lie  much  more  closely 
together  than  do  those  of  the  lower  segment,  and  therefore  a  small  lesion 
may  cause  paralysis  in  many  muscles.  This  is  more  particularly  true  in  the 
internal  capsule,  where  all  the  axis-cylinder  processes  of  this  segment  are  col- 
lected into  a  compact  bundle — the  pyramidal  tract.  A  lesion  in  this  region 
usually  causes  paralysis  of  most  of  the  muscles  on  the  opposite  side  of  the 
body — that  is,  hemiplegia.  The  pyramidal  tract  continues  in  a  compact  bundle, 
giving  off  fibres  to  the  motor  nuclei  at  different  levels;  a  lesion  anywhere  in 
its  course  is  followed  by  paralysis  of  all  the  muscles  whose  spinal  centres 
are  situated  below  the  lesion.  When  the  disease  is  above  the  decussation,  the 
paralysis  is  on  the  opposite  side  of  the  body ;  when  below,  the  paralyzed  muscles 
are  on  the  same  side  as  the  lesion.  Above  the  internal  capsule  the  path  is  some- 
what more  separated,  and  in  the  cortex  the  centres  for  the  movements  of  the 
different  sections  of  the  body  are  comparatively  far  apart,  and  a  sharply  local- 
ized lesion  in  this  region  may  cause  a  more  limited  paralysis,  affecting  a  limb 
or  a  segment  of  a  limb — the  cerebral  monoplegias ;  but  even  here  the  paralysis 
is  not  confined  to  an  individual  muscle  or  group  of  muscles,  as  is  commonly 
the  case  in  lower  segment  paralysis  (see  Fig.  1  and  explanation). 

To  sum  up,  the  paralyses  due  to  lesions  of  the  upper  motor  segment  are 
wide-spread,  often  hemiplegic;  the  paralyzed  muscles  are  spastic  (the  tendon 
reflexes  exaggerated),  they  do  not  undergo  degenerative  atrophy,  and  they 
do  not  present  the  degenerative  reaction  to  electrical  stimulation. 

There  is  an  exception  to  the  above  statement — that  is,  in  the  paralyses 
which  follow  a  complete  transverse  lesion  of  the  spinal  cord.  Here  the  limbs 
are  of  course  completely  paralyzed,  but  instead  of  being  spastic  they  are  flaccid 
and  the  deep  reflexes  are  absent.  The  muscles  react  normally  to  electricity. 
There  is  no  satisfactory  explanation  of  the  loss  of  the  reflexes  under  these 
conditions. 

Irritative  Lesions  of  the  Upper  Motor  Segment. — Our  knowledge 
of  such  lesions  is  confined  for  the  most  part  to  those  acting  on  the  motor  cor- 
tex. The  abnormal  muscular  contractions  resulting  from  lesions  so  situated 
have  as  their  type  the  localized  convulsive  seizures  classed  under  Jacksonian  or 
cortical  epilepsy,  which  are  characterized  by  the  convulsion  beginning  in  a 
single  muscle  or  group  of  muscles  and  involving  other  muscles  in  a  definite 
order,  depending  upon  the  position  of  their  representation  in  the  cortex. 
For  instance,  such  a  convulsion,  beginning  in  the  muscles  of  the  face,  next 
involves  those  of  the  arm  and  hand,  and  then  the  leg.  The  convulsion  is 
usually  accompanied  by  sensory  phenomena  and  followed  by  a  weakness  of 
the'  muscles  involved. 


884  DISEASES  OF  THE  NERVOUS  SYSTEM. 

A  majorit}'  of  lesions  of  the  motor  cortex  are  both  destructive  and  irri- 
tative— i.  e.,  they  destroy  the  nerve  cells  of  a  certain  centre,  and  either  in  their 
growth  or  by  their  presence  throw  into  abnormal  activity  those  of  the  sur- 
rounding centres. 

The  upper  motor  segment  is  involved  in  nearly  all  the  diseases  of  the 
brain  and  spinal  cord,  especially  in  injuries,  tumors,  abscesses,  and  haemor- 
rhages; transverse  lesions  of  the  cord;  syringomyelia,  progressive  muscular 
atrophy,  bulbar  paralysis,  etc.  One  lesion  often  involves  both  the  upper  and 
the  lower  motor  segments,  and  we  have  paralysis  in  the  different  parts  of  the 
body,  with  the  characteristics  of  each.  Such  a  combination  enables  us  in 
many  cases  to  make  an  accurate  local  diagnosis. 

Lesions  in  the  optic  path  and  in  the  different  speech  centres  also  give 
localizing  symptoms,  which  should  always  be  looked  for. 

(c)  Lesioxs  of  the  Sexsort  Path. — Here  again  the  lesion  may  be  either 
irritative  or  destructive.  Irritative  lesions  cause  abnormal  subjective  sensory 
impressions — para?sthesia,  formication,  a  sense  of  cold  or  constriction,  and 
pain  of  every  grade  of  intensity.  The  character  of  the  sensory  symptoms  gives 
very  little  indication  as  to  the  position  of  the  irritating  process.  Intense  pain 
is,  as  a  rule,  a  symptom  of  a  lesion  in  the  peripheral  sensory  neurones,  but  it 
may  be  caused  by  a  disease  of  the  sensory  path  within  the  central  nervous 
system. 

The  exact  distribution  of  symptoms  gives  us  more  accurate  data,  for  if 
they  are  confined  to  the  distribution  of  a  peripheral  nerve  or  of  a  spinal  seg- 
ment the  indication  is  plain.  If  one  side  of  the  body  is  more  or  less  completely 
affected,  we  must  think  of  a  lesion  somewhere  within  the  brain,  etc. 

Destructive  Lesions. — A  complete  destruction  of  the  sensory  paths  from 
any  part  of  the  body  would  of  course  deprive  that  part  of  sensation  in  all  its 
qualities.  This  occurs  most  frequently  from  injury  to  the  peripheral  sensory 
neurones  within  the  peripheral  nerves,  and  the  area  of  antesthesia  depends 
upon  the  nerve  injured.  Complete  transverse  lesion  of  the  cord  causes  com- 
plete anassthesia  below  the  injury. 

Unilateral  lesions  of  the  cord,  medulla,  dorsal  part  of  the  pons,  tegmentum, 
thalamus,  internal  capsule,  and  cortex  cause  disturbances  of  sensation  on  the 
opposite  side  of  the  body;  here  again  the  extent  of  the  defect  more  than  its 
character  helps  us  to  determine  the  position  of  the  lesion.  HemiauEesthesia  in- 
volving the  face  as  well  as  the  rest  of  the  body  can  only  occur  above  the  place 
where  the  sensory  paths  from  the  fifth  nerve  have  crossed  the  middle  line  on 
their  way  to  the  cortex.  This  is  in  the  upper  part  of  the  pons.  From  this 
point  to  where  they  leave  the  internal  capsule  the  sensory  paths  are  in  fairly 
close  relation,  and  are  at  times  involved  in  a  very  small  lesion.  Above  the 
internal  capsule  the  paths  diverge  quickly,  and  for.  this  reason  only  an  exten- 
sive lesion  can  involve  them  all,  and  in  lesions  of  this  part  we  are  more 
apt  to  have  the  sensory  disturbances  confined  to  one  or  another  region  of 
the  body.  Unilateral  lesions  of  the  pons,  medulla,  and  cord  usually  cause 
sensory  disturbances  on  the  same  side  of  the  body,  as  well  as  those  on  the 
opposite  side.  These  are  due  to  the  involvement  of  the  sensory  paths  as 
they  enter  the  central  nervous  system  at  or  a  little  below  the  site  of  the 
lesion  and  before  the  axones  of  the  sensory  neurones  of  the  second  order  have 
crossed  the  middle  line.     The  area  of  disturbed  sensation  on  the  same  side  is 


SYSTEM  DISEASES.  885 

limited  to  the  distribution  of  one  or  more  spinal  segments  and  often  indicates 
accurately  the  position  and  extent  of  the  diseased  process.  As  a  rule,  destruc- 
tive lesions  of  the  central  nervous  system  do  not  involve  all  the  paths  of 
sensory  conduction,  and  the  loss  of  sensation  is  not  complete.  It  is  often 
astonishing  how  very  slight  the  sensory  disturbances  are  which  result  from 
an  extensive  lesion.  Sensation  may  be  diminished  in  all  of  its  qualities, 
or,  what  is  more  common,  certain  qualities  may  be  affected  while  others 
are  normal.  These  cases  of  dissociation  of  sensation,  or  so-called  elective 
sensory  paralysis,  have  been  much  studied  of  late.  Thus  the  sense  of  pain 
and  temperature  may  be  lost  while  that  of  touch  remains  normal,  as  is  often 
the  case  in  diseases  of  the  spinal  cord,  or  there  may  be  simply  a  loss  of  the 
muscular  sense  and  of  the  stereognostic  sense  (the  complex  sensory  impression 
which  enables  one  to  recognize  an  object  placed  in  the  hand),  as  occurs  fre- 
quently from  lesions  of  the  cortex.  Occasionally  pain  sensation  persists  with 
loss  of  tactile  and  thermic  sensations.  Almost  every  other  combination  has 
been  described.  It  is  the  distribution  more  than  the  character  of  the  sensory 
defect  that  is  of  importance,  and  often  the  distribution  gives  but  uncertain 
indication  of  the  position  of  the  lesion.  The  combination  of  the  sensory  defect 
with  different  forms  of  paralysis  gives  the  most  certain  diagnostic  signs.  The 
student  is  referred  to  the  sections  on  the  individual  parts  of  the  nervous  sys- 
tem for  a  more  detailed  consideration  of  the  subject. 


B.    SYSTEM  DISEASES. 

I.     INTRODUCTION. 

There  are  certain  diseases  of  the  nervous  system  which  are  confined,  if 
not  absolutely,  still  in  great  part,  to  definite  tracts  (combinations  of  neurones) 
which  subserve  like  functions.  These  tracts  are  called  systems,  and  a  disease 
which  is  confined  to  one  of  them  is  a  system  disease.  If  more  than  one  system 
is  involved,  the  process  is  called  a  combined  system  disease.  Just  what  dis- 
eases should  be  classed  under  these  names  has  given  rise  to  much  discussion 
but  to  very  little  agreement.  We  can  not  speak  positively;  our  knowledge  is 
as  yet  not  sufficiently  accurate,  either  in  regard  to  the  exact  limits  of  the  sys- 
tems themselves,  or  to  the  nature  and  extent  of  the  morbid  process  in  the 
several  diseases.  In  the  classification  which  has  been  adopted  in  this  edition 
the  endeavor  has  been  to  make  the  arrangement  as  simple  as  possible,  and, 
while  it  is  based  upon  what  is  believed  to  be  the  best  founded  views  of  the 
systems  and  their  diseases,  there  has  been  no  attempt  to  carry  the  classification 
to  its  logical  conclusion,  nor  have  the  limits  of  the  theory  been  always 
respected. 

In  general  it  may  be  said  that  the  nervous  system  is  composed  of  two  great 
systems  of  neurones,  the  afferent  or  sensory  system  and  the  efferent  or  motor 
system,  and  the  connections  between  them.     (See  General  Introduction.) 

Locomotor  ataxia  is  a  disease  confined  at  its  onset  to  the  afferent  system, 
and  progressive  muscular  atrophy  is  one  of  the  efferent  system.  Eepresenting 
typical  system  diseases  as  we  now  understand  them,  they  have  been  taken  as 
the  basis  of  the  classification.    Several  theories  have  been  advanced  to  explain 


886  DISEASES  OF  THE  NERVOUS  SYSTEM. 

why  a  disease  should  be  limited  to  a  definite  system  of  neurones.  One  view  is 
based  upon  the  idea  that  in  certain  individuals  one  or  the  other  of  these  sys- 
tems has  an  innate  tendency  to  undergo  degeneration;  another  assumes  that 
neurones  with  a  similar  function  have  a  similar  chemical  construction  (which 
differs  from  that  of  neurones  with  a  different  function),  and  this  is  taken  to 
explain  why  a  poison  circulating  in  the  blood  should  show  a  selective  action  for 
a  single  functional  system  of  neurones. 

In  the  afferent  tract  locomotor  ataxia  stands  alone  as  a  system  disease, 
and  we  now  believe  that  herpes  zoster  is  an  inflammation  of  the  dorsal  root 
ganglia  and  stands  in  the  same  relation  to  tabes  that  acute  anterior  polio- 
myelitis does  to  chronic  progressive  muscular  atrophy.  In  the  efferent  tract 
progressive  (central)  muscular  atrophy  is  the  chief  representative,  as  in  it 
the  whole  motor  path  is  more  or  less  involved.  Theoretically,  primary  lateral 
sclerosis  is  a  disease  confined  to  the  upper  segment  of  the  efferent  tract,  while 
chronic  anterior  poliomyelitis  involves  the  lower  segment  of  the  tract. 

In  connection  with  locomotor  ataxia,  general  paralysis  is  considered  on 
account  of  their  frequent  association  and  of  the  possibility  of  their  being 
different  expressions  of  one  and  the  same  morbid  process ;  and  with  progressive 
(central)  muscular  atrophy,  the  other  forms  of  muscular  atrophy  are  consid- 
ered as  a  matter  of  convenience.  In  other  instances,  too,  diseases  are  arranged 
in  positions  to  which  they  might  not  be  entitled,  had  a  rigid  classification  of 
system  diseases  been  maintained. 

n.     DISEASES    OF    THE    AFFERENT    OR    SENSORY 

SYSTEM. 

Locomotor  Ataxia. 

{Tabes  Dorsalis;  Posterior  Spinal  Sclerosis.) 

Definition. — An  affection  characterized  clinically  by  sensory  disturbances, 
incoordination,  trophic  changes,  and  involvement  of  the  special  senses,  par- 
ticularly the  eyes.  Anatomically  there  are  found  degenerations  of  the  root 
fibres  of  the  dorsal  columns  of  the  cord,  of  the  dorsal  roots,  and  at  times  of 
the  spinal  ganglia  and  peripheral  nerves.  Degenerations  have  been  described 
in  the  brain,  particularly  the  cortex  cerebri,  in  the  ganglion  cells  of  the  cord, 
and  in  the  endogenous  fibres  of  the  dorsal  columns. 

Etiology. — It  is  a  wide-spread  disease,  more  frequent  in  cities  than  in  the 
country.  The  relative  proportion  may  be  judged  from  the  fact  that  of  16,562 
cases  in  the  neurological  dispensary  of  the  Johns  Hopkins  Hospital,  there  were 
201  cases  of  locomotor  ataxia.  Males  are  attacked  more  frequently  than 
females,  the  proportion  being  nearly  10  to  1.  The  disease,  although  uncom- 
mon in  the  negro^,  is  seen  in  them  more  frequently  than  some  authors  state. 
It  is  a  disease  of  adult  life,  the  great  majority  of  cases  occurring  between  the 
thirtieth  and  fiftieth  years.  Occasionally  cases  are  seen  in  young  men,  and 
it  may  occur  in  children  with  hereditary  s}-philis.  Of  special  causes  s}^hilis 
is  the  most  important.  According  to  the  figures  of  Erb,  Fournier,  Growers, 
Starr,  and  others,  in  from  50  to  90  per  cent  of  all  cases  there  is  a  history 
of  this  disease.  In  the  Johns  Hopkins  Hospital  the  percentage,  as  found  by 
Thomas,  was  63.1.     Erb's  recent  figures  are  most  striking — of  300  cases  of 


SYSTEM  DISEASES.  887 

tabes  in  private  practice,  89  per  cent  had  had  syphilis.  Moebius  goes  so  far 
as  to  say,  "  The  longer  I  reflect  upon  it,  the  more  firmly  I  believe  that  tabes 
never  originates  without  syphilis." 

Excessive  fatigue,  overexertion,  injury,  exposure  to  cold  and  wet,  and 
sexual  excesses  are  all  assigned  as  causes.  There  are  instances  in  which  ;the 
disease  has  closely  followed  severe  exposure.  James  Stewart  has  noted  that 
the  Ottawa  lumbermen,  who  live  a  very  hard  life  in  the  camps  during  the 
winter  months,  are  frequently  the  subjects  of  locomotor  ataxia.  Trauma  has 
been  noted  in  a  few  cases.  Alcoholic  excess  does  not  seem  to  predispose  to  the 
disease.  Among  patients  in  the  better  classes  of  life  I  do  not  remember  one 
in  which  there  had  been  a  previous  history  of  prolonged  drunkenness.  There 
are  now  a  good  many  cases  on  record  of  the  existence  of  the  disease  in  both 
husband  and  wife,  and  a  few  where  the  children  are  also  affected. 

Morbid  Anatomy  and  Pathology. — With  a  fuller  knowledge  of  the  anatomy 
of  the  nervous  system,  our  conception  of  tahes  dorsalis  has  undergone  many 
changes.  Posterior  spinal  sclerosis,  although  the  most  obvious  gross  change, 
is  now  no  longer,  as  in  Eomberg's  time,  an  adequate  description  of  the  con- 
dition, for  we  know  that  the  dorsal  columns  are  composed  of  definite  fibre 
systems,  and  many  attempts  have  been  made  to  determine  which  of  these  are 
affected  in  tabes,  and  where  the  primary  lesion  is  situated.  The  dorsal  fibres 
are  of  two  kinds,  those  with  their  cell  bodies  outside  the  cord  in  the  spinal 
ganglia,  the  so-called  exogenous,  or  root  fibres,  and  those  which  arise  from 
cells  within  the  cord,  the  endogenous  fibres.  These  two  sets  occupy  fairly 
well-determined  regions  of  the  dorsal  columns  and  a  study  of  early  cases  of 
tabes  has  shown  that  it  is  the  exogenous  or  root  fibres  that  are  first  affected. 
The  fibres  of  the  dorsal  roots  enter  the  cord  in  two  divisions,  an  external  and 
an  internal;  the  former  is  composed  of  fibres  of  small  calibre,  which,  in  the 
cord,  make  up  Lissauer's  tract,  and  occupy  the  space  between  the  apex  of 
the  dorsal  cornua  and  the  periphery  of  the  cord,  and  really  do  not  form  part 
of  the  dorsal  columns.  They  are  short,  soon  entering  the  gray  matter,  and  do 
not  seem  to  be  affected,  or  only  slightly  so,  in  early  cases  (Mott,  and  Orr  and 
Eowe). 

The  larger  fibres  enter  the  cord  by  the  internal  division,  just  medial  to  the 
cornua,  in  what  is  known  as  the  root  entry  zone.  Some  enter  the  gray  matter 
of  the  spinal  cord  almost  .directly  and  others  after  a  longer  course,  while  still 
others  run  in  the  cord  to  the  medulla,  to  end  in  the  nuclei  of  the  dorsal 
columns.  As  the  fibres  of  every  spinal  nerve  enter  the  cord  between  the 
dorsal  cornua  and  the  nerve  fibres  which  have  entered  lower  down,  the  fibres 
from  each  root  are  successively  pushed  more  and  more  toward  the  median 
line,  and  so  in  the  cervical  cord  the  fasciculi  of  Goll  are  largely  composed 
of  long  fibres  derived  from  the  sacral  and  lumbar  roots. 

That  it  is  the  coarse  dorsal  root  fibres  which  are  first  affected  in  tabes  is 
generally  admitted,  but  there  is  much  divergence  of  opinion  as  to  the  char- 
acter and  location  of  the  Initial  process. 

Certain  observers  believe  that  the  morbid  agent,  syphilis,  for  instance,  acts 
primarily  on  extra-nervous  tissues,  and  that  change  in  the  root  fibres  is  a 
secondary  degeneration.  Nageotte  calls  attention  to  the  frequency  of  a  trans- 
verse, interstitial  neuritis  of  the  dorsal  roots  just  after  they  have  left  the 
ganglia  and  are  still  surrounded  by  the  dura,  and  he  believes  that  it  is  this 


888  DISEASES  OF  THE  NERVOUS  SYSTEM. 

neuritis  which  is  the  primary  lesion  in  tabes.  Obersteiner  and  Eedlich  have 
laid  great  stress  on  the  presence  of  an  inflammation  of  the  pia  mater  over 
the  dorsal  aspect  of  the  cord,  which  involves  the  root  fibres  as  they  pass 
through.  They  point  out  that  it  is  just  here  that  the  dorsal  roots  are  most 
vulnerable,  for  at  this  point — that  is,  while  surrounded  by  the  pia — they  are 
almost  completely  devoid  of  their  myelin  sheaths.  Changes  in  the  blood- 
vessels of  the  cord,  of  the  pia,  and  of  the  nerve  roots  have  been  described 
in  early  tabes,  and  very  lately  Marie  and  Guillain  have  advanced  the  belief 
that  the  changes  in  the  cord  are  due  to  an  affection  (s}^hilis)  of  the  posterior 
lymphatic  system  which  is  confined  to  the  dorsal  columns  of  the  cord,  the  pia 
mater  over  them,  and  the  dorsal  roots.  For  them  the  changes  in  the  nervous 
system  are  only  apparently  radicular  or  systemic.  Other  observers  regard  the 
primary  change  as  an  interstitial  myelitis  of  the  dorsal  columns  accompanied 
by  secondary  changes. 

In  the  belief  of  most  authors,  tabes  is  a  systemic  disease,  at  least  it 
starts  as  such;  but  here  again  there  is  much  dispute  as  to  just  which  part  of 
the  sensory  neurones  is  first  affected.  The  peripheral  nerves,  the  dorsal  gan- 
glia, the  dorsal  roots,  and  the  intermeduUary  portions  of  the  neurones  have 
all  been  pointed  out  as  starting  places  of  the  disease. 

Flechsig,  Trepinsky,  and  others  hold  that  the  disease  is  so  truly  systemic 
that  the  degeneration  in  the  dorsal  columns  follows  closely  the  embryological 
systems  as  determined  by  the  time  of  their  myelinization.  Orr  and  Eowe,  in 
cases  of  general  paresis,  have  described  in  detail  what  appear  to  be  the  earliest 
tabetic  changes  in  the  dorsal  columns,  corresponding  closely  to  the  description 
given  by  Mott  in  certain  of  his  cases  of  tabo-paralysis. 

With  Marchi  stain,  degeneration  of  the  root  fibres  in  the  root  entry  zone 
was  a  constant  finding.  This  change  was  radicular  in  the  sense  that  it  varied 
in  intensity  with  the  different  roots  and  was  most  marked  in  the  sacral  and 
lumbar  regions.  The  degeneration  was  not  found  in  the  dorsal  roots,  but  began 
within  the  cord  just  beyond  where  the  root  fibres  had  lost  their  neurolemma 
and  their  myelin  sheaths,  and  the  authors  believe  that  it  is  here  that  the  fibres 
are  exposed  to  the  action  of  poisons.  They  found  no  meningitis  to  account  for 
it.  Degenerated  fibres  could  be  traced  into  the  dorsal  gray  matter  and  among 
the  ganglion  cells  of  the  columns  of  Clarke.  The  long  columns  which  ascend 
the  cord  also  degenerated. 

In  a  study  of  more  advanced  cases,  Mott  found,  in  addition  to  the  lesion  de- 
scribed above,  degeneration  of  the  dorsal  roots  and  some  alteration  of  the  cells 
in  the  spinal  ganglia.  The  fibres  distal  to  the  ganglia  were  practically  normal, 
although  at  times  the  sensory  fibres,  at  the  periphery  of  a  limb,  showed  de- 
generation. Within  the  cord,  the  exogenous  fibres  were  diseased  as  already 
described,  but  he  also  found  degeneration  in  the  endogenous  system  of  fi])res. 
This  was  in  advanced  cases  with  marked  ataxia.  He  thinks  the  process  shows 
both  a  systemic  and  a  segmental  election,  and  in  this  he  is  in  agreement  with  a 
number  of  other  observers.  In  some  cases  the  cells  of  Clarke's  columns  were 
found  diseased  with  secondary  changes  in  the  cerebellar  tracts. 

Mott  found  optic  atrophy  quite  frequently,  and  believes  that  had  he  exam- 
ined the  optic  nerves  of  all  the  cases  changes  would  have  been  found  in  60 
per  cent.  The  other  cranial  nerves,  especially  the  fifth  with  its  ganglion, 
have  been  found  degenerated. 


SYSTEM  DISEASES.  889 

The  disease  occasionally  spreads  beyond  the  sensory  system  in  the  cord, 
and  in  advanced  cases  the  cells  in  the  ventral  horns  may  be  degenerated  in 
association  with  muscular  atrophy.  In  his  asylum  cases,  Mott  very  generally 
found  more  or  less  marked  changes  in  the  pyramidal  fibres;  these  he  believed 
to  be  evidence  of  changes  in  the  cerebral  cortex.  Degeneration  of  the  cortex 
was  to  be  expected  in  his  cases  of  tabo-paralysis,  but  even  in  cases  where  the 
mental  symptoms  were  absent,  or  very  mild,  similar  though  slight  changes 
have  been  described,  just  as  in  general  paralysis,  without  marked  tabetic 
symptoms,  there  may  be  degeneration  of  the  dorsal  columns.  The  close  asso- 
ciation, or  even  identity,  of  tabes  and  general  paralysis  will  be  considered 
later. 

Symptoms. — These  are  best  considered  under  three  stages — the  incipient 
stage,  the  ataxic  stage,  and  the  paralytic  stage. 

The  Incipient  Stage. — This  is  sometim'es  called  the  pre-ataxic  stage. 
The  manner  in  which  tabes  makes  its  onset  differs  very  widely  in  the  different 
cases,  and  mistakes  in  diagnosis  are  often  made  early  in  the  disease.  The  fol- 
lowing are  the  most  characteristic  initial  symptoms : 

Pains,  usually  of  a  sharp  stabbing  character;  hence  the  term  lightning 
pains.  They  last  for  only  a  second  or  two  and  are  most  common  in  the  legs 
or  about  the  trunk,  and  tend  to  follow  dorsal  root  areas.  They  dart  from  place 
to  place.  At  times  they  are  associated  with  a  hot  burning  feeling  and  often 
leave  the  affected  area  painful  to  pressure,  and  occasionally  herpes  may  fol- 
low. The  intensity  of  the  pain  varies  from  a  sore,  burning  feeling  of  the  skin 
to  a  pain  so  intense  that  were  it  not  for  its  momentary  duration  it  would 
exceed  human  endurance.  They  occur  at  irregular  intervals,  and  are  prone 
to  follow  excesses  or  to  come  on  when  health  is  impaired.  When  typical,  these 
pains  are  practically  pathognomonic  of  the  condition.  (See  Sir  William 
Gowers'  clinical  lecture.)  The  gastric  crises  and  other  crises  may  occur, 
Parsesthesia  may  also  be  among  the  first  symptoms, — numbness  of  the  feet, 
tingling,  etc.,  and  at  times  a  sense  of  constriction  about  the  body. 

Ocular  Symptoms. —  (a)  Optic  atrophy.  This  occurs  in  about  10  per  cent 
of  the  cases,  and  is  often  an  early  and  even  the  first  symptom.  There  is  a 
gradual  loss  of  vision,  which  in  a  large  majority  of  cases  leads  to  total  blind- 
ness, (&)  Ptosis,  which  may  be  double  or  single,  (c)  Paralysis  of  the  exter- 
nal muscles  of  the  eye.  This  may  be  of  a  single  muscle  or  occasionally  of  all 
the  muscles  of  the  eye.  The  paralysis  is  often  transient,  the  patient  merely 
complaining  that  he  saw  double  for  a  certain  period,  (d)  Argyll  Eobertson 
pupil,  in  which  there  is  loss  of  the  iris  reflex  to  light  but  contraction  during 
accommodation.     The  pupils  are  often  very  small — spinal  myosis. 

Bladder  Symptoms. — The  first  warning  of  the  disease  which  the  patient 
has  may  be  a  certain  difficulty  in  emptying  the  bladder.  Incontinence  of 
urine  occurs  only  at  a  later  stage  of  the  disease.  Decrease  in  sexual  desire 
and  power  may  also  be  an  early  symptom. 

Trophic  Disturbances. — These  usually  occur  later  in  the  disease,  but  at 
times  they  are  very  early  symptoms  and  it  is  not  very  infrequent  to  have  one's 
attention  called  to  the  trouble  by  the  presence  of  a  perforating  ulcer  or  of  a 
characteristic  Charcot's  joint. 

Loss  of  the  Deep  Reflexes. — This  early  and  most  important  symptom  may 
occur  years  before  the  development  of  ataxia.     Even  alone  it  is  of  great  mo- 
S8 


890  DISEASES  OF  THE  NERVOUS  SYSTEM. 

ment,  since  it  is  very  rare  to  meet  with  individuals  in  whom  the  knee  and 
ankle  jerks  are  normally  absent.  The  combination  of  loss  of  either  of  these 
with  one  or  more  of  the  symptoms  mentioned  above,  especially  with  the  light- 
ning pains  and  ptosis  or  Argyll  Robertson  pupil,  is  practically  diagnostic. 
These  reflexes  gradually  decrease,  and  one  may  be  lost  before  the  other,  or 
disappear  first  in  one  leg. 

These  are  the  most  common  symptoms  of  the  initial  stage  of  tabes  and 
may  persist  for  years  without  the  development  of  incoordination.  The  patient 
may  look  well  and  feel  well,  and  be  troubled  only  by  occasional  attacks  of 
lightning  pains  or  of  one  of  the  other  subjective  symptoms.  Moebius  goes 
so  far  as  to  state  that  the  typical  Argyll  Robertson  pupil  means  either  tabes 
or  general  paralysis,  and  that  paralysis  of  the  external  muscles  of  the  eye 
developing  in  adults  is  of  almost  equal  importance,  especially  if  it  develops 
painlessly. 

The  time  between  the  syphilitic  infection  and  the  occurrence  of  the  first 
symptoms  of  locomotor  ataxia  varies  within  wide  limits.  About  one-half  the 
cases  occur  between  the  sixth  and  fifteenth  year,  but  many  begin  even  later 
than  this. 

The  disease  may  never  progress  beyond  this  stage,  and  when  optic  atrophy 
develops  early  and  leads  to  blindness,  ataxia  rarely,  if  ever,  supervenes,  but  the 
mental  symptoms  of  paresis  not  infrequently  follow,  a  sequence  which  must 
be  kept  in  mind.  There  is  a  sort  of  antagonism  between  the  ocular  symptoms 
and  the  progress  of  the  ataxia.  Charcot  laid  considerable  stress  upon  this,  and 
both  Dejerine  and  Spiller  have  since  emphasized  the  point. 

Ataxic  Stage. — Motor  Symptoms. — The  ataxia  is  believed  to  be  due  to 
a  disturbance  or  loss  of  the  afferent  impulses  from  the  muscles,  joints,  and 
deep  tissues,  and  a  disturbance  of  the  muscle  sense  itself  can  usually  be  demon- 
strated. It  develops  gradually.  One  of  the  first  indications  to  the  patient  is 
inability  to  get  about  readily  in  the  dark  or  to  maintain  his  equilibrium  when 
washing  his  face  with  the  eyes  shut.  When  the  patient  stands  with  the  feet 
together  and  the  eyes  closed,  he  sways  and  has  difficulty  in  maintaining  his 
position  (Romberg's  symptom),  and  he  may  be  quite  unable  to  stand  on  one 
leg.  He  does  not  start  off  promptly  at  the  word  of  command.  On  turning 
quickly  he  is  apt  to  fall.  He  descends  stairs  with  more  difficulty  than  he 
ascends  them.  Gradually  the  characteristic  ataxic  gait  develops.  The  patient, 
as  a  rule,  walks  with  a  stick,  the  eyes  are  directed  to  the  ground,  the  body 
is  thrown  forward,  and  the  legs  are  wide  apart.  In  walking,  the  leg  is  thrown 
out  violently,  the  foot  is  raised  too  high  and  is  brought  down  in  a  stamping 
manner  with  the  heel  first,  or  the  whole  sole  comes  in  contact  with  the  ground. 
Ultimately  the  patient  may  be  unable  to  walk  without  the  assistance  of  two 
canes.  This  gait  is  very  characteristic,  and  unlike  that  seen  in  any  other  dis- 
ease. The  incoordination  is  not  only  in  walking,  but  in  the  performance  of 
other  movements.  If  the  patient  is  asked,  when  in  the  recumbent  posture,  to 
touch  one  knee  with  the  other  foot,  the  irregularity  of  the  movement  is  very 
evident.  Incoordination  of  the  arms  is  less  common,  but  usually  develops  in 
some  grade.  It  may  in  rare  instances  exist  before  the  incoordination  of  the 
legs.  It  may  be  tested  by  asking  the  patient  to  close  his  eyes  and  to  touch  the 
tip  of  the  nose  or  the  tip  of  the  ear  with  the  finger,  or  with  the  arms  thrust 
out  to  bring  the  tips  of  the  fingers  together.     The  incoordination  may  early 


SYSTEM  DISEASES.  _        891 

be  noticed  by  a  difficulty  which  the  patient  experiences  in  buttoning  liis  collar 
or  in  performing  one  of  the  ordinary  routine  acts  of  dressing. 

One  of  the  most  striking  features  of  the  disease  is  that  with  marked  inco- 
ordination there  is  but  little  loss  of  muscular  power.  The  grip  of  the  hands 
may  be  strong  and  firm,  the  power  of  the  legs,  tested  by  trying  to  flex  them, 
may  be  unimpaired,  and  their  nutrition,  except  toward  the  close,  may  be 
unaffected. 

There  is  a  remarkable  muscular  relaxation  which  enables  the  joints  to 
be  placed  in  positions  of  hyperextension  and  hyperflexion.  It  gives  some- 
times a  marked  backward  curve  to  the  legs.  Frankel,  who  calls  the  condition 
hypotonia,  says  it  may  be  an  early  symptom. 

Sensory  Symptoms. — The  lightning  pains  may  persist.  They  vary  greatly 
in  different  cases.  Some  patients  are  rendered  miserable  by  the  frequent  occur- 
rence of  the  attacks;  others  escape  altogether.  In  addition,  common  symp- 
toms are  tingling,  pins  and  needles,  particularly  in  the  feet,  and  areas  of 
hypersesthesia  or  of  angesthesia.  The  patient  m,ay  complain  of  a  change  in 
the  sensation  in  the  soles  of  the  feet,  as  if  cotton  was  interposed  between  the 
floor  and  the  skin.  Sensory  disturbances  occur  less  frequently  in  the  hands. 
Objective  sensory  disturbances  can  usually  be  demonstrated,  and  indeed  almost 
every  variety  of  sensory  disturbance  has  been  described.  They  have  been 
carefully  studied  in  America  by  Knapp  and  by  Patrick,  and  in  Europe  by 
many  observers.  Bands  about  the  chest  of  a  moderate  grade  of  anaesthesia  are 
not  uncommon;  they  are  apt  to  follow  the  distribution  of  spinal  segments. 
The  most  marked  disturbances  are  usually  found  on  the  legs.  Eetardation  of 
the  sense  of  pain  is  common,  and  a  pin-prick  on  the  foot  is  first  felt  as  a  simple 
tactile  impression,  and  the  sense  of  pain  is  not  perceived  for  a  second  or  two 
or  may  be  delayed  for  as  much  as  ten  seconds.  The  pain  felt  may  persist. 
A  curious  phenomenon  is  the  loss  of  the  power  of  localizing  the  pain.  For 
instance,  if  the  patient  is  pricked  on  one  limb  he  may  say  that  he  feels  it 
on  the  other  (allocheiria),  or  a  pin-prick  on  the  foot  may  be  felt  on  both  feet. 
The  muscular  sense  which  is  usually  affected  early,  becomes  much  impaired 
and  the  patient  no  longer  recognizes  the  position  in  which  his  limbs  are  placed. 
This  may  be  present  in  the  pre-ataxic  stage. 

Reflexes. — As  mentioned,  the  loss  of  the  knee  and  ankle  jerks  is  one  of  the 
earliest  symptoms  of  the  disease.  Occasionally  a  case  is  found  in  which  they 
are  retained.  The  skin  reflexes  may  at  first  be  increased,  but  later  are  usually 
involved  with  the  deep  reflexes. 

Special  Senses. — The  eye  symptoms  noted  above  may  be  present,  but,  as 
mentioned,  ataxia  is  rare  with  atrophy  of  the  optic  nerve. 

Deafness  may  develop,  due  to  lesion  of  the  auditory  nerve.  There  may  also 
be  attacks  of  vertigo.     Olfactory  symptoms  are  rare. 

Visceral  Symptoms. — Among  the  most  remarkable  sensory  disturbances 
are  the  tabetic  crises,  severe  paroxysms  of  pain  referred  to  various  viscera; 
thus  laryngeal,  gastric,  nephric,  rectal,  urethral,  and  clitoral  crises  have  been 
described.  The  most  common  are  the  gastric  and  laryngeal.  In  the  former 
there  are  intense  pains  in  the  stomach,  vomiting,  and  a  secretion  of  hyperacid 
gastric  juice.  The  attack  may  last  for  several  days  or  even  longer.  There 
may  be  severe  pain  without  any  vomiting.  The  attacks  are  of  variable  intensity 
and  usually  require  morphia.     Paroxysms  of  rectal  pain  and  tenesmus  are 


892  DISEASES  OF  THE  NERVOUS  SYSTEM. 

described.  They  have  not  been  common  in  my  experience.  Laryngeal  crises 
also  are  rare.  There  may  be  true  spasm  with  dyspnoea  and  noisy  inspiration. 
In  one  instance  at  least  the  patient  has  died  in  the  attack.  There  are  also 
nasal  crises,  associated  with  sneezing  fits. 

The  sphincters  are  frequently  involved.  Early  in  the  disease  there  may 
be  a  retardation  or  hesitancy  in  making  water.  Later  there  is  retention,  and 
cystitis  may  occur.  L'nless  great  care  is  taken  the  inflammation  may  extend 
to  the  kidneys.  Constipation  is  extremely  common.  Late  in  the  disease  the 
sphincter  ani  is  weakened.    The  sexual  power  is  usually  lost  in  the  ataxic  stage. 

Trophic  Changes. — Skin  rashes  may  develop  in  the  course  of  the  light- 
ning pains,  such  as  herpes,  oedema,  or  local  sweating.  Alteration  in  the  nails 
may  occur.  A  perforating  ulcer  may  develop  on  the  foot,  usually  beneath 
the  great  toe.  A  perforating  buccal  ulcer  has  also  been  described.  Onychia 
may  prove  very  troublesome. 

Arthropathies  (Charcot's  Joints). — Anatomically  there  are:  (1)  enlarge- 
ment of  the  capsule  with  thickening  of  the  synovial  membranes  and  increase 
in  the  fluids;  (2)  slight  enlargement  of  the  ends  of  the  bones,  with  slight 
exostoses;  (3)  a  dull  velvety  appearance  of  the  cartilages,  with  atrophy  in 
places  {Y.  E.  Henderson).  The  knees  are  most  frequently  involved.  The 
spine  is  affected  in  rare  instances.  Eecurring  trauma  is  an  important  element 
in  the  causation,  but  trophic  disturbances  have  a  strong  influence  in  the  eti- 
ology. A  striking  feature  is  the  absence  of  pain.  Suppuration  may  occur, 
also  spontaneous  fractures.  Among  other  trophic  disturbances  may  be  men- 
tioned atrophy  of  the  muscles,  which  is  usually  a  late  manifestation,  but  may 
be  localized  and  associated  with  neuritis.  In  any  very  large  collection  of  cases 
many  instances  of  atrophy  are  found,  due  either  to  involvement  of  the  ventral 
horns  or  to  peripheral  neuritis. 

Cerehral  Symptoms. — Hemiplegia  may  develop  at  any  stage  of  the  disease, 
more  commonly  when  it  is  well  advanced.  It  may  be  due  to  hgemorrhagic 
softening  in  consequence  of  disease  of  the  vessels  or  to  progressive  cortical 
changes.  Hemiansesthesia  is  sometimes  present.  Very  rarely  the  hemiplegia 
is  due  to  coarse  syphilitic  disease. 

Dementia  paralytica  frequently  exists  with  tabes;  indeed  we  have  come 
to  regard  these  two  diseases  as  simply  different  localizations  of  the  same  mor- 
bid process.    In  other  instances  melancholia,  dementia,  or  paranoia  occur. 

Paralytic  Stage. — After  persisting  for  an  indefinite  number  of  years 
the  patient  gradually  loses  the  power  of  walking  and  becomes  bedridden  or 
paralyzed.  In  this  condition  he  is  very  likely  to  be  carried  off  by  some  inter- 
current affection,  such  as  pyelo-nephritis,  pneumonia,  or  tuberculosis. 

The  Course  of  the  Disease. — A  patient  may  remain  in  the  pre-ataxic  stage 
for  an  indefinite  period;  and  the  loss  of  knee-jerk  and  the  gray  atrophy  of 
the  optic  nerves  may  be  the  sole  indication  of  the  true  nature  of  the  disease. 
In  such  cases  incoordination  rarely  develops.  In  a  majority  of  cases  the 
progress  is  slow,  and  after  six  or  eight  j^ears,  sometimes  less,  the  ataxia  is 
well  developed.  The  sjonptoms  may  vary  a  good  deal;  thus  the  pains,  which 
may  have  been  excessive  at  first,  often  lessen.  The  disease  may  remain  station- 
ary for  years;  then  exacerbations  occur  and  it  makes  rapid  progress.  Occa- 
sionally the  process  seems  to  be  arrested.  There  are  instances  of  what  may 
be  called  acute  ataxia,  in  which,  within  a  vear  or  even  less,  the  incoordination 


SYSTEM  DISEASES.  893 

is  marked,  and  the  paralytic  stage  ma}^  develop  within  a  few  months.  The 
disease  itself  rarely  causes  death,  and  after  becoming  bedridden  the  patient 
may  live  for  fifteen  or  twenty  years. 

Diagnosis. — In  the  initial  stage  the  lightning  pains  are  almost  distinctive, 
and  when  combined  with  any  of  the  other  signs  are  quite  so.  The  associatipn 
of  progressive  atrophy  of  the  optic  nerves  with  loss  of  knee-jerk  is  also  char- 
acteristic. The  early  ocular  palsies  are  of  the  greatest  importance.  A  squint, 
ptosis,  or  the  Argyll  Eobertson  pupil  may  be  the  first  symptom,  and  may  exist 
with  the  loss  only  of  the  knee-jerk.  Loss  of  the  knee-jerk  alone,  however, 
does  occasionally  occur  in  healthy  individuals.  A  history  of  preceding  syphilis 
lends  added  weight  to  the  symptoms,  and  its  presence  or  absence  may  be  of 
the  utmost  importance  in  determining  the  diagnosis.  If  the  possibility  of 
syphilitic  infection  can  be  excluded,  a  circumstance  but  too  rarely  met  with, 
only  the  most  unequivocal  combination  of  symptoms  can  justify  the  diagnosis 
of  locomotor  ataxia.  Cytodiagnosis  may  be  a  help  in  doubtful  cases  (see 
General  Paresis),  and  Wassermann's  reaction  may  be  present. 

The  diseases  most  likely  to  be  confounded  with  locotomor  ataxia  are :  ( 1 ) 
Peeipheral  Neuritis. — The  steppage  gait  of  arsenical,  alcoholic,  or  diabetic 
paralysis  is  quite  unlike  that  of  locomotor  ataxia.  In  these  forms  there  is  a 
paralysis  of  the  feet,  and  the  leg  is  lifted  high  in  order  that  the  toes  may  clear 
the  floor.  The  use  of  the  word  ataxia  in  this  connection  should  no  longer  be 
continued.  In  the  rare  cases  in  which  the  muscle  sense  nerves  are  particularly 
affected  and  in  which  there  is  true  ataxia,  the  absence  of  the  lightning  pains 
and  eye  symptoms  and  the  history  will  suffice  in  a  majority  of  cases  to  make 
the  diagnosis  clear.  In  diphtheritic  paralysis  the  early  loss  of  the  knee-jerk 
and  the  associated  eye  symptoms  may  suggest  tabes,  but  the  history,  the  exist- 
ence of  paralysis  of  the  throat,  and  the  absence  of  pains  render  a  diagnosis 
easy. 

(2)  Ataxic  Paraplegia. — Marked  incoordination  with  spastic  paralysis 
is  characteristic  of  the  condition  which  Growers  has  termed  ataxic  paraplegia. 
In  a  majority  of  the  cases  this  affection  is  distinguished  also  by  the  absence 
of  pains  and  of  eye  symptoms,  but  it  may  be  a  manifestation  of  the  cord  lesions 
in  tabo-paralysis. 

(3)  Cerebral  Disease. — In  diseases  of  the  brain  involving  the  afferent 
tracts  ataxia  is  at  times  a  prominent  symptom.  It  is  usually  unilateral  or 
limited  to  one  limb;  this,  with  the  history  and  the  associated  symptoms, 
excludes  tabes. 

(4)  Cerebellar  Disease. — The  cerebellar  incoordination  has  only  a 
superficial  resemblance  to  that  of  locomotor  ataxia,  and  is  more  a  disturbance 
of  equilibrium  than  a  true  ataxia;  the  knee-jerk  is  usually  present,  there  are 
no  lightning  pains,  no  sensory  disturbances;  while,  on  the  other  hand,  there 
are  headache,  optic  neuritis,  and  vomiting. 

(5)  Some  acute  affections  involving  the  dorsal  columns  of  the  cord  may 
be  followed  by  incoordination  and  resemble  tabes  very  closely.  In  a  case  under 
my  care,  the  gait  was  characteristic  and  Romberg's  symptom  was  present. 
The  knee-jerk,  however,  was  retained  and  there  were  no  ocular  symptoms. 
The  condition  had  developed  within  three  or  four  months,  and  there  was  a 
well-marked  history  of  syphilis.  Under  large  doses  of  iodide  of  potassium 
the  ataxia  and  other  symptoms  completely  disappeared. 


894  DISEASES  OF  THE  NERVOUS  SYSTEM. 

(6)  General  Paresis. — Even  though  these  two  diseases  are  so  uearly 
allied  and  often  associated,  it  is  of  very  great  practical  importance  to  deter- 
mine, when  possible,  whether  the  type  is  to  be  spinal  or  cerebral,  for,  in  the 
great  majorit}^  of  cases,  when  this  is  established,  it  does  not  change.  The 
difficulty  arises  in  the  premonitory  stage,  when  ocular  changes  and  abnor- 
malities of  sensation  and  the  deep  reflexes  may  be  the  only  symptoms.  At 
this  stage  any  alteration  in  the  mental  characteristics  is  of  the  utmost  sig- 
nificance. (See  General  Paresis.)  Loss  of  the  deep  reflexes  and  lightning 
pains  speak  for  tabes;  active  reflexes,  with  ocular  changes,  especially  ojjtic 
atrophy,  are  suggestive  of  paresis, 

(7)  Visceral  crises  and  >7EItralgic  symptoms  may  lead  to  error,  and  in 
middle-aged  men  with  severe,  recurring  attacks  of  gastralgia  it  is  always 
well  to  bear  in  mind  the  possibility  of  tabes,  and  to  make  a  careful  examina- 
tion of  the  eyes  and  of  the  knee-jerk. 

Prognosis. — Complete  recovery  can  not  be  expected,  but  arrest  of  the 
process  is  not  uncommon  and  a  marked  amelioration  of  the  symptoms  is 
frequent.  Optic-nerve  atrophy,  one  of  the  most  serious  events  in  the  disease, 
has  this  hopeful  aspect — that  incoordination  rarely  follows  and  the  progress 
of  the  spinal  sjTnptoms  may  be  arrested.  On  the  other  hand,  mental  symptoms 
are  nxore  likely  to  follow.  The  optic  atrophy  itself  is  occasionally  checked. 
On  the  whole,  the  prognosis  in  tabes  is  bad.  The  experience  of  such  men  as 
Weir  Mitchell,  Charcot,  and  Gowers  is  distinctly  opposed  to  the  belief  that 
locomotor  ataxia  is  ever  completely  cured.  Xo  such  ease  has  come  under 
my  personal  observation. 

Treatment. — To  arrest  the  progress  and  to  relieve,  if  possible,  the  S3Tnp- 
toms  are  the  objects  which  the  practitioner  should  have  in  view.  A  quiet,  well- 
regulated  method  of  life  is  essential.  It  is  not  well,  as  a  rule,  for  a  patient  to 
give  up  his  occupation  so  long  as  he  is  able  to  keep  about  and  perform  ordinary 
work,  provided  there  is  no  evident  mental  change.  I  know  tabetics  who  have 
for  years  conducted  large  businesses,  and  there  have  been  several  notable  in- 
stances in  our  profession  of  men  who  have  risen  to  distinction  in  spite  of  the 
existence  of  this  disease.  Excesses  of  all  sorts,  more  particularly  in  hacclio 
et  venere,  should  be  carefully  avoided.  A  man  in  the  pre-ataxic  stage  should 
not  marry. 

Care  should  be  taken  in  the  diet,  particularly  if  gastric  crises  have  oc- 
curred. To  secure  arrest  of  the  disease  many  remedies  have  been  employed. 
Although  syphilis  plays  such  an  important  role  in  the  etiolog}^,  it  is  univer- 
sally acknowledged  that  neither  mercury  nor  the  iodide  of  potassium  have  any- 
thing like  the  same  influence  over  the  tabetic  lesions  that  they  have  over  the 
ordinary  syphilitic  processes.  However,  when  the  syphilis  is  comparatively 
recent,  when  symptoms  develop  within  two  years  of  the  primary  infection, 
the  disease  may  be  arrested  by  mercury  and  iodide  of  potassium.  The  French 
authors  have  recently  spoken  mnch  more  hopefully  of  the  benefit  of  anti- 
syphilitic  treatment  in  early  cases  of  tabes,  and  it  is  well  to  give  the  patient 
the  benefit  of  at  least  one  thorough  course  of  mercurial  inunctions  and  iodide 
of  potassium.  Of  remedies  which  may  be  tried  and  are  believed  by  some 
writers  to  retard  the  progress,  the  following  are  recommended :  Arsenic  in 
full  doses,  nitrate  of  silver  in  quarter-grain  doses,  Calabar  bean,  ergot,  and 
the  preparations  of  gold. 


SYSTEM  DISEASES.  895 

For  the  pains,  complete  rest  in  bed,  as  advised  by  Weir  Mitchell,  and 
coimter-irritation  to  the  spine  (either  blisters  or  the  thermo -cautery)  may 
be  employed.  The  severe  spells  which  come  on  particularly  after  excesses  of 
any  kind  are  often  promptly  relieved  by  a  hot  bath  or  by  a  Turkish  bath. 
For  the  severe  recurring  attacks  of  lightning  pains  spinal  cocainization  may 
be  tried.  In  an  instance  reported  to  me  by  Dr.  George  Goodfellow,  of  San 
Francisco,  excellent  results  followed.  A  prolonged  course  of  nitrate  of  silver 
seems  in  some  cases  to  allay  the  pains  and  lessen  the  liability  to  the  attacks. 
I  have  never  seen  ill  effects  from  its  use  in  spinal  sclerosis.  Antipyrin  and 
antifebrin  may  be  employed,  and  occasionally  do  good,  but  their  analgesic 
powers  in  this  disease  have  been  greatly  overrated.  Cannabis  indica  is  some- 
times useful.  In  the  severe  paroxysms  of  pain  hypodermics  of  morphia  or  of 
cocaine  must  be  used.  The  use  of  morphia  should  be  postponed  as  long  as 
possible.  Electricity  is  of  very  little  benefit.  For  the  severe  attacks  of  gas- 
tralgia,  morphia  is  also  required.  The  laryngeal  crises  are  rarely  dangerous. 
x\n  application  of  cocaine  may  be  made  during  the  spasm,  or  a  few  whiffs  of 
chloroform  may  be  given,  or  nitrate  of  amyl.  In  all  cases  of  tabes  with  in- 
creased arterial  tension  the  prolonged  use  of  nitroglycerin,  given  in  increasing 
doses  until  the  physiological  effect  is  produced,  is  of  great  service  in  allaying 
the  neuralgic  pains  and  diminishing  the  frequency  of  the  crises.  Its  use  must 
be  guarded  when  there  is  aortic  insufficiency.  The  special  indication  is  in- 
creased tension.  The  bladder  symptom^  demand  constant  care.  When  the 
organ  can  not  be  perfectly  emptied  the  catheter  should  be  used,  and  the  patient 
may  be  taught  its  use  and  how  to  keep  it  thoroughly  sterilized. 

Frenkel's  method  of  re-education  often  helps  the  patient  to  regain  to  a 
considerable  extent  the  control  of  the  voluntary  movements  which  he  has 
lost.  (English  translation  of  his  work  by  P.  Blakiston's  Son  &  Co.)  By  this 
method  the  patient  is  first  taught,  by  repeated  systematic  efforts,  to  perform 
simple  movements ;  from  this  he  goes  to  more  and  more  complex  movements. 
The  treatment  should  be  directed  and  supervised  by  a  trained  teacher,  as  the 
result  depends  upon  the  skill  of  the  teacher  quite  as  much  as  upon  the  perse- 
verance of  the  patient. 

General  Paralysis  of  the  Insane  and  Tabo-paralysis 
(Dementia  Paralytica;  General  Paresis). 

As  has  been  said  in  the  last  section,  the  belief  in  the  essential  identity  of 
general  paralysis  and  tabes  has  gained  more  and  more  ground  and  has  much  in 
its  favor.  Mott  says :  "  I  maintain  that  etiologically  and  pathogenetically  there 
is  one  tales  which  may  begin  in  the  brain  (especially  in  certain  regions),  or  in 
the  spinal  cord  in  certain  regions,  or  in  the  peripheral  nervous  structures  con- 
nected with  vision,  or  in  nervous  structures  connected  with  the  viscera, 
constituting,  therefore,  different  types,  any  of  which  m^ay  be  present  or  be 
associated  with  one  or  all  of  the  others.^'  Fournier  has  taken  practically  the 
same  view  and  describes  them  together  under  the  heading  Les  Affections  Para- 
sypliilitiques.  Moebius,  Shaffer,  and  others  are  equally  positive  in  their 
statements. 

It  is  undoubted  that  most  cases  of  tabes  run  their  course  with  practically 
no  mental  symptoms,  and  that  cases  of  general  paralysis  may  never  present 


896  DISEASES  OF   THE  NERVOUS  SYSTEM. 

symptoms  that  suggest  tabes.  For  practical  purposes  we  are  forced  to  keep 
the  distinction  clearly  in  mind,  and  for  this  reason  it  seems  best,  at  least  for 
the  present,  to  consider  them  separately. 

There  is,  however,  a  group  of  cases  in  which  the  symptoms  of  the  two  dis- 
eases are  associated  in  every  combination.  The  name  "  tabo-paralysis  "  has 
been  given  to  these  cases. 

(a)   General  Paralysis. 

Definition. — A  chronic,  progressive  disease  of  the  brain  and  its  meninges, 
associated  with  psychical  and  motor  disturbances,  finally  leading  to  dementia 
and  paralysis. 

Etiology. — As  in  tabes,  the  most  important  individual  factor  is  syphilis, 
which  is  antecedent  in  both  conditions  in  from  70  to  90  per  cent  of  all  cases. 
Males  are  affected  much  more  frequently  than  females.  It  occurs  chiefly 
between  the  ages  of  thirty  and  fifty-five,  although  it  may  begin  in  childhood 
as  the  result  of  congenital  syphilis.  An  overwhelming  majority  of  the  cases 
are  in  married  people,  and  not  infrequently  both  husband  and  wife  are  affected, 
or  one  has  paresis  and  the  other  tabes.  Statistics  show  that  it  is  more  common 
in  the  lower  classes  of  society,  but  in  America  in  general  medical  practice  the 
disease  is  certainly  more  common  in  the  well-to-do  classes.  Heredity  is  a 
more  important  factor  here  than  in  tabes,  although  its  influence  is  not  great. 
An  important  predisposing  cause  is  "  a  life  absorbed  in  ambitious  projects 
with  all  its  strongest  mental  efforts,  its  long-sustained  anxieties,  deferred 
hopes,  and  straining  expectation^'  (Mickle).  The  habits  of  life  so  frequently 
seen  in  active  business  men  in  our  large  cities,  and  well  expressed  by  the 
phrase  "  burning  the  candle  at  both  ends,"  strongly  predispose  to  the  disease. 

Morbid  Anatomy. — The  dura  is  often  thickened,  and  its  inner  surface 
may  show  the  various  forms  of  hypertrophic  pachymeningitis.  The  pia  is 
cloudy,  thickened,  and  adherent  to  the  cortex.  The  cerebro-spinal  fluid  is 
increased  in  the  meningeal  spaces,  especially  in  the  meshes  of  the  pia,  and  at 
times  to  such  an  extent  as  to  resemble  cysts.  The  brain  is  small,  and  weighs 
less  than  normal.  The  convolutions  are  atrophied,  especially  in  the  anterior 
and  middle  lobes.  In  acute  cases  the  brain  may  be  swollen,  hyperffimic,  and 
oedematous.  The  brain  cortex  is  usually  red,  and,  except  in  advanced  cases, 
it  may  not  be  atrophied,  the  atrophy  of  the  hemispheres  being  at  the  expense 
of  the  white  matter.  The  lateral  ventricles  are  dilated  to  compensate  for  the 
atrophy  of  the  brain,  and  the  ependyma  may  be  granular.  The  fourth  ven- 
tricle is  more  constantly  dilated,  with  granulations  of  its  floor  covering  the 
calamus  scriptorius,  a  condition  seldom  seen  in  any  other  affection. 

Histologically  there  is  atrophy  of  the  nerve  fibres,  especially  the  tangental 
and  supra-radial,  degeneration  of  the  nerve  cells  of  the  cortex,  and  a  great 
overgrowth  of  the  neuroglia,  with  the  presence  of  numerous  giant  spider  cells. 
In  the  dilated  adventitial  spaces  of  the  blood-vessels  there  is  a  great  accumu- 
lation of  cells — plasma  cells  with  a  few  lymphocytes  and  an  occasional  mast 
cell.  In  the  tissue  itself  are  found  the  curious  rod-shaped  structures,  which 
are  derived  from  the  vessel  walls.  Compound  granular  corpuscles  are  also 
found  near  necrotic  areas.  There  is  often  a  very  great  increase  in  the  small 
blood-vessels,  and  various  kinds  of  alterations  of  the  vessel  walls  have  been 
described.     The  improved  methods  of  staining  the  neuro-fibrils   (Cajal  and 


SYSTEM  DISEASES.  897 

Pielschowsky)  are  beginning  to  tlirow  light  upon  the  essential  cellular 
changes. 

The  disease  process  is  diffuse,  and  affects  practically  all  parts  of  the  brain, 
but  its  intensity  varies  greatly,  even  in  adjoining  areas.  As  a  rule  the  cortex 
of  the  frontal  and  central  convolutions  and  the  gray  matter  about  the  ven- 
tricles are  most  affected. 

In  many  cases  changes  are  present  in  the  spinal  cord  and  peripheral  nerves. 
There  are  the  typical  tabetic  changes  described  in  the  preceding  section.  There 
may  be  degeneration  of  the  pyramidal  systems  of  fibres  secondary  to  the  cor- 
tical changes.  Most  commonly  there  is  a  combination  of  these  two  processes. 
Foci  of  haemorrhages,  and  softening  dependent  upon  coarse  vascular  changes, 
are  not  infrequently  found,  but  are  not  typical  of  the  disease. 

There  are  various  views  as  to  the  nature  of  the  changes.  The  vascular 
theory  is  that  from  an  inflammatory  process  starting  in  the  sheaths  of  the 
arterioles  there  is  a  diffuse  parenchymatous  degeneration  with  atrophic  changes 
in  the  nerve  cells  and  neuroglia.  The  most  generally  accepted  view  is  that 
some  unknown  toxin  causes  degeneration  in  the  nervous  tissues  with  secondary 
changes  in  the  neuroglia  and  vascular  systems. 

Symptoms. — Pkodromal  Stage. — This  is  of  variable  duration,  and  is  char- 
acterized by  a  general  mental  state  which  finds  expression  in  symptoms  trivial 
in  themselves  but  important  in  connection  with  others.  Irritability,  inatten- 
tion to  business  amounting  sometimes  to  indifference  or  apathy,  and  some- 
times a  change  in  character,  marked  by  acts  which  may  astonish  the  friends 
and  relatives,  may  be  the  first  indications.  There  may  be  unaccountable 
fatigue  after  moderate  physical  or  mental  exertion.  Instead  of  apathy  or  indif- 
ference there  may  be  an  extraordinary  degree  of  physical  and  mental  restless- 
ness. The  patient  is  continually  planning  and  scheming,  or  may  launch  into 
extravagances  and  speculation  of  the  wildest  character.  A  common  feature 
at  this  period  is  the  display  of  an  unbounded  egoism.  He  boasts  of  his  per- 
sonal attainments,  his  property,  his  position  in  life,  or  of  his  wife  and  chil- 
dren. Following  these  features  are  important  indications  of  moral  perversion, 
manifested  in  offences  against  decency  or  the  law,  many  of  which  acts  have 
about  them  a  suspicious  effrontery.  Forgetfulness  is  common,  and  may  be 
shown  in  inattention  to  business  details  and  in  the  minor  courtesies  of  life. 
At  this  period  there  may  be  no  motor  phenomena.  The  onset  of  the  disease  is 
usually  insidious,  although  cases  are  reported  in  which  epileptiform  or  apo- 
plectiform seizures  were  the  first  symptoms.  Among  the  early  motor  features 
are  tremor  of  the  tongue  and  lips  in  speaking,  slowness  of  speech  and  hesi- 
tancy. Inequality  of  the  pupils,  the  Argyll  Robertson  pupil,  optic  atrophy, 
and  changes  in  the  deep  refiexes  may  precede  the  occurrence  of  mental  symp- 
toms for  years. 

Second  Stage. — This  is  characterized  in  brief  by  mental  exaltation  or 
excitement  and  a  progress  in  the  motor  symptoms.  "  The  intensity  of  the 
excitement  is  often  extreme,  acute  maniacal  states  are  frequent;  incessant 
restlessness,  obstinate  sleeplessness,  noisy,  boisterous  excitement,  and  blind, 
uncalculating  violence  especially  characterize  such  states"  (Lewis).  It  is  at 
this  stage  that  the  delusion  of  grandeur  becomes  marked  and  the  patient 
believes  himself  to  be  possessed  of  countless  millions  or  to  have  reached  the 
most  exalted  sphere  possible  in  profession  or  occupation.     This  expansive 


DISEASES  OF  THE  NERVOUS  SYSTEM. 

delirium,  as  it  is  called,  is,  however,  not  characteristic,  as  was  formerly  sup- 
posed, of  paralytic  dementia.  Besides,  it  does  not  always  occur,  but  in  its 
stead  there  may  be  marked  melancholia  or  hypochondriasis,  or,  in  other  in- 
stances, alternate  attacks  of  delirium  and  depression. 

The  facies  has  a  peculiar  stolidity,  and  in  speaking  there  is  marked  tremu- 
lousness  of  the  lips  and  facial  muscles.  The  tongue  is  also  tremulous,  and  may 
be  protruded  with  difficulty.  The  speech  is  slow,  interrupted,  and  blurred. 
Writing  becomes  difficult  on  account  of  unsteadiness  of  the  hand.  Letters, 
syllables,  and  words  may  be  omitted.  The  subject  matter  of  the  patient's 
letters  gives  valuable  indications  of  the  mental  condition.  In  many  instances 
the  pupils  are  unequal,  irregular,  sluggish,  sometimes  large.  Important 
symptoms  in  this  stage  are  apoplectiform  seizures  and  paralysis.  There  may 
be  slight  sjTicopal  attacks  in  which  the  patient  turns  pale  and  may  fall.  Some 
of  these  are  petit  mal.  In  the  true  apoplectiform  seizure  the  patient  falls  sud- 
denly, becomes  unconscious,  the  limbs  are  relaxed,  the  face  is  flushed,  the 
breathing  stertorous,  the  temperature  increased,  and  death  may  occur.  Epi- 
leptic seizures  are  more  common  than  the  apoplectiform.  There  may  be 
a  definite  aura.  The  attack  usually  begins  on  one  side  and  may  not  spread. 
There  may  be  twitchings  either  in  the  facial  or  brachial  muscles.  Typical 
Jacksonian  epilepsy  may  occur.  In  a  case  which  died  recently  under  my 
care,  these  seizures  were  among  the  early  symptoms  and  the  disease  was 
regarded  as  cerebral  syphilis.  Eecurring  attacks  of  aphasia  are  not  un- 
common, and  paralysis,  either  monoplegic  or  hemiplegic,  may  follow  these 
epileptic  seizures,  or  may  come  on  with  great  suddenness  and  be  transient. 
In  this  stage  the  gait  becomes  impaired,  the  patient  trips  readily,  has  diffi- 
culty in  going  up  or  down  stairs,  and  the  walk  may  be  spastic  or  occa- 
sionally tabetic.  This  paresis  may  be  progressive.  The  deep  reflexes  are 
usually  increased,  but  may  be  lost.  Bladder  or  rectal  symptoms  gradually 
develop.  The  patient  becomes  helpless,  bedridden,  and  completely  demented, 
and  unless  care  is  taken  may  suffer  from  bedsores.  Death  occurs  from  exhaus- 
tion or  from  some  intercurrent  affection.  The  spinal-cord  features  of  dementia 
paralytica  may  come  on  with  or  precede  the  mental  troubles.  There  are  cases 
in  which  one  is  in  doubt  for  a  time  whether  the  symptoms  indicate  tal^es  or 
dementia  paralytica,  and  it  is  well  to  bear  in  mind  that  every  feature  of  pre- 
ataxic  tabes  may  exist  in  the  early  stage  of  general  paresis. 

(&)  Taho-paralysis. 

Emphasis  has  been  laid  on  the  probable  identity  of  the  processes  underlying 
tabes  and  dementia  paralytica,  the  spinal  cord  in  the  first  case  receiving  the 
full  force  of  the  attack,  and  the  brain  in  the  second.  It  has  been  thought  that 
stress  is  the  factor  which  determines  the  location  of  the  process,  and  that  men 
whose  occupations  require  much  bodily  exercise  would  be  apt  to  have  tabes, 
while  those  whose  activities  are  largely  mental  would  suffer  from  paresis. 
Usually  when  the  cord  symptoms  are  pronounced  the  symptoms  from  the  brain 
remain  in  abeyance,  and  the  reverse  is  also  true.  There  are  exceptions  to 
this,  and  cases  of  well  marked  tabes  may  later  show  the  typical  symptoms 
of  paresis,  but  even  then  the  ataxia,  if  it  is  not  of  too  high  a  grade,  often 
improves. 


SYSTEM  DISEASES.  899 

Optic  atrophy,  when  it  occurs  in  the  pre-ataxic  stage  of  tabes,  usually  indi- 
cates that  the  ataxia  will  never  be  pronounced,  but  unfortunately  it  is  fre- 
quently followed  by  the  occurrence  of  mental  symptoms.  Mott  believes  that 
about  50  per  cent  of  his  asylum  cases  of  tabo-paralysis  had  had  preceding  optic 
atrophy.  Its  occurrence  is  therefore  of  grave  significance.  The  mental  symp- 
toms may  be  delayed  for  many  years. 

The  symptom  complex  of  tabo-paralysis  is  made  up  of  a  combination  of 
the  symptoms  of  the  two  conditions,  and  varies  greatly.  It  may  begin  as  tabes 
with  lightning  pains,  bladder  symptoms,  Argyll  Eobertson  pupil,  loss  of  the 
deep  reflexes,  etc.,  to  have  the  mental  symptoms  added  later ;  or,  on  the  other 
hand,  cord  symptoms  may  come  on  after  the  patient  has  shown  marked 
mental  changes.  In  a  number  of  cases  the  symptoms  are  from  the  first  so 
combined  that  the  name  tabo-paralysis  is  at  once  applicable.  Absent  knee- 
jerks,  ocular  palsies,  or  pupillary  symptoms  may  precede  the  breakdown  for 
many  years,  but  none  of  them  have  so  grave  a  significance  in  regard  to  the 
mental  state  as  has  optic  atrophy.  Other  types  of  alienation  may  interrupt 
the  course  of  tabes,  and  the  mistake  must  not  be  made  of  regarding  them 
all  as  general  paralysis.  In  such  instances  the  mind  may  become  clear  and 
remain  so  to  the  end. 

Diagnosis. — The  recognition  of  general  paralysis  in  the  earliest  stage  is 
extremely  difficult,  as  it  is  often  impossible  to  decide  that  the  slight  altera- 
tion in  conduct  is  anything  more  than  one  of  the  moods  or  phases  to  which 
most  men  are  at  times  subject.  The  following  description  by  Folsom  is  an 
admirable  presentation  of  the  diagnostic  characters  of  the  early  stage  of  the 
disease :  "  It  should  arouse  suspicion  if,  for  instance,  a  strong,  healthy  man, 
in  or  near  the  prime  of  life,  distinctly  not  of  the  '  nervous,'  neurotic,  or  neu- 
rasthenic type,  shows  some  loss  of  interest  in  his  affairs  or  impaired  faculty  of 
attending  to  them;  if  he  becomes  varyingly  absent-minded,  heedless,  indif- 
ferent, negligent,  apathetic,  inconsiderate,  and,  although  able  to  follow  his 
routine  duties,  his  ability  to  take  up  new  work  is,  no  matter  how  little, 
diminished;  if  he  can  less  well  command  mental  attention  and  concentration, 
conception,  perception,  reflection,  judgment;  if  there  is  an  unwonted  lack  of 
initiative,  and  if  exertion  causes  unwonted  mental  and  physical  fatigue;  if  the 
emotions  are  intensified  and  easily  change,  or  are  excited  readily  from  trifling 
causes ;  if  the  sexual  instinct  is  not  reasonably  controlled ;  if  the  finer  feelings 
are  even  slightly  blunted;  if  the  person  in  question  regards  with  a  placid 
apathy  his  own  acts  of  indifference  and  irritability  and  their  consequences, 
and  especially  if  at  times  he  sees  himself  in  his  true  light  and  suddenly  fails 
again  to  do  so;  if  any  symptoms  of  cerebral  vaso-motor  disturbances  are 
noticed,  however  vague  or  variable," 

There  are  cases  of  cerebral  syphilis  which  closely  simulate  dementia  para- 
lytica. The  mode  of  onset  is  important,  particularly  since  paralytic  symp- 
toms are  usually  early  in  syphilis.  The  affection  of  the  speech  and  tongue 
is  not  present.  Epileptic  seizures  are  more  common  and  more  liable  to  be 
cortical  or  Jacksonian  in  character.  The  expansive  delirium  is  rare.  While 
symptoms  of  general  paresis  are  not  common  in  connection  with  the  develop- 
ment of  gummata  or  definite  gummatous  meningitis,  there  are,  on  the  other 
hand,  instances  of  paresis  following  closely  upon  the  syphilitic  infection. 
Post  mortem  in  such  cases  there  may  be  nothing  more  than  a  general  arterio- 


900  DISEASES  OF  THE  NERVOUS  SYSTEM. 

sclerosis  and  diffuse  meningo-enceplialitis,  which  may  present  nothing  dis- 
tinctive, but  the  lesions,  nevertheless,  may  be  caused  by  the  syphilitic  virus. 
Cases  also  occur  in  which  typical  syphilitic  lesions  are  combined  with  the  ordi- 
nar}'  lesions  of  dementia  paralytica.  There  are  certain  forms  of  lead  enceph- 
alopathy which  resemble  general  paresis,  and,  considering  the  association  of 
plumbism  with  arterio-sclerosis,  it  is  not  unlikely  that  the  anatomical  sub- 
stratum of  the  disease  may  result  from  this  poison.  Tumor  may  sometimes 
simulate  progressive  paresis,  but  in  the  former  the  signs  of  general  increase 
of  the  intracranial  pressure  are  usually  present.  The  Wassermann  reaction 
(see  SA'iDhilis)  is  present  in  a  majority  of  cases. 

Cytodiagnosis. — The  study  of  the  cellular  elements  suspended  in  the  cere- 
bro-spinal  fluid,  first  instituted  by  Widal  and  Eavaut  (1900)  in  cases  of  de- 
mentia paralytica,  has  come  to  be  an  important  diagnostic  measure,  particu- 
larly in  tabes  and  paresis.  In  both  of  these  affections  spinal  hmiphocytosis  is 
the  rule  and  is  usually  associated  with  a  marked  albumin  reaction — the  nor- 
mal fluid  containing  no  albumiu,  or  at  most  minute  traces,  and  a  negligible 
number  of  formed  elements.  It  is  simply  the  expression  of  a  subacute  or 
clironic  inflammatory  process,  just  as  polymorphonuclear  leukocytosis  is  char- 
acteristic of  an  acute  process.  It  is,  however,  first  and  foremost  the  syphilitic 
triad — tabes,  paresis,  and  cerebro-spinal  lues — which  is  suggested  by  lympho- 
c}i;osis  in  the  spinal  fluid.  Positive  reactions,  etiological  and  chemical,  are 
among  the  earliest  somatic  s}Tnptoms,  and  may  therefore  clear  up  obscure 
cases  of  tabes  and  paresis,  just  at  the  time  when  diagnosis  is  most  difficult. 

Prognosis. — The  disease  rarely  ends  in  recovery.  As  a  rule  the  progress 
is  si  owl}'  downward  and  the  case  terminates  in  a  few  years,  although  it  is 
occasionally  prolonged  ten  or  fifteen  years. 

Treatment. — The  only  hope  of  permanent  relief  is  in  the  cases  following 
sj^philis,  which  should  be  placed  upon  large  doses  of  iodide  of  potassium,  and 
given  a  mercurial  course.  Careful  nursing  and  the  orderly  life  of  an  asylum 
are  the  only  measures  necessary  in  a  great  majority  of  the  cases.  For  sleep- 
lessness and  the  epileptic  seizures  bromides  may  be  used.  Prolonged  remis- 
sions, which  are  not  uncommon,  are  often  erroneously  attributed  to  the  action 
of  remedies.  Active  treatment  in  the  early  stage  by  wet-packs,  cold  to  the 
head,  and  systematic  massage  have  been  followed  by  temporary  improvement. 

Herpes  Zostee 
{Zona;  Acute  HcBmorrliagic  Inflammation  of  the  Dorsal  Root  Ganglia). 

Zoster  is  an  acute  specific  disease  of  the  nervous  system  with  a  localization 
in  the  ganglia  of  the  posterior  roots  (Head  and  Campbell).  There  are  hsemor- 
rhages  and  inflammatory  foci,  with  destruction  of  certain  of  the  ganglion  cells, 
leading  to  degeneration  of  their  axis-cylinder  processes.  "W.  T.  Howard  has 
shown,  even  in  the  herpes  facialis  such  as  accompanies  pneumonia,  that  hsemor- 
rhagic  lesions  akin  to  those  of  true  zoster  are  demonstrable  in  the  Gasserian 
ganglion.     The  two  conditions,  however,  are  etiologically  quite  distinct. 

Chauffard  reports  cases  which  indicate  an  extension  of  the  process  from 
the  posterior  ganglia  to  the  neighboring  meninges.  There  may  be  pains  down 
the  spine,  girdle  pains,  and  exaggerated  knee  jerks  with  marked  lymphocytosis. 
Herpes  auricularis  is  associated  with  lesions  in  the  otic  ganglion    (Ramsay 


SYSTEM  DISEASES.  901 

Hunt),  and  this  form  may  be  complicated  with  a  transient  facial  paralysis  and 
sometimes  with  severe  auditory  symptoms. 

In  zoster  there  is  often  a  prodromal  period,  in  which  the  patient  feels  ill, 
has  pain,  and  the  rash  comes  out  on  the  third  or  fourth  day.  The  character- 
istic outcrop  of  vesicles  has  a  segmental  distribution,  one  or  more  of  the 
adjoining  skin-fields  being  affected,  almost  invariably  limited  to  one  side  of 
the  body.  With  involvement  of  cervical,  lumbar,  or  sacral  ganglia  the  zonal 
or  girdle  form  of  the  vesicular  outcrop,  from  which  the  disease  gets  its  name, 
is  naturally  lost  owing  to  the  distortion  of  the  skin-fields  from  the  growth 
of  the  limbs.  It  is  present  in  its  typical  form  only  when  the  thoracic  ganglia 
are  aifected.  The  eruption  is  most  abundant  in  patches,  corresponding  to  the 
anterior,  lateral,  and  posterior  divisions  of  the  nerves,  and  in  severe  cases 
the  vesicles  over  these  areas  may  become  confluent  and  lead  to  ulcerations. 
True  zoster  not  infrequently  affects  one  or  more  of  the  divisions  of  the  Gas- 
serian  ganglion. 

Individuals  rarely  suffer  from  more  than  one  attack  of  zoster.  The  disease 
is  much  more  common  in  children,  in  whom  it  may  be  accompanied  by  slight, 
if  any,  discomfort,  and  leave  no  traces.  Severe  cases  in  elderly  people,  how- 
ever, are  often  followed  by  the  most  intractable  forms  of  neuralgia. 


III.    DISEASES   OF  THE  EFFERENT  OR  MOTOR  TRACT. 

A.    OF    WHOLE    TRACT. 

1.  Progressive  (Central)  Muscular  Atrophy 

(Poliomyelitis  Anterior  Chronica;  Amyotrophic  Lateral  Sclerosis;  Progressive 

Bulbar  Paralysis). 

Definition. — A  disease  characterized  by  a  chronic  degeneration  of  the  motor 
tract.  The  whole  tract  is  usually  involved,  but  at  times  the  degeneration  is 
limited  to  the  lower  segment.  Associated  with  it  is  a  progressive  atrophy  of 
the  muscles,  combined  with  more  or  less  spastic  rigidity.  Three  affections, 
as  a  rule  described  apart,  belong  together  in  this  category:  (a)  Progressive 
muscular  atrophy  of  spinal  origin;  (&)  amyotrophic  lateral  sclerosis;  and  (c) 
progressive  bulbar  paralysis.  A  slow  atrophic  change  in  the  motor  neurones  is 
the  anatomical  basis,  and  the  disease  is  one  of  the  whole  motor  path,  involving, 
in  many  cases,  the  cortical,  bulbar,  and  spinal  centres.  There  may  be  simple 
muscular  atrophy  with  little  or  no  spasm,  or  progressive  wasting  with  marked 
spasm'  and  great  increase  in  the  reflexes.  In  others,  there  are  added  symptoms 
of  involvement  of  the  motor  nuclei  in  the  medulla — a  glosso-labio-laryngeal 
paralysis;  while  in  others,  again,  with  atrophy  (especially  of  the  arms),  a 
spastic  condition  of  the  legs  and  bulbar  phenomena,  tremors  develop  and  signs 
of  cortical  lesion.    These  various  stages  may  be  traced  in  the  same  case. 

For  convenience,  bulbar  paralysis  will  be  considered  separately,  and  I  shall 
here  take  up  together  progressive  muscular  atrophy  and  amyotrophic  lateral 
sclerosis. 

The  disease  is  known  as  the  Aran-Duchenne  type  of  progressive  muscular 
atrophy  and  as  Cruveilhier's  palsy,  after  the  French  physicians  who  early  de- 


902  DISEASES  OF  THE  NERVOUS  SYSTEM. 

scribed  it.  Luys  and  Lockhart  Clarke  first  demonstrated  that  the  cells  of  the 
ventral  horns  of  the  spinal  cord  were  diseased.  Charcot  separated  two  types — 
one  with  simple  wasting  of  the  muscles,  due,  he  believed,  to  degeneration 
confined  to  the  ventral  horns  (and  to  this  he  restricted  the  name  progressive 
muscular  atrophy — type,  Aran-Duchenne) ;  the  other,  in  which  there  was  spas- 
tic paralysis  of  the  muscles  followed  by  atrophy.  As  the  anatomical  basis  for 
this  he  assumed  a  primary  degeneration  of  the  pyramidal  tracts  and  a  second- 
ary atrophy  of  the  ventral  horns.  To  this  he  gave  the  name  of  amyotrophic 
lateral  sclerosis.  There  is  but  little  evidence,  however,  to  show  that  any  such 
sharp  distinction  can  be  made  between  these  two  diseases,  and  Leyden  and 
Gowers  regard  them  as  identical. 

Etiology. — The  cause  of  the  disease  is  unknown.  It  is  more  frequent  in 
males  than  in  females.  It  affects  adults,  developing  after  the  thirtieth  year, 
though  occasionally  younger  persons  are  attacked.  A  large  majority  of  all 
cases  of  progressive  muscular  atrophy  under  twenty-five  years  of  age  belong 
to  the  dystrophies.  Cold,  wet,  exposure,  fright,  and  mental  worries  are  men- 
tioned as  possible  causes.  Erb  has  lately  called  attention  to  certain  cases  fol- 
lowing injury.  Hereditary  influences  are  present  in  certain  cases.  The  rare 
form  which  occurs  in  infancy  usually  affects  several  members  of  the  same 
family.  Hereditary  and  family  influences,  however,  play  but  a  small  part  in 
the  etiology  of  this  disease,  and  in  this  it  is  in  contrast  to  progressive  neural 
muscular  atrophy  and  the  dystrophies.  Yet,  in  the  Farr  family,  which  I 
recorded  some  years  ago,  in  which  thirteen  members  were  affected  in  two  gen- 
erations, with  the  exception  of  two,  the  cases  occurred  or  proved  fatal  above 
the  age  of  forty,  and  the  late  onset  speaks  rather  for  a  central  affection.  The 
spastic  form  may  develop  late  in  life — after  seventy — as  a  senile  change. 

Morbid  Anatomy. — The  essential  anatomical  change  is  a  slow  degenera- 
tion of  the  motor  path,  involving  particularly  the  lower  motor  neurones. 
The  upper  neurones  are  also  involved,  either  first,  simultaneously,  or  at  a 
later  period.  Associated  with  the  degeneration  in  the  cells  of  the  ventral 
horns  there  is  a  degenerative  atrophy  of  the  muscles.-  The  following  are  the 
important  anatomical  changes:  (a)  The  gray  matter  of  the  cord  shows  the 
most  marked  alteration.  The  large  ganglion  cells  of  the  ventral  horns  are 
atrophied,  or,  in  places,  have  entirely  disappeared,  the  neuroglia  is  increased, 
and  the  medullated  fibres  are  much  decreased.  The  fibres  of  the  ventral 
nerve-roots  passing  through  the  white  matter  are  wasted,  (h)  The  ventral 
roots  outside  of  the  cord  are  also  atrophied,  (c)  The  muscles  which  are 
affected  show  degenerative  atrophy,  and  the  inter-muscular  branches  of  the 
motor  nerves  are  degenerated,  (d)  The  degeneration  of  the  gray  matter  is 
rarely  confined  to  the  cord,  but  extends  to  the  medulla,  where  the  nuclei  of 
the  motor  cerebral  nerves  are  found  extensively  wasted,  (e)  In  a  majority  of 
all  the  cases  there  is  sclerosis  in  the  ventro-lateral  white  tracts,  the  lateral 
pyramidal  tracts  particularly  are  diseased,  but  the  degeneration  is  not  confined 
to  these  tracts,  and  extends  into  the  ventro-lateral  ground  bundles.  The  direct 
cerebellar  and  the  ventro-lateral  ascending  tracts  are  spared.  The  degenera- 
tion in  the  pyramidal  tracts  extends  toward  the  brain  to  different  levels,  and 
in  several  cases  has  been  traced  to  the  motor  cortex,  the  cells  of  which  have 
been  found  degenerated.  In  the  medulla  the  medial  longitudinal  fasciculus 
has  been  found  diseased.     (/)  In  those  cases  in  which  no  sclerosis  has  been 


SYSTEM  DISEASES.  903 

found  in  the  pyramidal  tracts  there  has  been  a  sclerosis  of  the  ventro-lateral 
ground  bundle  (short  tracts). 

Symptoms. — Irregular  pains  may  precede  the  onset  of  the  wasting,  and 
cases  may  be  treated  for  chronic  rheumatism.  The  hands  are  usually  first 
affected,  and  there  is  difficulty  in  performing  delicate  manipulations.  The 
muscles  of  the  ball  of  the  thumb  waste  early,  then  the  interossei  and  lum- 
bricales,  leaving  marked  depressions  between  the  metacarpal  bones.  Ultimately 
the  contraction  of  the  flexor  and  extensor  muscles  and  the  extreme  atrophy 
of  the  thumb  muscles,  the  interossei,  and  lumbricales  produces  the  claw-hand 
— main  en  griff e  of  Duchenne.  The  flexors  of  the  forearm  are  usually  involved 
before  the  extensors.  In  the  shoulder-girdle  the  deltoid  is  first  affected;  it 
may  waste  even  before  the  other  muscles  of  the  upper  extremity.  The  trunk 
muscles  are  gradually  attacked;  the  upper  part  of  the  trapezius  long  remains 
unaffected.  Owing  to  the  feebleness  of  the  muscles  which  support  it,  the  head 
tends  to  fall  forward.  The  platysma  myoides  is  unaffected  and  often  hyper- 
trophies. The  arms  and  the  trunk  muscles  may  be  much  atrophied  before  the 
legs  are  attacked.  The  face  muscles  are  attacked  late.  Ultimately  the  inter- 
costal and  abdominal  muscles  may  be  involved,  the  wasting  proceeds  to  an 
extreme  grade,  and  the  patient  may  be  actually  "  skin  and  bone,"  and,  as, 
"  living  skeletons,"  the  cases  are  not  uncommon  in  "  museums  "  and  "  side- 
shows." Deformities  and  contractures  result,  and  lordosis  is  almost  always 
present.  A  curious  twitching  of  the  muscles  (fibrillation)  is  a  common  symp- 
tom, and  may  occur  in  muscles  which  are  not  yet  attacked.  It  is  a  most 
important  symptom,  but  is  not,  as  was  formerly  supposed,  a  characteristic 
feature  of  the  disease.  The  irritability  of  the  muscles  is  increased.  Sensa- 
tion is  unimpaired,  but  the  patient  may  complain  of  numbness  and  coldness 
of  the  affected  limbs.  The  galvanic  and  faradic  irritability  of  the  muscles 
progressively  diminishes  and  may  become  extinct,  the  galvanic  persisting  for 
the  longer  time.  In  cases  of  rapid  wasting  and  paralysis  the  reaction  of  de- 
generation may  be  obtained.  The  excitability  of  the  nerve-trunks  may  persist 
after  the  muscles  have  ceased  to  respond.  The  loss  of  power  is  usually  pro- 
portionate to  the  wasting. 

The  foregoing  description  applies  to  the  group  of  cases  in  which  the 
atrophy  and  paralysis  are  flaccid — atonic,  as  Gowers  calls  it.  In  other  cases, 
those  which  Charcot  describes  as  amyotrophic  lateral  sclerosis,  spastic  paraly- 
sis precedes  the  wasting.  This  tonic  atrophy  first  involves  the  arms  and 
then  the  legs.  The  reflexes  are  greatly  increased.  It  is  one  of  the  rare  con- 
ditions in  which  a  jaw  clonus  may  be  obtained.  The  most  typical  condition  of 
spastic  paraplegia  may  be  produced.  On  starting  to  walk,  the  patient  seems 
glued  to  the  ground  and  makes  ineffectual  attempts  to  lift  the  toes ;  then  four 
or  five  short,  quick  steps  are  taken  on  the  toes  with  the  body  thrown  forward ; 
and  finally  he  starts  off,  sometimes  with  great  rapidity.  Some  of  the  patients 
can  walk  up  and  down  stairs  better  than  on  the  level.  The  wasting  is  never 
so  extreme  as  in  the  atonic  form,  and  the  loss  of  power  may  be  out  of  pro- 
portion to  it.  The  sphincters  are  unaffected.  Sexual  power  may  be  lost  early. 
Cases  are  met  with  which  correspond  accurately  to  the  clinical  picture  given 
by  Charcot  of  amyotrophic  lateral  sclerosis.  These  are  not  very  common,  and 
it  is  much  more  usual  to  have  a  combination  of  the  two  types.  A  flaccid 
atrophic  paralysis  with  increased  reflexes  is  often  met  with.    These  differences 


904  DISEASES  OF   THE  NERVOUS  SYSTEM. 

depend  upon  the  relative  extent  of  the  involvement  of  the  upper  and  lower 
motor  segments  and  the  time  of  the  involvement  of  each.  The  condition  ma}^ 
be  unilateral. 

As  the  degeneration  extends  upward  an  important  change  takes  place  from 
the  development  of  bulbar  symptoms,  which  may,  however,  precede  the  spinal 
manifestations.  The  lips,  tongue,  face,  pharynx,  and  larynx  may  be  involved. 
The  lips  may  be  affected  and  articulation  impaired  for  years  before  serious 
symptoms  occur.  In  the  final  stage  there  may  be  tremor,  the  memory  fails, 
and  a  condition  of  dementia  may  develop. 

Gowers  gives  the  following  useful  classification  of  the  varieties  of  this 
affection:  (1)  Atonic  atrophy,  becoming  extreme;  (2)  muscular  weakness 
with  spasm,  but  without  wasting  or  with  only  slight  wasting;  and  (3)  atonic 
atrophj^,  rarely  extreme  in  degree,  with  exaggeration  of  the  reflexes.  These 
conditions  may  "  coexist  in  every  degree  and  combination — between  universal 
atonic  atrophy  on  the  one  hand  and  universal  spastic  paralysis  without  wast- 
ing on  the  other." 

Diagnosis. — Progressive  (central)  muscular  atrophy  begins,  as  a  rule,  in 
adult  life,  without  hereditary  or  family  influences  (the  early  infantile  form 
being  an  exception),  and  usually  affects  first  the  muscles  of  the  thumb,  and 
gradually  involves  the  interossei  and  lumbricales.  Fibrillary  contractions  are 
common,  electrical  changes  occur,  and  the  deep  reflexes  are  usually  increased. 
These  characteristics  are  usually  sufficient  to  distinguish  it  from  the  other 
forms  of  muscular  wasting. 

In  syringo-myelia  the  symptoms  may  be  very  similar  to  those  in  the  spastic 
form  of  muscular  atrophy.  The  sensory  disturbances  in  the  former  disease, 
as  a  rule,  make  the  diagnosis  clear,  but  when  these  are  absent  or  but  little 
developed  it  may  be  very  difficult  or  even  impossible  to  distinguish  the  diseases. 

Treatment. — The  disease  is  incurable.  I  have  never  seen  the  slightest 
benefit  from  drugs  or  electricity.  The  downward  progress  is  slow  but  cer- 
tain, though  in  a  few  cases  a  temporary  arrest  may  take  place.  With  a  history 
of  syphilis,  mercury  and  iodide  of  potassium  may  be  tried,  and  Gowers  recom- 
mends courses  of  arsenic  and  the  hypodermic  injection  of  strychnine.  Prob- 
ably the  most  useful  means  is  systematic  massage,  particularly  in  the  spastic 
cases. 

Bulbar  Paralysis  (Glosso-Iahio-laryngeal  Paralysis). 

When  the  disease  affects  the  motor  nuclei  of  the  medulla  first  or  early,  it 
is  called  bulbar  paralysis,  but  it  has  practically  no  independent  existence,  as 
the  spinal  cord  is  sooner  or  later  involved. 

Symptoms. — The  disease  usually  begins  with  slight  defect  in  the  speech, 
and  the  patient  has  difficulty  in  pronouncing  the  dentals  and  Unguals.  The 
paralysis  starts  in  the  tongue,  and  the  superior  lingual  muscle  gradually  be- 
comes atrophied,  and  finally  the  mucous  membrane  is  thrown  into  transverse 
folds.  In  the  process  of  wasting  the  fibrillary  tremors  are  seen.  Owing  to 
the  loss  of  power  in  the  tongue,  the  food  is  with  difficulty  pushed  back  into 
the  pharynx.  The  saliva  also  may  be  increased,  and  is  apt  to  accumulate 
in  the  mouth.  When  the  lips  become  involved  the  patient  can  neither  whistle 
nor  pronounce  the  labial  consonants.  The  mouth  looks  large,  the  lips  are 
prominent,  and  there  is  constant  drooling.    The  food  is  masticated  with  diffi- 


SYSTEM  DISEASES.  905 

culty.  Swallowing  becomes  difficult,  owing  partly  to  the  regurgitation  into 
the  nostrils,  partly  to  the  involvement  of  the  pharyngeal  muscles.  The  mus- 
cles of  the  vocal  cords  waste  and  the  voice  becomes  feeble,  but  the  laryngeal 
paralysis  is  rarely  so  extreme  as  that  of  the  lips  and  tongue. 

The  course  of  the  disease  is  slow  but  progressive.  Death  often  results 
from  an  aspiration  pneumonia,  sometimes  from  choking,  more  rarely  from 
involvement  of  the  respiratory  centres.  The  mind  usually  remains  clear.  The 
patient  may  become  emotional.  In  a  majority  of  the  cases  the  disease  is  only 
part  of  a  progressive  atrophy,  either  simple  or  associated  with  a  spastic  con- 
dition. In  the  later  stage  of  amyotrophic  lateral  sclerosis  the  bulbar  lesions 
may  paralyze  the  lips  long  before  the  pharynx  or  larynx  becomes  affected., 

The  diagnosis  of  the  disease  is  readily  made,  either  in  the  acute  or  chronic 
form.  The  involvement  of  the  lips  and  tongue  is  usually  well  marked,  while 
that  of  the  palate  may  be  long  deferred.  A  condition  has  been  described, 
however,  which  may  closely  simulate  bulbar  paralysis.  This  is  the  so-called 
pseudo-hulhar  form  or  bulbar  palsy  of  cerebral  origin.  Bilateral  disease  of 
the  motor  cortex  in  the  lower  part  of  the  ascending  frontal  convolution,  or 
about  the  knee  of  the  internal  capsule,  may  cause  paralysis  of  the  lips  and 
tongue  and  pharynx,  which  closely  simulates  a  lesion  of  the  medulla.  Some- 
times the  symptoms  appear  on  one  side,  but  in  many  instances  they  develop 
suddenly  on  both  sides.  A  bilateral  lesion  has  usually  been  found,  but  in 
several  instances  the  disease  was  unilateral. 

The  so-called  acute  hulhar  paralysis  may  be  due  to  (a)  hgemorrhagic  or 
embolic  softening  in  the  pons  and  medulla;  (&)  acute  inflammatory  softening, 
analogous  to  polio-myelitis,  occurring  occasionally  as  a  post-febrile  affection. 
It  has  occasionally  followed  diphtheria,  and  Mills  and  Weisenburg  have  re- 
ported two  fatal  cases  beginning  with  acute  bulbar  symptoms  after  severe 
electric  shocks  of  high  voltage.  It  usually  comes  on  very  suddenly,  hence  the 
term  apoplectiform.  The  symptoms  in  this  form  may  correspond  closely  to 
those  of  an  advanced  case  of  chronic  bulbar  paralysis.  The  sudden  onset  and 
the  associated  symptoms  make  the  diagnosis  easy.  In  these  acute  cases  there 
may  be  loss  of  power  in  one  arm,  or  hemiplegia,  sometimes  alternate  hemi- 
plegia, with  paralysis  on  one  side  of  the  face  and  loss  of  power  on  the  other 
side  of  the  body. 

2.  Progressive  Neural  Muscular  Atrophy. 

This  form,  known  also  as  the  peroneal  type,  or  by  the  names  of  the  men 
who  have  described  it  most  accurately — namely,  Charcot,  Marie,  and  Tooth 
— occurs  either  as  a  hereditary  or  as  a  family  affection.  It  usually  begins 
in  early  childhood,  affecting  first  the  muscles  of  the  feet  and  the  peroneal 
group;  as  a  result  of  the  weakening  of  these  muscles,  club-foot,  either  pes 
equinus  or  pes  equino-varus  occurs.  In  rare  instances  the  disease  may  be- 
gin in  the  hands,  but  the  upper  limbs,  as  a  rule,  are  not  affected  for  some 
years  after  the  legs  are  attacked,  and  the  trouble  then  begins  in  the  small 
muscles  of  the  hands.  Sensory  disturbances  are  frequently  present  and  form 
important  diagnostic  features.  Fibrillary  contractions  and  twitchings  also 
occur.  The  electrical  reactions  are  altered ;  there  is  either  a  loss  or  a  very 
great  decrease  of  the  excitability,  which  can  be  demonstrated  not  only  in 


906  DISEASES  OF  THE  NERVOUS  SYSTEM. 

the  atrophic  muscles,  but  also  in  muscles  and  nerves  which  are  apparently 
normal. 

This  form  of  muscular  atrophy  seems  to  stand  between  the  central  form 
and  the  muscular  dystrophies.  Occurring  in  families  and  beginning  in  early 
life,  it  resembles  the  latter,  but  it  is  more  like  the  former  in  that  fibrillary 
contractions  and  muscular  twitchings  are  common,  that  the  small  muscles  of 
the  hand  are  apt  to  be  involved,  and  that  electrical  changes  are  present.  In 
the  prominence  of  sensory  symptoms  it  differs  from  both.  In  cases  of  acquired 
double  club-foot  this  disease  should  be  suspected. 

3.  The  Muscular  Dystrophies 

[Dystrophia  muscularis  progressiva,  Erb). 

Definition. — Muscular  wasting,  with  or  without  an  initial  hypertrophy, 
beginning  in  various  groups  of  muscles,  usually  progressive  in  character,  and 
dependent  on  primary  changes  in  the  muscles  themselves.  A  marked  hered- 
itary disposition  is  met  with  in  the  disease. 

Etiology. — 'No  etiological  factors  of  any  moment  are  known  other  than 
heredity.  The  influence  may  show  itself  by  true  heredity — the  disease  occur- 
ring in  two  or  more  generations — or  several  members  of  the  same  generation 
may  be  affected,  showing  a  family  tendency.  Many  members  of  the  same 
family  may  be  attacked  through  several  generations.  Males,  as  a  rule,  are 
more  frequently  affected  than  females.  The  disease  is  usually  transmitted 
through  the  mother,  though  she  may  not  herself  be  affected.  As  many  as  20 
or  30  cases  have  been  described  in  five  generations.  In  Erb's  cases  44  per  cent 
showed  no  heredity.  The  disease  usually  sets  in  before  puberty,  but  may  be 
as  late  as  the  twentieth  or  twenty-fifth  year,  or  in  some  instances  even 
later. 

Symptoms. — The  first  sjnnptom  noticed  is,  as  a  rule,  clumsiness  in  the 
movements  of  the  child,  and  on  examination  certain  muscles  or  groups  of 
muscles  seem  to  be  enlarged,  particularly  those  of  the  calves.  The  extensors 
of  the  leg,  the  glutei,  the  lumbar  muscles,  the  deltoid,  triceps  and  infra- 
spinatus, are  the  next  most  frequently  involved,  and  may  stand  out  with 
great  prominence.  The  muscles  of  the  neck,  face,  and  forearm  rarely  suffer. 
Sometimes  only  a  portion  of  a  muscle  is  involved.  With  this  hypertrophy  of 
some  muscles  there  is  wasting  of  others,  particularly  the  lower  portion  of 
the  pectorals  and  the  latissimus  dorsi.  The  attitude  when  standing  is  very 
characteristic.  The  legs  are  far  apart,  the  shoulders  thrown  back,  the  spine 
is  greatly  curved,  and  the  abdomen  protrudes.  The  gait  is  waddling  and 
awkward.  In  getting  up  from  the  floor  the  position  assumed,  so  well  known 
now  through  Gowers'  figures,  is  pathognomonic.  The  patient  first  turns 
over  in  the  all-fours  position  and  raises  the  trunk  with  his  arms;  the 
hands  are  then  moved  along  the  ground  until  the  knees  are  reached;  then 
with  one  hand  upon  a  knee  he  lifts  himself  up,  grasps  the  other  knee,  and 
gradually  pushes  himself  into  the  erect  posture,  as  it  has  been  expressed,  by 
climbing  up  his  legs.  The  striking  contrast  between  the  feebleness  of  the 
child  and  the  powerful-looking  pseudo-hypertrophic  muscles  is  very  character- 
istic.   The  enlarged  muscles  may,  however,  be  relatively  very  strong. 

The  course  of  the  disease  is  slow,  but  progressive.    Wasting  proceeds  and 


SYSTEM  DISEASES.  907 

finally  all  traces  of  the  enlarged  condition  of  the  muscles  disappear.  At  this 
late  period  distortions  and  contractions  are  common. 

The  muscles  of  the  shoulder-girdle  are  nearly  always  affected  early  in  the 
disease,  causing  a  symptom  upon  which  Erb  lays  great  stress.  With  the 
hands  under  the  arms,  when  one  endeavors  to  lift  the  patient,  the  shoulders 
are  raised  to  the  level  of  the  ears,  and  one  gets  the  impression  as  though  the 
child  were  slipping  through.  These  "  loose  shoulders "  are  very  character- 
istic. The  abnormal  mobility  of  the  shoulder-blades  gives  them  a  winged 
appearance,  and  makes  the  arms  seem  much  longer  than  usual  when  they  are 
stretched  out. 

The  patients  complain  of  no  sensory  symptoms.  The  atrophic  mus- 
cles do  not  show  the  reaction  of  degeneration  except  in  extremely  rare  in- 
stances. 

Clinical  Forms. — A  number  of  different  types  have  been  described,  depend- 
ing upon  the  age  at  the  onset,  the  muscles  first  affected,  the  occurrence  of 
hypertrophy,  the  prominence  of  heredity,  etc.  But  Erb  has  shown  that  there 
is  no  sharp  division  between  these  different  forms,  and  classes  them  all  under 
the  name  of  dystrophia  muscularis  progressiva.  For  convenience  of  descrip- 
tion he  subdivides  the  disease  into  two  large  groups : 

I.  Those  cases  which  occur  in  childhood. 

II.  The  cases  occurring  in  youth  and  adult  life. 

The  first  division  is  subdivided  into  (1)  the  hypertrophic  and  (3)  the 
atrophic  form. 

Under  the  hypertrophic  form,  which  is  the  pseudo-hypertrophic  muscular 
paralysis  of  authors,  he  thinks  it  is  useful  to  distinguish  between  the  cases  in 
which  (a)  the  enlarged  muscles  have  undergone  lipomatosis — i.  e.,  pseudo- 
hypertrophy— from  those  (&)  in  which  there  is  a  real  hypertrophy. 

The  atrophic  form  also  includes  two  subclasses:  (a)  Those  cases  in  which 
the  muscles  of  the  face  are  involved  early;  this  corresponds  to  the  infantile 
form  of  Duchenne — the  Landouzy-Dejerine  type.  (&)  Those  cases  in  which 
the  face  is  not  involved, 

I.  Dystrophia  muscularis  progressiva  infantum. 

1.  Hypertrophic  form. 

(a)   With  pseudo-hypertrophy. 
(&)   With  real  hypertrophy. 

2.  Atrophic  form. 

(a)   With  primary  involvement  of  the  face  (infantile  form  of 

Duchenne). 
(&)  Without  involvement  of  the  face. 

II.  Dystrophia  muscularis  progressiva  juvenum  vel  aduttorum  (Erb's 
juvenile  form). 

Morbid  Anatomy. — According  to  Erb,  the  disease  consists  in  a  change  in 
the  muscles  themselves.  At  first  the  muscle-fibres  hypertrophy,  and  become 
round;  the  nuclei  increase,  and  the  muscle-fibres  may  become  fissured.  At 
the  same  time  there  is  a  slight  increase  in  the  connective  tissue.  Sooner  or 
later  the  muscle-fibres  begin  to  atrophy,  and  the  nuclei  become  greatly  in- 
creased. Vacuoles  and  fissures  appear,  and  the  fibres  finally  become  completely 
atrophic,  the  connective  tissue  becoming  markedly  increased.  Fat  may  be 
deposited  in  the  connective  tissue  to  such  an  extent  as  to  cause  hypertrophic 


908  DISEASES  OF  THE  NERVOUS  SYSTEM. 

lipomatosis — pseuclo-h3^pertrophy.  The  different  stages  of  these  changes  may 
be  found  in  a  single  muscle  at  the  same  time. 

The  nervous  system  has  very  generally  been  found  to  be  without  demon- 
strable lesions,  but  in  certain  cases  changes  in  the  cells  of  the  ventral  horns 
have  been  described. 

Diagnosis. — The  muscular  dystrophies  can  usually  be  distinguished  readily 
from  the  other  forms  of  muscular  atrophy. 

(a)  In  the  cerebral  atrophy  loss  of  power  usually  precedes  the  atrophy, 
which  is  either  of  a  monoplegic  or  hemiplegic  type. 

(&)  From  progressive  (central)  muscular  atrophy  the  distinctions  are 
plainly  marked.  This  form  begins  in  the  small  muscles  of  the  hand,  a  situa- 
tion rarely,  if  ever,  affected  by  the  dystrophies,  which  involve  first  those  of 
the  calves,  the  trunk,  the  face,  or  the  shoulder-girdle.  In  the  central  atrophy 
the  reaction  of  degeneration  is  present  and  fibrillary  twitchings  occur  in  both 
the  atrophied  and  non-atrophied  muscles.  In  many  cases,  in  addition  to  the 
wasting  in  the  arms,  there  is  a  spastic  condition  in  the  legs  and  increase  in  the 
reflexes.  The  central  atrophies  come  on  late  in  life;  the  dystrophies  develop, 
as  a  rule,  early.  In  the  progressive  muscular  dystrophies  heredity  plays  an 
important  role,  which  in  the  central  form  is  quite  subsidiary'.  In  the  rare 
cases  of  early  infantile  spinal  muscular  atrophy  occurring  in  families  the 
symptoms  are  so  characteristic  of  a  central  disease  that  the  diagnosis  presents 
no  difficulty. 

(c)  In  the  neuritic  muscular  atrophies,  whether  due  to  lead  or  to  trauma, 
the  general  characters  and  the  mode  of  onset  are  distinctive.  In  the  cases 
of  multiple  neuritis  seen  for  the  first  time  •  at  a  period  when  the  wasting 
is  marked  there  is  often  difficulty,  but  the  absence  of  family  history  and  the 
distribution  are  important  features.  Moreover,  the  paralysis  is  out  of  propor- 
tion to  the  atrophy.  Sensory  symptoms  may  be  present,  and  in  the  cases  in 
which  the  legs  are  chiefly  involved  there  is  usuall}^  the  steppage  gait  so  char- 
acteristic of  peripheral  neuritis. 

(d)  Progressive  neural  muscular  atrophy.  Here  heredity  is  also  a  factor, 
and  the  disease  usually  begins  in  early  life,  but  the  distribution  of  atrophy 
and  paralysis,  which  in  this  affection  is  at  first  confined  to  the  periphery  of 
the  extremities,  helps  to  distinguish  it  from  the  dystrophies ;  while  the  occur- 
rence of  sensory  sjanptoms,  fibrillary  contractions,  and  the  marked  decrease  in 
the  electrical  excitability  usually  make  the  distinction  clear. 

The  outlook  in  the  primary  muscular  dystrophies  is  bad.  The  wasting 
progresses  uniformly,  uninfluenced  by  treatment.  Erb  holds  that  by  electricity 
and  massage  the  progress  is  occasionally  arrested.  The  general  health  should 
be  carefully  looked  after,  moderate  exercise  allowed,  frictions  with  oil  applied 
to  the  muscles,  and  when  the  patient  becomes  bedfast,  as  is  inevitable  sooner 
or  later,  care  should  be  taken  to  prevent  contractures  in  awkward  positions. 

The  three  forms  of  progressive  muscular  wasting — progressive  (central) 
muscular  atrophy,  progressive  neural  muscular  atrophy,  and  the  muscular 
dystrophies — have  been  considered  as  distinct  diseases,  but  certain  recent 
writings  make  it  probable  that  the  distinction  may  not  be  so  sharp  as  we 
believe.  Certain  cases  occur  which  seem  not  to  belong  to  any  one  of  the 
forms  but  to  stand  between  them.  The  changes  in  the  muscles  which  were 
thought  to  be  characteristic  of  the  dystrophies  have  been  found  in  the  other 


SYSTEM  DISEASES.  909 

forms.    The  central  form  occurs  as  a  family  disease  in  infancy,  and  the  nervous 
system  has  been  found  diseased  in  the  dystrophies. 

The  whole  question  is  in  a  chaotic  state,  and  it  is  at  present  better  to 
keep  to  the  old  divisions.  Even  if  it  should  turn  out  to  be  true,  as  Striimpell 
suggests,  that  all  the  forms  depend  upon  a  congenital  tendency  of  the  motor 
system  to  degenerate,  they  represent  well-defined  clinical  types,  into  which 
the  cases  can,  as  a  rule,  be  grouped  without  difficulty,  while  corresponding 
to  each  there  is  a  fairly  well-determined  anatomical  basis. 

B.    SYSTEM    DISEASES    OF    THE    UPPEE    MOTOR    SEGMENT. 

The  question  of  an  uncomplicated  primary  degeneration  of  the  upper 
motor  neurones  has  not  been  decided.  Cases  with  a  clinical  picture  corre- 
sponding to  this  lesion  are  not  uncommon,  and  they  may  persist  for  a  long 
time  without  change.  Unfortunately  the  cases  which  have  come  to  autopsy 
have  shown  various  conditions.  In  only  two  or  three  has  the  disease  been 
so  nearly  confined  to  the  pyramidal  tract  that  they  can  be  used  as  an  argu- 
ment for  the  independence  of  this  condition.  The  cases  of  Minkowski,  Dresch- 
feld,  and  Striimpell  are  not  absolutely  conclusive,  as  they  are  not  quite  pure, 
although  they  go  far  to  prove  that  a  degeneration  in  the  pyramidal  tract  may 
be  uncomplicated,  at  least  for  a  long  time.  The  same  may  be  said  for  the 
group  of  cases  described  by  Bernhardt  and  Striimpell  under  the  name  heredi- 
tary spastic  spinal  paralysis,  in  which  the  extensive  systemic  degeneration  of 
the  pyramidal  tracts  is  combined  with  slight  degeneration  in  other  tracts  of 
the  cord. 

1.  Spastic  Paralysis  of  Adults 

(Tabes  dorsalis  spasmodique;  Primary  Lateral  Sclerosis). 

Definition. — A  gradual  loss  of  power  with  spasm  of  the  muscles  of  the 
body,  the  lower  extremities  being  first  and  most  affected,  unaccompanied  by 
muscular  atrophy,  sensory  disturbance,  or  other  symptoms.  The  pathological 
anatomy  is  undetermined,  but  a  systemic  degeneration  of  the  pyramidal  tracts 
is  assumed. 

Symptoms. — The  general  symptoms  of  spastic  paraplegia  in  adults  are  very 
distinctive.  The  patient  complains  of  feeling  tired,  of  stiffness  in  the  legs,  and 
perhaps  of  pains  of  a  dull  aching  character  in  the  back  or  in  the  calves.  There 
may  be  no  definite  loss  of  power,  even  when  the  spastic  condition  is  well 
established.  In  other  instances  there  is  definite  weakness.  The  stiffness  is 
felt  most  in  the  morning.  In  a  well-developed  case  the  gait  is  most  char- 
acteristic. The  legs  are  moved  stiffly  and  with  hesitation,  the  toes  drag  and 
catch  against  the  ground,  and,  in  extreme  cases,  when  the  ball  of  the  foot 
rests  upon  the  ground  a  distinct  clonus  develops.  The  legs  are  kept  close 
together,  the  knees  touch,  and  in  certain  cases  the  adductor  spasm  may  cause 
cross-legged  progression.  On  examination,  the  legs  may  at  first  appear  tol- 
erably supple,  perhaps  flexed  and  extended  readily.  In  other  cases  the  rigidity 
is  marked,  particularly  when  the  limbs  are  extended.  The  spasm  of  the 
adductors  of  the  thigh  may  be  so  extreme  that  the  legs  are  separated  with 
the  greatest  difficulty.  In  cases  of  this  extreme  rigidity  the  patient  usually 
loses  the  power  of  walking.    The  nutrition  is  well  maintained,  the  muscles  may 


910  DISEASES   OF   THE  NERVOUS  SYSTEM. 

be  li^-pertropliied.  The  reflexes  are  greatly  increased.  The  slightest  touch 
ujoon  the  patellar  tendon  produces  an  active  knee-jerk.  The  rectus  clonus 
and  the  ankle  clonus  are  easily  obtained.  In  some  instances  the  slightest 
touch  may  throw  the  legs  into  ^dolent  clonic  spasm,  the  condition  to  which 
Brown-Sequard  gave  the  name  of  spinal  epilepsy.  The  superficial  reflexes 
are  also  increased.  The  arms  may  be  unaffected  for  years,  but  occasionally 
thev  become  weak  and  stiff  at  the  same  time  as  the  legs.  This  was  the  case 
in  a  colored  boy  who  was  in  my  wards  for  several  years.  He  presented  a 
degree  of  general  spastic  rigidity  that  I  have  never  seen  equalled.  The  disease 
had  begun  after  puberty,  developed  gradually,  and  remained  quite  stationary 
for  more  than  a  year  before  he  left  the  wards.    There  were  no  other  sjTuptoms. 

The  course  of  the  disease  is  progi'essively  downward.  Years  may  elapse 
before  the  patient  is  bedridden.  Involvement  of  the  sphincters,  as  a  rule, 
is  late;  occasionally,  however,  it  is  early.  The  sensory  sjonptoms  rarely  pro- 
gress, and  the  patients  may  retain  their  general  nutrition  and  enjoy  excellent 
health.     Ocular  s^inptoms  are  rare. 

Diagnosis. — The  diagnosis,  so  far  as  the  clinical  picture  is  concerned,  is 
readily  made,  but  it  is  often  very  difficult  to  determine  accurately  the  nature 
of  the  underh-ing  pathological  condition.  A  history  of  syphilis  is  present  in 
many  of  the  cases.  Cases  which  have  run  a  fairly  typical  clinical  course  upon 
coming  to  autopsy  have  been  found  to  have  been  due  to  very  different  condi- 
tions— transverse  myelitis,  multiple  sclerosis,  cerebral  tumor,  etc.  General 
paralysis  of  the  insane  may  begin  with  symptoms  of  spastic  paraplegia,  and 
We5t|Dhal  believed  that  it  was  only  in  relation  to  this  disease  that  a  primary 
sclerosis  of  the  2^;^Tamidal  tracts  ever  occurred.  In  any  case  the  diagnosis 
of  primary  systemic  degeneration  of  the  j^yramidal  tract  is,  to  say  the  least, 
doubtful. 

2.  Spastic  Paralysis  of  Ixfaxts — Spastic  Diplegia — ^Bieth  Palsies 
(Paraplegia  cerebralls  spastica  (Heine);  Little's  Disease). 

In  this  condition  there  is  a  paralysis  with  spasm  of  all  extremities,  dating 
from  or  shortly  succeeding  birth,  more  rarely  following  the  fevers  or  an 
attack  of  convulsions.  The  legs  are  usually  more  involved  than  the  arms; 
there  is  no  wasting,  no  disturbance  of  sensation.  The  reflexes  are  increased. 
The  mental  condition  is  usually  much  disturbed.  The  patients  are  often 
imbeciles  or  idiots,  helpless  in  mind  and  body.  Ataxic  and  athetoid  move- 
ments of  the  most  exaggerated  kind  may  occur. 

While  only  a  limited  number  of  cases  of  infantile  hemiplegia  are  con- 
genital, on  the  other  hand,  in  spastic  diplegia  and  paraplegia  a  large  pro- 
portion of  the  cases  results  from  injury  at  birth.  The  arms  may  be  so  slightly 
affected  as  to  make  it  difficult  to  determine  whether  it  is  a  case  of  diplegia  or 
paraplegia.  The  disease  usually  dates  from  birth,  and  a  majority  of  the  chil- 
dren are  born  in  first  labors  or  are  forceps  cases,  and  are  at  birth  asph}mated 
blue  babies.  Pioss  suggests  that  in  feet  presentations  there  may  be  laceration 
or  tearing  of  the  cerebro- spinal  membranes.  Premature  birth  is  also  given  as 
a  cause. 

Morbid  Anatomy. — The  birth  palsies  which  ultimately  induce  the  spastic 
diplegias  or  paraplegias  are  most  frequently  the  result  of  meningeal  hsemor- 


SYSTEM  DISEASES.  911 

rhage.  The  importance  of  this  condition  has  been  shown  by  the  studies  of 
Litzmann  and  Sarah  J,  McNutt.  The  bleeding  may  come  from  the  veins, 
or,  as  in  one  case  which  I  saw  with  Hirst,  from  the  longitudinal  sinus.  The 
haemorrhage  has  in  many  cases  been  thickest  over  the  motor  areas,  and  in  these 
cases  the  intelligence  may  suffer  but  little ;  with  a  more  extensive  haemorrhage, 
especially  when  it  implicates  the  frontal  lobes,  any  grade  of  amentia  may 
be  occasioned.  It  seems  probable  that  the  sclerosis  found  in  these  cases  may 
result  from  compression  by  the  blood-clot.  In  other  instances  the  condition 
may  be  due  to  a  foetal  meningo-encephalitis.  In  16  autopsies  collected  in 
the  literature,  in  which  the  patients  died  at  ages  varying  from  two  to  thirty, 
the  anatomical  condition  was  either  a  diffuse  atrophy,  which  was  most  com- 
mon, or  porencephalus.  From  the  fact  that  certain  of  the  cases  are  bdtn 
prematurely,  before  the  pyramidal  tracts  are  developed,  it  has  been  assumed 
by  some  that  a  non-development  of  these  tracts  is  the  cause  of  the  disease. 
This  hypothesis  has  been  urged  by  Marie,  who  limits  the  name  spastic  para- 
plegia to  that  group  of  the  infantile  cases  in  which  there  is  no  evidence  of 
involvement  of  the  brain — intellectual  disturbances,  epilepsy,  etc.,  and  it  is 
in  these  cases  that  he  believes  the  pyramidal  tract  has  remained  undeveloped. 

Symptoms. — At  first  nothing  abnormal  may  be  noticed  about  the  child.  In 
some  instances  there  have  been  early  and  frequent  convulsions;  then  at 
the  age  when  the  child  should  begin  to  walk  it  is  noticed  that  the  limbs  are 
not  used  readily,  and  on  examination  a  stiffness  of  the  legs  and  arms  is  found. 
Even  at  the  age  of  two  the  child  may  not  be  able  to  sit  up,  and  often  the 
head  is  not  well  supported  by  the  neck  muscles.  The  rigidity,  as  a  rule,  is 
more  marked  in  the  legs,  and  there  is  an  adductor  spasm.  When  supported  on 
the  feet,  the  child  either  rests  on  its  toes  and  the  inner  surface  of  the  feet, 
with  the  knees  close  together,  or  the  legs  may  be  crossed.  The  stiffness  of  the 
upper  limbs  varies.  It  may  be  scarcely  noticeable  or  the  rigidity  may  be  as 
marked  as  in  the  legs.  When  the  spastic  condition  affects  the  arms  as  well  as 
the  legs,  we  speak  of  the  condition  as  diplegia;  when  the  legs  alone  are  in- 
volved, as  paraplegia.  There  seems  to  be  no  sufficient  reason  for  considering 
them  separately.  Constant  irregular  movements  of  the  arms  are  not  uncom- 
mon. The  child  has  great  difficulty  in  grasping  an  object.  The  spasm  and 
weakness  may  be  more  evident  on  one  side  than  the  other.  The  mental  con- 
dition is,  as  a  rule,  defective  and  convulsive  seizures  are  common. 

Associated  with  the  spastic  paralysis  are  two  allied  conditions  of  consid- 
erable interest,  characterized  by  spasm  and  disordered  movements.  A  child 
with  spastic  diplegia  may  present,  in  an  unusual  degree,  irregular  movements 
of  the  muscles.  In  attempting  to  grasp  an  object  the  fingers  may  be  thrown 
out  in  a  stiff,  spasmodic,  irregular  manner,  or  there  may  be  constant  irregular 
movements  of  the  shoulders,  arms,  and  hands,  with  slight  incoordination  of  the 
head.  Cases  of  this  description  have  been  described  as  chorea  spastica^  and 
they  may  be  difficult  to  separate  from  multiple  sclerosis  and  from  Friedreich's 
ataxia. 

A  still  more  remarkable  condition  is  that  of  hilateral  athetosis,  in  which 
there  is  a  combination  of  spasm  more  or  less  marked  with  the  most  extraor- 
dinary bizarre  movements  of  the  muscles.  The  condition,  as  a  rule,  dates  from 
infancy.  The  patient  may  not  be  able  to  walk.  The  head  is  turned  from  side 
to  side;  there  are  continual  irregular  movements  of  the  face  muscles,  and 


912  DISEASES  OF  THE  NERVOUS  SYSTEM. 

the  mouth  is  drawn  and  greatly  distorted.  The  extremities  are  more  or  less 
rigid,  particularly  in  extension.  On  the  slightest  attempt  to  move,  often  spon- 
taneously, there  are  extraordinary  movements  of  the  arms  and  legs,  particu- 
larly of  the  arms,  somewhat  like  athetosis,  though  much  more  exaggerated. 
The  patients  are  often  unahle  to  help  themselves  on  account  of  these  move- 
ments. The  reflexes  are  increased.  The  mental  condition  is  variable.  The 
patient  may  be  idiotic,  but  in  3  of  the  6  cases  which  I  have  seen  the  patients 
were  intelligent.  Massalongo,  who  has  carefully  studied  this  condition,  de- 
scribes 3  cases  in  one  family.  I  have  collected  53  cases  from  the  literature, 
33  of  which  occurred  in  males  and  20  in  females. 

Treatment. — Little  can  be  done  for  these  children  when  the  symptoms  are 
extreme.  In  the  milder  cases  patient  training  may  do  much  to  better  the 
mental  state  when  feeble-mindedness  accompanies  the  motor  palsies.  Exercises 
and  massage  should  be  given  for  the  spastic  muscles,  and  in  many  instances 
tenotomies  and  tendon  transplantations  may  be  helpful  in  improving  the 
usefulness  particularly  of  the  lower  extremities.  On  the  view  that  most  of 
these  cases  date  back  to  an  intracranial  haemorrhage  during  parturition,  it  is 
reasonable  to  suppose  that  an  immediate  operation  with  the  removal  of  the 
cortical  clot — for  the  effusion  of  blood  is  usually  on  the  surface  of  the  hemi- 
sphere— might  ward  off  the  disastrous  consequences  of  compression  on  the 
infant's  brain.  Four  of  these  cases,  with  asphyxia  and  convulsions  after 
difficult  labors,  have  been  operated  upon  soon  after  birth  by  Gushing,  and  cor- 
tical clots  have  been  removed.  In  two  cases  there  has  seemingly  been  a  com- 
plete restoration  to  health  and  an  avoidance  of  the  usual  spastic  sequels. 

3.  Hereditary  Spastic  Paraplegia 

(Hereditary  Spastic  Spinal  Paralysis;  Family  form  of  Spastic  Spinal 

Paralysis) . 

It  is  a  family  affection  and  only  occasionally  are  the  ascendants  affected. 
There  are  several  forms : 

1.  The  pure  spastic  paraplegia — Striimpell's  type — in  which  two  or  more 
members  of  a  family  are  attacked.    Trunk,  arms,  and  brain  are  not  affected. 

2.  Mixed  forms:  (a)  with  features  of  multiple  sclerosis  as  described  by 
Cestan  and  Guillain;  (&)  amyotrophic  lateral  sclerosis  type,  with  the  added 
feature  of  atrophy;  (c)  forms  resembling  Friedreich's  ataxia  and  the  hered- 
itary cerebellar  ataxia;  (d)  forms  resembling  cerebral  diplegia. 

In  a  majority  of  the  cases  the  disease  begins  in  children  between  the  seventh 
and  the  fifteenth  years.  It  may  not  develop  until  the  twentieth  year.  Two, 
three,  or  four  members  of  a  family  are  affected.  Beginning  in  the  legs  with 
characteristic  spastic  gait  and  all  the  features  of  an  ordinary  spinal  paralysis, 
the  disease  may  extend  and  affect  the  arms,  or  there  are  added  the  symptoms 
of  multiple  sclerosis  or  of  one  of  the  other  above-named  affections.  Boys  are 
more  often  affected  than  girls,  88  to  51,  in  the  cases  collected  by  Delearde  and 
Minet  (1908). 

The  pathology  of  the  disease  is  still  under  discussion. 

Amaurotic  Family  Idiocy  (Sachs'  Disease). — A  remarkable  form  of  in- 
fantile paralysis  has  been  described  by  Sachs,  Peterson,  and  Hirsch.    The  dis- 


SYSTEM  DISEASES.  913 

ease  is  one  which  involves  the  entire  gray  matter  of  the  central  nervous  system. 
The  symptoms  as  summarized  by  Sachs  are:  1.  Psychic  disturbances  that 
appear  in  early  life  (first  or  second  year)  and  progress  to  total  idiocy.  2. 
Paresis,  and  ultimately  complete  paralysis  of  the  extremities,  which  may  be 
either  flaccid  or  spastic.  3.  Increased,  decreased,  or  normal  tendon  reflexes. 
4.  Partial,  followed  by  total  blindness  (macular  changes,  with  subsequent 
atrophy  of  the  optic  nerve) .  5.  Marasmus  and  death,  usually  before  the  second 
year.  6.  Distinct  familial  type.  Occasional  symptoms  are  nystagmus,  stra- 
bismus, hyperacusis,  or  impairment  of  hearing.  The  pathological  changes 
are  primitive  type  of  the  cerebral  convolutions,  macrogyria,  degenerative 
changes  in  the  large  pyramidal  cells,  absence  of  the  tangential  fibres,  and 
decrease  of  the  fibres  of  the  white  matter.  The  blood-vessels  are  normal. 
There  is  also  degeneration  of  the  pyramidal  columns  of  the  cord.  Of  27  cases 
collected  by  Sachs,  17  occurred  in  six  families ;  all  in  Jews. 

4.  Erb's  Syphilitic  Spinal  Paralysis. 

Erb  has  described  a  symptom  group  under  the  term  syphilitic  spinal 
paralysis,  to  which  much  attention  has  been  given.  The  points  upon  which 
he  lays  stress  are  a  very  gradual  onset  with  a  development  finally  of  the  fea- 
tures of  a  spastic  paresis;  the  tendon  reflexes  are  greatly  increased,  but  the 
muscular  rigidity  is  slight  in  comparison  with  the  exaggerated  deep  reflexes. 
There  is  rarely  much  pain,  and  the  sensory  disturbances  are  trivial,  but  there 
may  be  paresthesia  and  the  girdle  sensation.  The  bladder  and  rectum  are 
usually  involved,  and  there  is  sexual  failure  or  impotence.  And,  lastly,  im- 
provement is  not  infrequent.  A  majority  of  instances  of  spastic  paralysis  of 
adults  not  the  result  of  slow  compression  of  the  cord  are  associated  with 
syphilis  and  belong  to  this  group. 

Erb  thought  the  lesion  to  be  a  special  form  of  transverse  myelitis,  but  per- 
haps it  should  be  classed  with  the  system  diseases,  under  the  name  toxic  spastic 
spinal  paralysis. 

5.  Secondary  Spastic  Paralysis. 

Following  any  lesion  of  the  pyramidal  tract  we  may  have  spastic  paralysis ; 
thus,  in  a  transverse  lesion  of  the  cord,  whether  the  result  of  slow  compression 
(as  in  caries),  chronic  myelitis,  the  pressure  of  tumor,  chronic  meningo-mye- 
litis,  or  multiple  sclerosis,  degeneration  takes  place  in  the  pyramidal  tracts, 
below  the  point  of  disease.  The  legs  soon  become  stiff  and  rigid,  and  the 
reflexes  increase.'  Bastian  has  shown  that  in  compression  paraplegia  if  the 
transverse  lesion  is  complete,  the  limbs  may  be  flaccid,  without  increase  in  the 
reflexes — paraplegic  flasque  of  the  French.  The  condition  of  the  patient 
in  these  secondary  forms  varies  very  much.  In  chronic  myelitis  or  in  mul- 
tiple sclerosis  he  may  be  able  to  walk  about,  but  with  a  characteristic  spastic 
gait.  In  the  compression  myelitis,  in  fracture,  or  in  caries,  there  may  be 
complete  loss  of  power  with  rigidity. 

It  may  be  difficult  or  even  impossible  to  distinguish  these  cases  from  those 
of  primary  spastic  paralysis.     Eeliance  is  to  be  placed  upon  the  associated 
symptoms;  when  these  are  absent  no  deflnite  diagnosis  as  to  the  cause  of  the 
spastic  paralysis  can  be  given. 
59 


914  DISEASES  OF  THE  NERVOUS  SYSTEM. 

6.  Hysterical  Spastic  Paeaplegia. 

There  is  no  spinal-cord  disease  which  may  be  so  accurately  mimicked  as 
spastic  paraplegia.  In  the  hysterical  form  there  is  wasting,  the  sensory  symp- 
toms are  not  marked,  the  loss  of  power  is  not  complete,  and  there  is  not  that 
extensor  spasm  so  characteristic  of  organic  disease.  The  reflexes  are,  as  a 
rule,  increased.  The  knee-jerk  is  present,  and  there  may  be  a  well-developed 
ankle  clonus.  Gowers  calls  attention  to  the  fact  that  it  is  usually  a  spurious 
clonus,  "due  to  a  half -voluntary  contraction  in  the  calf  muscles."  A  true 
clonus  does  occur,  however,  and  there  may  be  the  greatest  difficulty  in  deter- 
mining whether  or  not  the  case  is  one  of  hysterical  paraplegia.  The  hysterical 
contracture  will  be  considered  later. 

C.   SYSTEM  DISEASES   OF  THE  LOWEE  MOTOE   SEGMENT. 

1.  Chronic  Anterior  Polio-myelitis 

(Progressive  Muscular  Atrophy — Aran-Duclienne) . 

This  disease  has  been  considered  as  one  of  the  types  making  up  the  pro- 
gressive (central)  muscular  atrophies.  In  certain  rare  cases  the  process  is 
confined  to  the  lower  motor  segment.  They,  however,  differ  so  little  clinically 
from  many  of  the  cases  in  which  the  pyramidal  tracts  are  involved  that  it 
seems  better  to  make  no  sharp  distinction  between  them.  The  same  may  be 
said  of  chronic  bulbar  paralysis. 

2.  Ophthalmoplegia. 

This  disease  is  at  times  due  to  a  chronic  degeneration  of  the  nuclei  of  the 
motor  nerves  of  the  eyeballs,  and  so  is  a  system  disease  of  the  lower  motor  seg- 
ment. It  is  treated  of  in  connection  with  the  other  ocular  palsies  for  the  sake 
of  simplicity  and  because  all  ophthalmoplegias  are  not  due  to  nuclear  disease. 

3.  Acute  Anterior  Polio-myelitis 

(Epidemic  and  Sporadic). 

Definition. — An  acute  infection  of  unknown  origin  occurring  at  times  in 
epidemic  form,  more  usually  as  sporadic  eases,  characterized  anatomically  in 
the  former  by  wide-spread  lesions  in  the  spinal  cord  and  brain,  in  the  latter 
by  an  acute  myelitis  of  the  anterior  horns. 

Etiology. — Small  epidemics  have  been  described  from  time  to  time,  par- 
ticularly in  Norway  and  in  the  United  States.  In  1905-6  there  were  in  the 
former  country  many  outbreaks — 1,053  cases  in  all,  with  145  deaths.  In 
1907-8  a  serious  epidemic  occurred  in  New  York  City.  About  2,000  cases 
occurred,  with  6  to  7  per  cent  mortality.  Harbitz  and  Schiel  in  their  mono- 
graph describe  very  fully  the  Norwegian  outbreaks,  which  have  been  chiefly 
in  country  districts,  though  there  have  been  numerous  cases  in  Christiania; 
some  years  ago  Medin  reported  two  outbreaks  in  and  about  Stockholm.  Until 
the  New  York  experience  just  mentioned  the  United  States  epidemics  have 
been  in  country  districts.    The  autumn  months  have  been  the  periods  of  the 


SYSTEM  DISEASES.  915 

greatest  number  of  cases.  A  special  feature  of  this  form  is  the  large  number 
of  adults.  The  sporadic  form  is  a  widely  distributed  disease  of  children  from 
the  second  to  the  fourth  year.  It  rarely  proves  fatal.  For  1905  no  cases  are 
reported  in  the  Eegistrar  General's  returns  for  England  and  Wales.  Sink- 
ler's"  observations  show  that  the  incidence  of  the  disease  is  greatest  in  the 
summer.  The  cause  is  unknown.  It  has  been  attributed  to  cold,  overexertion, 
and  to  falls.  From  the  days  of  Mephibosheth  infantile  paralysis  has  been 
attributed  to  the  carelessness  of  nurses  in  letting  the  children  fall.  In  young 
adults  overexertion  may  have  an  influence.  I  saw  one  case  which  followed 
unusual  effort  in  a  football  match.  In  the  recent  epidemics  the  bacteriology 
of  the  disease  has  been  studied,  but  without  definite  results. 

Morbid  Anatomy. — In  the  epidemic  form  wide-spread  changes  are  met 
with.  Harbitz  and  Schiel  report  on  19  cases.  There  was  nothing  in  the 
throat  or  nose.  In  the  spinal  cord  the  gray  matter  was  chiefly  affected,  the 
anterior  horns  more  severely  and  in  close  relation  with  the  blood-vessels. 
The  ganglion  cells  were  greatly  degenerated.  There  were  changes  in  the  pia 
mater  with  lymphocytic  infiltration.  Above  the  cord  this  slight  infiltration 
of  the  pia  could  also  be  traced  even  to  the  hemispheres.  In  the  medulla  and 
pons  many  of  the  nuclei  were  involved  in  a  hgemorrhagic  inflammation,  and 
infiltrations  and  degenerations  were  found  in  the  gray  matter  of  the  hemi- 
spheres. In  the  severe  cases  the  anatomical  picture  is  that  of  a  diffuse 
meningo-myelitis  and  encephalitis.  In  the  milder  cases,  too,  the  changes  found 
were  very  wide-spread.  The  morbid  anatomy  of  the  sporadic  form  has  been 
carefully  studied.  In  his  Goulstonian  lectures,  1904,  Buzzard  gives  in  full 
detail  the  lesions  which  are  those  of  an  acute  hsemorrhagic  poliomyelitis.  In 
cases  in  which  the  examination  is  not  made  for  some  months  or  years  the 
changes  are  very  characteristic.  The  ventral  cornu  in  the  affected  region  is 
greatly  atrophied  and  the  large  motor  cells  are  either  entirely  absent  or  only 
a  few  remain.  The  affected  half  of  the  cord  may  be  considerably  smaller  than 
the  other.  The  ventro-lateral  column  may  show  slight  sclerotic  changes,  chiefly 
in  the  pyramidal  tract.  The  corresponding  ventral  nerve  roots  are  atrophied, 
and  the  muscles  are  wasted  and  gradually  undergo  a  fatty  and  sclerotic  change. 

Symptoms. — The  epidemic  form  presents  special  features.  I  have  already 
mentioned  that  young  adults  are  frequently  attacked.  There  are  remarkable 
abortive  forms — cases  with  transient  fever,  headaches,  vomiting,  twitchings  of 
the  limbs,  but  without  subsequent  paralysis.  Bulbar  cases  have  occurred  in 
which  the  localization  was  in  the  medulla  with  a  rapid  course  of  from  two 
to  eight  days.  And,  lastly,  there  are  a  few  cases  with  the  symptoms  of  an 
acute  meningo-encephalitis,  coma,  convulsions,  rigidity,  without  local  paralysis. 
These  features  were  noted  by  many  observers  in  the  New  York  epidemic. 

In  a  majority  of  the  cases  of  the  sporadic  form,  after  slight  indisposi- 
tion and  feverishness,  the  child  is  noticed  to  have  lost  the  use  of  one  limb. 
Convulsions  at  the  outset  are  rare,  not  constant  as  in  the  acute  cerebral 
palsies  of  children.  Fever  is  usually  present,  the  temperature  rising  to  101°, 
sometimes  to  103°.  Pain  is  often  complained  of  in  the  early  stages.  This  may 
be  localized  in  the  back  or  between  the  shoulders ;  any  pressure  on  the  paralyzed 
limbs  may  be  painful,  causing  the  patient  to  cry  out  when  he  is  moved  in  bed. 
The  paralysis  is  abrupt  in  its  onset  and,  as  a  rule,  is  not  progressive,  but  reaches 
its  maximum  in  a  very  short  time,  even  within  twenty-four  hours.    It  is  rarely 


916  DISEASES  OF   THE  NERVOUS  SYSTEM. 

generalized.  The  suddenness  of  onset  is  remarkable  and  suggests  a  primary 
affection  of  the  blood-vessels,  a  view  which  the  haemorrhagic  character  of  the 
early  lesion  supports.  The  distribution  of  the  paralysis  is  very  variable.  Its 
irregularity  and  lack  of  symmetry  is  quite  characteristic  of  the  disease.  One 
or  both  arms  may  be  affected,  one  arm  and  one  leg,  or  both  legs;  or  it  may 
be  a  crossed  paralysis,  the  right  leg  and  the  left  arm.  In  the  upper  extremi- 
ties the  paralysis  is  rarely  complete  and  groups  of  muscles  may  be  affected. 
As  Eemak  has  pointed  out,  there  is  an  upper-arm  and  a  lower-arm  type  of 
palsy.  The  deltoid,  the  biceps,  brachialis  anticus,  the  supinator  longus  may 
be  affected  in  the  former,  and  in  the  latter  the  extensors  or  flexors  of  the  fingers 
and  wrists.  This  distribution  is  due  to  the  fact  that  muscles  acting  function- 
ally together  are  represented  near  each  other  in  the  spinal  cord. 

In  the  legs  the  tibialis  anticus  and  extensor  groups  of  muscles  are  more 
affected  than  the  hamstrings  and  glutei.  The  muscles  of  the  face  are  very 
rarely,  the  sphincters  hardly  ever  involved.  While  the  rule  is  for  the  paralysis 
to  be  abrupt  and  sudden,  there  are  cases  in  which  it  comes  on  slowly  and  takes 
from  three  to  five  days  for  its  development.  At  first  the  affected  limb  looks 
natural,  and  as  children  between  two  and  three  are  usually  fat,  very  little 
change  may  be  noticed  for  some  time;  but  the  atrophy  proceeds  rapidly,  and 
the  limb  becomes  flaccid  and  feels  soft  and  flabby.  Usually  as  early  as  the 
end  of  the  first  week  the  reaction  of  degeneration  is  present.  The  nerves  are 
found  to  have  lost  their  irritability.  The  muscles  do  not  react  to  the  induced 
current,  but  to  the  constant  current  they  respond  by  a  sluggish  contraction, 
usually  to  a  weaker  current  than  is  normal.  The  paralysis  remains  stationary 
for  a  time,  and  then  there  is  gradual  improvement.  Complete  recovery  is  rare, 
and,  when  the  anatomical  condition  is  considered,  is  scarcely  to  be  expected. 
The  large  motor  cells  of  the  cornua,  when  thoroughly  disintegrated,  can  not  be 
restored.  In  too  many  cases  the  improvement  is  only  slight,  and  permanent 
paralysis  remains  in  certain  groups.  Sensation  is  unaffected ;  the  skin  reflexes 
are  absent,  and  the  deep  reflexes  in  the  affected  muscles  are  usually  lost. 

When  the  paralysis  persists  the  wasting  is  extreme,  the  growth  of  the  bones 
of  the  affected  limb  is  arrested,  or  at  any  rate  retarded,  and  the  joints  may  be 
very  relaxed;  as,  for  instance,  when  the  deltoid  is  affected,  the  head  of  the 
humerus  is  no  longer  kept  in  contact  with  the  glenoid  cavity.  In  the  later 
stages  very  serious  deformities  may  be  produced  by  the  shortening  of  the 
unopposed  intact  muscles. 

Diagnosis. — The  condition  is  only  too  evident  in  the  majority  of  cases. 
There  is  a  flaccid,  flabby  paralysis  of  one  or  more  limbs  which  has  set  in 
abruptty.  The  rapid  wasting,  the  lax  state  of  the  muscles,  the  electrical  reac- 
tions, and  the  absence  of  reflexes  distinguish  it  from  the  cerebral  palsies.  In 
multiple  neuritis,  a  rare  disease  in  childhood,  the  paralysis  is  bilaterally  sym- 
metrical, affects  the  muscles  at  the  periphery  of  the  limbs,  and  is  combined 
with  sensory  symptoms.  The  pseudo-paresis  of  rickets  is  a  condition  to  be 
carefully  distinguished.  In  this  the  loss  of  power  is  in  the  legs,  rapid  atrophy 
is  not  present,  and  certain  movements  are  possible  but  painful.  The  general 
hyperaesthesia  of  the  skin,  the  characteristic  changes  in  the  bones,  and  the  dif- 
fuse sweats  are  present.  Disease  of  the  hip  or  knee  may  produce  a  pseudo- 
paralysis which  with  care  can  be  readily  distinguished.  Limp  chorea  may  also 
be  confused  with  it. 


SYSTEM  DISEASES.  917 

Prognosis. — The  outlook  in  any  case  for  complete  recovery  is  bad.  The 
natural  course  of  the  disease  must  be  borne  in  mind;  the  sudden  onset,  the 
rapid  but  not  progressive  loss  of  power,  a  stationary  period,  then  marked  im- 
provement in  certain  muscle  groups,  and  finally  in  many  cases  contractures 
and  deformities.  There  is  no  other  disease  in  which  the  physician  is  so  often 
subject  to  unjust  criticism,  and  the  friends  should  be  told  at  the  outset  that 
in  the  severe  and  extensive  paralysis  complete  recovery  should  not  be  expected. 
The  best  to  be  hoped  for  is  a  gradual  restoration  of  power  in  certain  muscle 
groups.  In  estimating  the  probable  grade  of  permanent  paralysis,  the  electrical 
examination  is  of  great  value. 

Treatment. — The  treatment  of  acute  infantile  paralysis  has  a  bright  and 
a  dark  side.  In  a  case  of  any  extent  complete  recovery  can  not  be  expected; 
on  the  other  hand,  it  is  remarkable  how  much  improvement  may  finally  take 
place  in  a  limb  which  is  at  first  completely  flaccid  and  helpless.  The  follow- 
ing treatment  may  be  pursued :  If  seen  in  the  febrile  stage,  a  brisk  laxative 
and  a  fever  mixture  may  be  given.  The  child  should  be  in  bed  and  the  affected 
limb  or  limbs  vi^rapped  in  cotton.  As  in  the  great  majority  of  cases  the 
damage  is  already  done  when  the  physician  is  called  and  the  disease  makes 
no  further  progress,  the  application  of  blisters  and  other  forms  of  counter- 
irritation  to  the  back  is  irrational  and  only  cruel  to  the  child. 

The  general  nutrition  should  be  carefully  maintained  by  feeding  the 
child  well,  and  taking  it  out  of  doors  every  day.  .  As  soon  as  the  child  can 
bear  friction  the  affected  part  should  be  carefully  rubbed ;  at  first  once  a  day, 
subsequently  morning  and  evening.  Any  intelligent  mother  can  be  taught  sys- 
tematically to  rub,  knead,  and  pinch  the  muscles,  using  either  the  bare  hand 
or,  better  still,  sweet  oil  or  cod-liver  oil.  This  is  worth  all  the  other  measures 
advised  in  the  disease,  and  should  be  systematically  practised  for  months,  or 
even,  if  necessary,  a  year  or  more.  Electricity  has  a  much  more  limited  use, 
and  can  not  be  compared  with  massage  in  maintaining  the  nutrition  of  the 
muscles.  The  faradic  current  should  be  applied  to  those  muscles  which 
respond.  The  essence  of  the  treatment  is  in  maintaining  the  nutrition  of  the 
muscles,  so  that  in  the  gradual  improvement  which  takes  place  in  parts,  at 
least,  of  the  affected  segments  of  the  cord  the  motor  impulses  may  have  to 
deal  with  well-nourished,  not  atrophied  muscle  fibres. 

Of  medicines,  in  the  early  stage  ergot  and  belladonna  have  been  warmly 
recommended,  but  it  is  unlikely  that  they  have  the  slightest  influence.  Later 
in  the  disease  strychnia  may  be  used  with  advantage  in  one  or  two  minim 
doses  of  the  liquor  strychninse,  which,  if  it  has  no  other  effect,  is  a  useful  tonic. 

The  most  distressing  cases  are  those  which  come  under  the  notice  of  the 
physician  six,  eight,  or  twelve  months  after  the  onset  of  the  paralysis,  when 
one  leg  or  one  arm  or  both  legs  are  flaccid  and  have  little  or  no  motion.  Can 
nothing  be  done  ?  A  careful  electrical  test  should  be  made  to  ascertain  which 
muscles  respond.  This  may  not  be  apparent  at  first,  and  several  applications 
may  be  necessary  before  any  contractility  is  noticed.  With  a  few  lessons  an 
intelligent  mother  can  be  taught  to  use  the  electricity  as  well  as  to  apply  the 
massage.  If  in  a  case  in  which  the  paralysis  has  lasted  for  six  or  eight  months 
no  observable  improvement  takes  place  in  the  next  six  months  with  thorough 
and  systematic  treatment,  little  or  no  hope  can  be  entertained  of  further 
change.  ' 


918  DISEASES  OF  THE  NERVOUS  SYSTEM. 

In  the  later  stage  care  should  be  taken  to  prevent  the  deformities  resulting 
from  the  contractions.  Great  benefit  often  results  from  a  carefully  applied 
apparatus.  Surgical  measures,  particularl}^  the  transplantation  of  tendons 
from  intact  to  paral3'zed  groups  of  muscles  in  order  to  restore  the  motor  bal- 
ance of  the  extremity,  have  proven  of  distinct  advantage  in  many  cases.  A 
large  number  of  these  operations  have  been  done  in  the  past  few  years.  Very 
ingenious  and  complicated  procedures  are  often  carried  out,  and  the  partial 
transference  of  function  from  a  flexor  to  a  paralyzed  extensor,  or  from  a  pro- 
nator to  a  paralyzed  supinator  muscle,  or  vice  versa,  may  be  satisfactorily 
accomplished.  It  is  possible  that  nerve  anastomoses  In  favorable  cases  may 
come  to  supplant  these  tendon  transplantations. 

4.  Acute  axd  Subacute  Polio-myelitis  in  Adults. 

An  acute  polio-myelitis  in  adults,  the  exact  counterpart  of  the  disease  in 
children,  is  recognized.  A  majority,  however,  of  the  cases  described  under  this 
heading  have  been  multiple  neuritis;  but  the  suddenness  of  onset,  the  rapid 
wasting,  and  the  marked  reaction  of  degeneration  are  thought  by  some  to  be 
distinguishing  features.  Multiple  neuritis  may,  however,  set  in  with  rapidity ; 
there  may  be  great  wasting  and  the  reaction  of  degeneration  is  sometimes 
present.  The  time  element  alone  may  determine  the  true  nature.  Recovery 
in  a  case  of  extensive  multiple  paralysis  from  polio-myelitis  will  certainly  be 
with  loss  of  power  in  certain  groups  of  muscles ;  whereas,  in  multiple  neuritis 
the  recovery,  while  slow,  may  be  perfect. 

The  subacute  form,  the  paralysie  generate  spinale  anterieure  subaigue  of 
Diichenne,  is  in  all  probability  a  peripheral  palsy.  The  paralysis  usually  begins 
in  the  legs  with  atrophy  of  the  muscles,  then  the  arms  are  involved,  but  not 
the  face.     Sensation,  as  a  rule,  is  not  involved. 

5.  Acute  Ascexdixg  (Laxdrt's)   Paralysis. 

Definition. — An  ascending  flaccid  paralysis,  beginning  in  the  legs,  rapidl}^ 
extending  to  the  trunk  and  arms,  and  finally  involving  the  muscles  of  respira- 
tion. Sensation  and  electrical  reactions  are  normal,  and  there  is  retention  of 
sphincter  control. 

Etiology  and  Pathology. — This  disease  occurs  most  commonly  in  males 
between  the  twentieth  and  thirtieth  years.  It  has  sometimes  followed  the 
specific  fevers.  Many  of  the  common  pathogenic  organisms  may,  especially 
in  patients  debilitated  by  disease,  give  rise  to  sjanptoms  of  acute  ascending 
paralysis  and  can  produce  changes  in  the  cord  and  nerves  resembling  those 
found  in  Landrj^^s  paralysis.  Thus  the  t3^hoid  bacillus  may  produce  clinically 
an  acute  ascending  paralysis.  The  most  recent  careful  studies  have  not  solved 
the  problem  of  this  remarkable  disease.  There  are  two  views :  First,  that  it  is 
a  peripheral  neuritis  (Ross,  Xeuwerk,  Earth,  and  many  others).  Spiller 
in  a  rapidly  fatal  case  found  destructive  changes  in  the  peripheral  nerves 
and  corresponding  alterations  in  the  cell  bodies  of  the  ventral  horns.  He  sug- 
gests that  the  toxic  agent  acts  on  the  lower  motor  neurones  as  a  whole,  and 
that  possibly  the  reason  why  no  lesions  were  found  in  some  of  the  cases  ia 
that  the  more  delicate  histological  methods  were  not  used.  Buzzard  has  iso- 
lated in  pure  culture  in  one  case  a  micrococcus   (M.  tliecalis),  and  found 


SYSTEM  DISEASES.  919 

the  organism  in  large  numbers  in  the  tissues  outside  the  spinal  dura.  Sec- 
ondly, that  it  is  a  functional  disorder  without  a  recognizable  anatomical 
basis.  Eecent  negative  autopsies  support  this  view.  While  waiting  for  addi- 
tional light,  we  may  regard  the  disease  as  an  acute  poisoning  of  the  lower 
motor  neurones. 

Symptoms. — Weakness  of  the  legs,  gradually  progressing,  often  with  toler- 
able rapidity,  is  the  first  symptom.  In  some  cases  within  a  few  hours  the 
paralysis  of  the  legs  becomes  complete.  The  muscles  of  the  trunk  are  next 
affected,  and  within  a  few  days,  or  even  less  in  more  acute  cases,  the  arms 
are  also  involved.  The  neck  muscles  are  next  attacked,  and  finally  the  muscles 
of  respiration,  deglutition,  and  articulation.  The  reflexes  are  lost,  but  the 
muscles  neither  waste  nor  show  electrical  changes.  The  sensory  symptoms  are 
variable;  in  some  cases  tingling,  numbness,  and  hypersethesia  have  been 
present.  In  the  more  characteristic  cases  sensation  is  intact  and  the  sphincters 
are  uninvolved.  Enlargement  of  the  spleen,  which  occurred  in  the  only  two 
cases  in  my  wards,  has  been  noticed  in  several  other  cases.  The  course  of  the 
disease  is  variable.  It  may  prove  fatal  in  less  than  two  days.  Other  cases 
persist  for  a  week  or  for  two  weeks.  In  a  large  proportion  of  the  cases  the 
disease  is  fatal.  One  patient  was  kept  alive  for  41  days  by  artificial  respira- 
tion (C.  L.  Greene). 

Diagnosis. — The  diagnosis  is  difficult,  particularly  from  certain  forms  of 
multiple  neuritis,  and  if  we  include  in  Landry's  paralysis  the  cases  in  which 
sensation  is  involved,  distinction  between  the  two  affections  is  impossible.  We 
apparently  have  to  recognize  the  existence  of  a  rapidly  advancing  motor  par- 
alysis without  involvement  of  the  sphincters,  without  wasting  or  electrical 
changes  in  the  muscles,  without  trophic  lesions,  and  without  fever — features 
sufficient  to  distinguish  it  from  either  the  acute  central  myelitis  or  the  polio- 
myelitis anterior.  It  is  doubtful,  however,  whether  these  characters  always 
suffice  to  enable  us  to  differentiate  the  cases  of  multiple  neuritis. 

IV.     COMBINED    SYSTEM    DISEASES. 

When  the  disease  is  not  confined  within  the  limits  of  either  the  afferent 
or  efferent  systems,  but  affects  both,  it  is  known  as  a  combined  system  disease. 
Some  authors  contend  that  the  diseases  usually  classed  under  this  head  are 
not  really  system  diseases,  but  are  diffuse  processes.  This  is  the  view  taken 
by  Leyden  and  Goldscheider,  who  limit  the  term  system  disease  to  locomotor 
ataxia  and  progressive  muscular  atrophy. 

In  certain  cases  of  locomotor  ataxia  which  have  run  a  fairly  typical  course 
there  may  be  found  after  death,  besides  the  anatomical  picture  corresponding 
to  this  disease,  a  moderate  degeneration  of  the  pyramidal  tracts  and  of  the 
ventral  horns.  In  progressive  muscular  atrophy,  on  the  other  hand,  there 
may  be  degeneration  in  the  dorsal  columns.  During  life  these  secondary  in- 
volvements of  other  systems,  as  they  may  be  termed,  may  or  may  not  be 
accompanied  by  demonstrable  symptoms,  and  when  such  do  occur  they  make 
their  appearance  late  in  the  disease. 

There  is  another  group  of  cases  in  which  from  the  very  first  the  symptoms 
point  to  an  involvement  of  both  the  afferent  and  efferent  systems,  and  it  is 
to  these  that  the  term  primary  combined  system  disease  is  usually  limited. 


920  DISEASES  OF  THE  NERVOUS  SYSTEM. 


1.  Ataxic  Paraplegia. 

This  name  is  applied  by  Gowers  to  a  disease  characterized  clinically  by  a 
combination  of  ataxia  and  spastic  paraplegia,  and  anatomically  by  involvement 
of  the  dorsal  and  lateral  columns. 

The  disease  is  most  common  in  middle-aged  males.  Exposure  to  cold  and 
traumatism  have  been  occasional  antecedents.  In  striking  contrast  to  ordi- 
nary tabes  a  history  of  syphilis  is  rarely  to  be  obtained. 

The  anatomical  features  are  a  sclerosis  of  the  dorsal  columns,  which  is 
not  more  marked  in  the  lumbar  region  and  not  specially  localized  in  the  root 
zone  of  the  cuneate  fasciculi.  The  involvement  of  the  lateral  columns  is 
diffuse,  not  always  limited  to  the  pyramidal  tracts,  and  there  may  be  an 
annular  sclerosis.  Marie  believes  that  in  many  cases  the  distribution  of  the 
sclerosis  is  due  to  the  arterial  supply  and  not  to  a  true  systemic  degeneration, 
the  vessels  involved  being  branches  of  the  dorsal  spinal  artery. 

The  symptoms  are  well  defined.  The  patient  complains  of  a  tired  feeling 
in  the  legs,  not  often  of  actual  pain.  The  sensory  symptoms  of  true  tabes  are 
absent.  An  unsteadiness  in  the  gait  gradually  develops  with  progressive  weak- 
ness. The  reflexes  are  increased  from  the  outset,  and  there  may  be  well- 
developed  ankle  clonus.  Eigiditv  of  the  legs  slowly  comes  on,  but  it  is  rarely 
so  marked  as  in  the  uncomplicated  cases  of  lateral  sclerosis.  From  the  start 
incoordination  is  a  well-characterized  feature,  and  the  difficulty  of  walking 
in  the  dark,  or  swaying  when  the  eyes  are  closed  may,  as  in  true  tabes,  be 
the  first  symptom  to  attract  attention.  In  walking  the  patient  uses  a  stick, 
keeps  the  eyes  fixed  on  the  ground,  the  legs  far  apart,  but  the  stamping  gait, 
with  elevation  and  sudden  descent  of  the  feet,  is  not  often  seen.  The  inco- 
ordination may  extend  to  the  arms.  Sensory  symptoms  are  rare,  but  Gowers 
calls  attention  to  a  dull,  aching  pain  in  the  sacral  region.  The  sphincters  usu- 
■ally  become  involved.  Eye  sjmiptoms  are  rare.  Late  in  the  disease  mental 
s}Tnptoms  may  develop,  similar  to  those  of  general  paresis. 

In  well-marked  cases  the  diagnosis  is  easy.  The  combination  of  marked 
incoordination  with  retention  of  the  reflexes  and  more  or  less  spasm  are  char- 
acteristic features.  The  absence  of  ocular  and  sensory  symptoms  is  an  impor- 
tant point. 

2.  Primary  Combin^ed  Sclerosis  (Putnam). 

The  studies  of  J.  J.  Putnam,  Dana,  Bastianelli,  Eisien  Eussell,  Collier, 
and  Batten  have  separated  from  among  the  lesions  of  the  cord  a  fairly  well 
defined  disease,  characterized  anatomically  by  a  diffuse  degeneration,  often  in 
discrete  patches.  The  dorsal  and  lateral  columns  are  constantly  involved, 
chiefly  in  the  thoracic  and  cervical  regions.  The  nerve  roots  and  the  gray 
matter  show  no  changes.  The  lesions  have  the  "  appearance  of  a  non-systemic 
primary  neurone  degeneration,  not  dependent  upon  antecedent  inflammation  " 
(E.W.Taylor). 

Of  Putnam's  50  cases,  31  were  women,  all  but  5  above  thirty  years  old. 
A  majority  of  the  patients  were  of  small  stature  and  slender  frame,  and  in 
many  there  had  been  a  general  lack  of  vigor  and  a  chronic  pallor  and  debility ; 
7  presented  profound  anaemia.  There  was  no  luetic  history.  The  relation  of 
this  group  to  anaemia  is  interesting.     Eussell,  Batten,  and  Collier  make  three 


SYSTEM  DISEASES.  921 

groups:  (1)  cavses  of  profound  anaemia  (and  one  may  add  of  cachexia),  in 
which  during  life  no  symptoms  were  present,  but  in  which  tliere  were  found 
combined  scleroses  of  the  cord  post  mortem;  (2)  cat.es  of  progressive  pernicious 
anaemia,  in  which  spinal  symptoms  have  occurred;  (3)  cases  of  chronic 
sclerosis  of  the  cord,  in  which  there  occurs,  as  a  secondary  feature,  a  severe 
anaemia. 

The  symptoms  are  both  sensory  and  motor.  The  onset  is  usually  with 
numbness  in  the  extremities,  progressive  loss  of  strength,  and  emaciation. 
Paraplegia  gradually  develops,  before  which  there  have  been,  as  a  rule,  spastic 
symptoms  with  exaggerated  knee-jerk.  The  amis  are  affected  less  than  the 
legs.  Mental  symptoms  suggestive  of  dementia  paralytica  may  develop  toward 
the  close. 

3.  Hereditary  Ataxia  (Friedreich's  Ataxia). 

In  1861  Friedreich  reported  6  cases  of  a  form  of  hereditary  ataxia,  and 
the  affection  has  usually  gone  by  his  name.  Unfortunately,  paramyoclonus 
multiplex  is  also  called  Friedreich's  disease;  so  it  is  best,  if  his  name  is  used 
in  connection  with  this  affection,  to  term  it  Friedreich's  ataxia.  It  is  a  very 
different  disease  in  many  respects  from  ordinary  tabes.  It  may  or  may  not 
be  hereditary.  It  is  really  a  family  disease,  several  brothers  and  sisters  being, 
as  a  rule,  affected.  The  143  cases  analyzed  by  Griffith  occurred  in  71  unrelated 
families.  In  his  series  inheritance  of  the  disease  itself  occurred  in  only  33 
cases.  Various  influences  in  the  parents  have  been  noted;  alcoholism  in  only 
7  cases.  Syphilis  has  rarely  been  present.  Of  the  143  cases,  86  were  males 
and  57  females;  The  disease  sets  in  early  in  life,  and  in  Griffith's  series  15 
occurred  before  the  age  of  two  years,  39  before  the  sixth  year,  45  between 
the  sixth  and  tenth,  20  between  the  eleventh  and  fifteenth,  18  between  the 
sixteenth  and  twentieth,  and  5  between  the  twentieth  and  twenty-fifth  years. 

The  morbid  anatomy  shows  an  extensive  sclerosis  of  the  dorsal  and  lateral 
columns  of  the  spinal  cord.  The  periphery,  and  the  cerebellar  tracts  are  usu- 
ally involved.  The  observations  of  Dejerine  and  Letulle  are  of  special  interest, 
since  they  seem  to  indicate  that  the  change  in  this  disease  is  a  neurogliar 
(ectodermal)  sclerosis,  differing  entirely  from  the  ordinary  spinal  sclerosis. 
According  to  this  view,  Friedreich's  disease  is  a  gliosis  of  the  dorsal  columns 
due  to  developmental  errors ;  but  the  question  is  still  unsettled. 

Symptoms. — The  ataxia  differs  somewhat  from  the  ordinary  form.  The 
incoordination  begins  in  the  legs,  but  the  gait  is  peculiar.  It  is  swaying, 
irregular,  and  more  like  that  of  a  drunken  man.  There  is  not  the  characteristic 
stamping  gait  of  the  true  tabes.  Eomberg's  symptom  may  or  may  not  be 
present.  The  ataxia  of  the  arms  occurs  early  and  is  very  marked;  the  move- 
ments are  almost  choreiform,  irregular,  and  somewhat  swajdng.  In  making 
any  voluntary  movement  the  action  is  overdone,  the  prehension  is  claw-like, 
and  the  fingers  may  be  spread  or  overextended  just  before  grasping  an  object. 
The  hand  frequently  moves  about  an  object  for  a  moment  and  then  suddenly 
pounces  upon  it.  There  are  irregular,  swaying  movements  of  the  head  and 
shoulders,  some  of  which  are  choreiform.  There  is  present  in  many  cases  what 
is  known  as  static  ataxia,  that  is  to  say,  ataxia  of  quiet  action.  It  occurs  when 
the  body  is  held  erect  or  when  a  limb  is  extended — irregular,  oscillating  move- 
ments of  the  head  and  body  or  of  the  extended  limb. 
60 


922  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Sensory  symptoms  are  not  usually  present.  The  deep  reflexes  are  lost  early 
in  the  disease,  and,  next  to  the  ataxia,  this  is  the  most  constant  and  important 
s}mip'tom  (Striimpell) .  The  skin  reflexes  are  usually  normal,  and  the  pupillary 
reflex  to  light  is  practically  never  aflEected. 

Xystagmus  is  a  characteristic  sj'mptom.  Atrophy  of  the  optic  nerve  rarely 
occurs.  A  striking  feature  is  early  deformity  of  the  feet.  There  is  talipes 
equinus,  and  the  patient  walks  on  the  outer  edge  of  the  feet.  The  big  toe  is 
flexed  dorsally  on  the  first  phalanx.    Scoliosis  is  very  common. 

Trophic  lesions  are  rare.  As  the  disease  advances  paralysis  comes  on  and 
may  ultimately  be  complete.     Some  of  the  patients  never  walk. 

Disturbance  of  speech  is  common.  It  is  usually  slow  and  scanning;  the 
expression  is  often  dull ;  the  mental  power  is,  as  a  rule,  maintained,  but  late 
in  the  disease  becomes  impaired. 

Diagnosis. — The  diagnosis  of  the  disease  is  not  difficult  when  several  mem- 
bers of  a  family  are  afE ected.  The  onset  in  childhood,  the  curious  form  of 
incoordination,  the  loss  of  knee-kicks,  the  early  talipes  equinus,  the  posi- 
tion of  the  great  toe,  the  scoliosis,  the  nystagmus,  and  scanning  speech  make 
up  an  unmistakable  picture.  The  disease  is  often  confounded  with  chorea, 
with  the  ordinary  form  of  which  it  has  nothing  in  common.  With  hereditary 
chorea  it  has  certain  similarities,  but  usually  this  disease  does  not  set  in  until 
after  the  thirtieth  year. 

The  affection  lasts  for  many  years  and  is  incurable.  Care  should  be  taken 
to  prevent  contractures.  ,'' 

CereieUar  Type. 

There  is  a  form  of  hereditary  ataxia,  described  by  Marie  "as  cerelellar 
Jieredo-ataxia,  which  starts  later  in  life,  after  the  age  of  twenty,  with  disa- 
bility in  the  legs,  but  the  gait  is  less  ataxic  than  "  groggy."  The  knee-jerks 
are  retained,  and  a  spastic  condition  of  the  legs  ultimately  develops.  There 
is  no  scoliosis,  nor  does  club-foot  develop.  Sanger  Brown's  cases,  25  in  one 
family,  and  J.  H.  Xefl's,  13,  appear  to  belong  to  this  type.  The  cerebellum 
has  been  found  atrophied  in  2  cases. 

4.  Progressive  Interstitial  Hypertrophic  Neuritis  op  Infants. 

Under  this  imposing  title  Dejerine  and  Sottas  described  a  rare  and  inter- 
esting affection.  It  is  a  family  disease,  and  begins  in  early  life.  The  symp- 
toms are  those  typical  of  locomotor  ataxia,  to  which  is  added  progressive  mus- 
cular atrophy,  with  involvement  of  the  face  and  a  hypertrophy  and  hardening 
of  the  peripheral  nerves.  As  the  name  indicates,  it  is  an  interstitial  hyper- 
trophic neuritis  with  secondary  involvement  of  the  dorsal  columns  of  the  cord. 
This  disease  has  been  associated  with  progressive  neural  muscular  atrophy,  but 
Dejerine  has  shown  that  it  is  quite  distinct. 

5.  Toxic  Combined  Sclerosis. 

Certain  poisons  cause  changes  in  the  lateral  and  dorsal  columns  of  the 
cord  that  resemble  those  of  the  combined  system  diseases.  They  have  been 
demonstrated  in  pellagra  and  in  ergotism,  and  have  already  been  described. 
In  pernicious  anaemia  and  many  chronic  wasting  diseases  these  scleroses  occur, 
and  are  believed  to  be  due  to  the  action  of  poisons  produced  within  the  system. 


DIFFUSE  DISEASES  OF  THE  NERVOUS  SYSTEM.  923 

C.    DIFFUSE   DISEASES   OF   THE   NERVOUS   SYSTEM. 

I.    AFFECTIONS    OF    THE    MENINGES. 

Diseases  of  the  Dura  Mater  (Pachymeningitis). 

Pachymeningitis  Externa. — Cerebral. — Haemorrhage  often  occurs  as  a 
result  of  fracture.  Inflammation  of  the  external  layer  of  the  dura  is  rare. 
Caries  of  the  bone,  either  extension  from  middle-ear  disease  or  due  to  syphilis, 
is  the  principal  cause.  In  the  syphilitic  cases  there  may  be  a  great  thickening 
of  the  inner  table  and  a  large  collection  of  pus  between  the  dura  and  the  bone. 

Occasionally  the  pus  is  infiltrated  between  the  two  layers  of  the  dura  mater 
or  may  extend  through  and  cause  a  dura-arachnitis. 

The  symptoms  of  external  pachymeningitis  are  indefinite.  In  the  syph- 
ilitic cases  there  may  be  a  small  sinus  communicating  with  the  exterior.  Com- 
pression symptoms  may  occur  with  or  without  paralysis. 

Spinal. — An  acute  form  may  occur  in  syphilitic  affections  of  the  bones, 
in  tumors,  and  in  aneurism.  The  symptoms  are  those  of  a  compression  of 
the  cord.  A  chronic  form  is  much  more  common,  and  is  a  constant  accom- 
paniment of  tuberculous  caries  of  the  spine.  The  internal  surface  of  the  dura 
may  be  smooth,  while  the  external  is  rough  and  covered  with  caseous  masses. 
The  entire  dura  may  be  surrounded,  or  the  process  may  be  confined  to  the 
ventral  surface. 

Pachymeningitis  Interna. — This  occurs  in  three  forms:  (1)  Pseudo-mem- 
branous, (2)  purulent,  and  (3)  hemorrhagic.  The  first  two  are  unimportant. 
Pseudo-membranous  infiammation  of  the  lining  membrane  of  the  dura  is  not 
usually  recognized,  but  a  most  characteristic  example  of  it  came  under  my 
observation  as  a  secondary  process  in  pneumonia.  Purulent  pachymeningitis 
may  follow  an  injury,  but  is  more  commonly  the  result  of  extension  from 
infiammation  of  the  pia.  It  is  remarkable  how  rarely  pus  is  found  between 
the  dura  and  arachnoid  membranes. 

HuSiMORRHAGio  PACHYMENINGITIS   {HcEmatoma  of  the  Dura  Mater). 

Cerebral  Form. — This  remarkable  condition,  first  described  by  Virchow, 
is  very  rare  in  general  medical  practice.  During  ten  years  no  instance  of  it 
came  under  my  observation  at  the  Montreal  General  Hospital,  On  the  other 
hand,  in  the  post-mortem  room  of  the  Philadelphia  Hospital,  which  received 
material  from  a  large  almshouse  and  asylum,  the  cases  were  not  uncommon, 
and  within  three  months  I  saw  four  characteristic  examples,  three  of  which 
came  from  the  medical  wards.  The  frequency  of  the  condition  in  asylum  work 
may  he  gathered  from  the  fact  that  in  1,185  post  mortems  at  the  Government 
Hospital  for  the  Insane,  Washington,  to  June  30,  1897,  there  were  197  cases 
with  "a  true  neo-membrane  of  internal  pachymeningitis"  (Blackburn).  Of 
these  cases,  45  were  chronic  dementia,  37  were  general  paresis,  30  senile  de- 
mentia, 28  chronic  mania,  28  chronic  melancholia,  22  chronic  epileptic  insan- 
ity, 6  acute  mania,  and  1  case  imbecility.  Forty-two  of  the  cases  were  in 
persons  over  seventy  years  of  age. 
■     It  has  also  been  found  in  profound  anaemia  and  other  diseases  of  the  blood 


924  DISEASES  OF  THE  NERVOUS  SYSTEM. 

and  of  the  blood-vessels,  and  is  said  to  have  followed  certain  of  the  acute 
fevers.  Herter  has  called  attention  to  the  not  infrequent  occurrence  of  the 
lesion  in  badly  nourished,  cachectic  children. 

The  morbid  anatomy  is  interesting.  Yirchow's  view  that  the  delicate  vas- 
cular membrane  precedes  the  haemorrhage  is  undoubtedly  correct.  Practically 
we  see  one  of  three  conditions  in  these  cases:  {a)  subdural  vascular  mem- 
branes, often  of  extreme  delicacy,  formed  by  the  penetration  of  blood-vessels 
and  granulation  tissue  into  an  inflammatory  exudate  (so-called  '''organiza- 
tion" of  an  inflammatory  exudate);  (h)  simple  subdural  haemorrhage;  (c) 
a  combination  of  the  two,  vascular  membrane  and  blood-clot.  Certainly  the 
vascular  membrane  may  exist  without  a  trace  of  hsemorrhage — simply  a 
fibrous  sheet  of  varying  thickness,  permeated  with  large  vessels,  which  may 
form  beautiful  arborescent  tufts.  On  the  other  hand,  there  are  instances  in 
which  the  subdural  haemorrhage  is  found  alone,  but  it  is  possible  that  in 
some  of  these  at  least  the  haemorrhage  may  have  destroyed  all  trace  of  the 
vascular  membrane.  In  some  cases  a  series  of  laminated  clots  are  found, 
forming  a  layer  from  3  to  5  mm.  in  thickness.  Cysts  may  occur  within  this 
membrane.  The  source  of  the  haemorrhage  is  probably  the  dural  vessels. 
Huguenin  and  others  hold  that  the  bleeding  comes  from  the  vessels  of  the 
pia  mater,  but  certainly  in  the  early  stage  of  the  condition  there  is  no  evidence 
of  this;  on  the  other  hand,  the  highly  vascular  subdural  membrane  may  be 
seen  covered  with  the  thinnest  possible  sheeting  of  clot,  which  has  evidently 
come  from  the  dura.  The  subdural  haemorrhage  is  usually  associated  with 
atrophy  of  the  convolutions,  and  it  is  held  that  this  is  one  reason  why  it  is  so 
common  in  the  insane,  especially  in  dementia  paralytica  and  dementia  senilis. 
We  meet  with  the  condition  also  in  phthisis  and  various  cachectic  conditions 
in  which  the  cerebral  wasting  is  as  common  and  almost  as  marked  as  in  cases 
of  insanity.  Konig  found  in  135  cases  of  ha?morrhagic  paclnmeningitis  from 
the  Berlin  Pathological  Institute  that, 2 3  per  cent  accompanied  phthisis. 
Atrophy,  however,  may  not  be  the  only  factor. 

The  s}Tnptoms  are  indefinite,  or  there  may  be  none  at  all,  especially  when 
the  hemorrhages  are  small  or  have  occurred  very  gradually,  and  the  diagnosis 
can  not  be  made  with  certainty.  Headache  has  been  a  prominent  symptom 
in  some  cases,  and  when  the  condition  exists  on  one  side  there  may  be  hemi- 
plegia. The  most  helpful  sjonptoms  for  diagnosis,  indicating  that  the  haemor- 
rhage in  an  apoplectic  attack  is  meningeal,  are  (1)  those  referable  to  increased 
intracranial  pressure  (slowing  and  irregularity  of  the  pulse,  vomiting,  coma, 
contracted  pupils  reacting  to  light  slowly  or  not  at  all)  and  (2)  paresis  and 
paralysis,  graduall}'  increasing  in  extent,  accompanied  by  symptoms  which 
point  to  a  cortical  origin.  Extensive  bilateral  disease  may,  however,  exist 
without  any  symptoms  whatever. 

Spinal  Form. — The  spinal  pachymeningitis  interna,  described  by  Char- 
cot and  Joffroy,  involves  chiefly  the  cervical  region  (P.  cervicalis  liyper- 
trophica).  The  space  between  the  cord  and  the  dura  is  occupied  by  a  firm, 
concentrically  arranged,  fibrinous  growth,  which  is  seen  to  have  developed 
within,  not  outside  of,  the  dura  mater.  It  is  a  condition  anatomically 
identical  with  the  haemorrhagic  pachymeningitis  interna  of  the  brain.  The 
cord  is  usually  compressed ;  the  central  canal  may  be  dilated — ^hydromyelus — 
and  there  are  secondary  degenerations.     The  nerve  roots  are  involved  in  the 


DIFFUSE  DISEASES  OF  THE  NERVOUS  SYSTEM.  925 

growth  and  are  damaged  and  compressed.  The  extent  is  variable.  It  may  be 
limited  to  one  segment,  but  more  commonly  involves  a  considerable  portion  of 
the  cervical  enlargement.  The  disease  is  chronic,  and  in  some  cases  presents 
a  characteristic  group  of  symptoms.  There  are  intense  neuralgic  pains  in  the 
course  of  the  nerves  whose  roots  are  involved.  They  are  chiefly  in  the  arms 
and  in  the  cervical  region,  and  vary  greatly  in  intensity.  There  may  be  hyper- 
a?sthesia  with  numbness  and  tingling ;  atrophic  changes  may  develop,  and  there 
may  be  areas  of  anaesthesia.  Gradually  motor  disturbances  appear ;  the  arms 
become  weak  and  the  muscles  atrophied,  particularly  in  certain  groups,  as  the 
flexors  of  the  hand.  The  extensors,  on  the  other  hand,  remain  intact,  so  that 
the  condition  of  claw-hand  is  gradually  produced.  The  grade  of  the  atrophy 
depends  much  upon  the  extent  of  involvement  of  the  cervical  nerve  roots,  and 
in  many  cases  the  atrophy  of  the  muscles  of  the  shoulders  and  arms  becomes 
extreme.  The  condition  is  one  of  cervical  paraplegia,  with  contractures, 
flexion  of  the  wrist,  and  typical  main  en  griff e.  Usually  before  the  arms  are 
greatly  atrophied  there  are  the  symptoms  of  what  the  French  writers  term 
the  second  stage — namely,  involvement  of  the  lower  extremities  and  the  grad- 
ual production  of  a  spastic  paraplegia,  which  may  develop  several  months  after 
the  onset  of  the  disease,  and  is  due  to  secondary  changes  in  the  cord. 

The  disease  runs  a  chronic  course,  lasting,  perhaps,  two  or  more  years. 
In  a  few  instances,  in  which  symptoms  pointed  definitely  to  this  condition, 
recovery  has  taken  place.  The  disease  is  to  be  distinguished  from  amyotrophic 
lateral  sclerosis,  syringomyelia,  and  tumors.  From  the  first  it"  is  separated  by 
the  marked  severity  of  the  initial  pains  in  the  neck  and  arms ;  from  the  second 
by  the  absence  of  the  sensory  changes  characteristic  of  syringomyelia.  From 
certain  tumors  it  is  very  difficult  to  distinguish;  in  fact,  the  fibrinous  layers 
form  a  tumor  around  the  cord. 

The  condition  known  as  hcematoma  of  the  dura  mater  may  occur  at  any 
part  of  the  cord,  or,  in  its  slow,  progressive  form — pachymeningitis  haem- 
orrhagica  interna — may  be  limited  to  the  cervical  region  and  produce  the 
symptoms  just  mentioned.  It  is  sometimes  extensive,  and  may  coexist  with 
a  similar  condition  of  the  cerebral  dura.  Cysts  may  occur  filled  with  hsem- 
orrhagic  contents. 

Diseases  oe  the  Pia  Mater  (Acute  Cerebrospinal  Leptomeningitis). 
Etiology. — Under  cerebro-spinal  fever  and  tuberculosis  the  two  most  im- 
portant forms  of  meningitis  have  been  described.  Other  conditions  with  which 
meningitis  is  associated  are:  (1)  The  acute  fevers,  more  particularly  pneu- 
monia, erysipelas,  and  septicaemia;  less  frequently  small-pox,  typhoid  fever, 
scarlet  fever,  measles,  etc.  (3)  Injury  or  disease  of  the  bones  of  the  skull. 
In  this  group  by  far  the  most  frequent  cause  is  necrosis  of  the  petrous  portion 
of  the  temporal  bone  in  chronic  otitis.  (3)  Extension  from  disease  of  the 
nose.  Meningitis  has  followed  perforation  of  the  skull  in  sounding  the  frontal 
sinuses,  suppurative  disease  of  these  sinuses,  and  necroses  of  the  cribriform 
plate.  As  mentioned  under  cerebro-spinal  fever,  the  infection  is  thought  to 
be  possible  through  the  nose.  (4)  As  a  terminal  infection  in  chronic  nephritis, 
arterio-sclerosis,  heart-disease,  gout,  and  the  wasting  diseases  of  children. 

The  following  etiological  table  of  the  acute  forms  of  meningitis  may  be 
useful  to  the  student : 


926 


DISEASES  OF   THE  NERVOUS  SYSTEM. 


ti>  f  1.  Of  cerebro-spinal")    (a)  Sporadic.     )  -r\-   i  •   *.        n   i     • 

53  I  fever.  |  (b)  Epidemic.    \  Diplococcus  intracellularis 

»    -    -  •         ^    Meninges  involved  alone  or  in  a  general    ( 

pneumococus  infection.  \ 


I   i    3 

(1h     I 


Pneumococcic. 


} 


Pneumococcus. 


tz 

fc 

w 

^^ 

p- 

(>-. 

P4 

p-:^ 

n3 

pa 

EH 

C  i 

O 

o 

<5 

02 

.          . 

1.  Tuberculous 

r      (a)  Secondary  lo  pneumonia,  en- 

2.  Pneumo-  J  doearditis,  etc. 

coccie.         I       (b)  Secondary  to  disease  or  injury 
(^  of  cranium  or  its  fossae. 

{(a)  Following  local  disease  of  cra- 
nium or  a  local  infection  elsewhere. 
(b)  Terminal  infection  in  various 
chronic  maladies. 
4.  Miscella-  (       In  typhoid  fever,  influenza,  diph- 
neous  acute  <  theria,  gonorrhoea,  anthrax,  actino- 
infections.     (  mycosis,  and  other  acute  diseases. 


Bacillus  tuberculosis, 

Pneumococcus. 


Various  forms  of  staphy- 
lococci and  streptococci. 

Typhoid  bacillus,  influ- 
enza bacillus,  diphtheria 
bacillus,  gonococcus,  etc. 

Morbid  Anatomy. — The  basal  or  cortical  meninges  may  be  chiefly  attacked. 
The  degree  of  involvement  of  the  spinal  meninges  varies.  In  the  form  asso- 
ciated with  pneumonia  and  ulcerative  endocarditis  the  disease  is  bilateral  and 
usually  limited  to  the  cortex.  In  extension  from  disease  of  the  ear  it  is  often 
unilateral  and  may  be  accompanied  with  abscess  or  with  thrombosis  of  the 
sinuses.  In  the  non-tuberculous  form  in  children,  in  the  meningitis  of  chronic 
Bright^s  disease,  and  in  cachectic  conditions  the  base  is  usually  involved.  In 
the  cases  secondary  to  pneumonia  the  effusion  beneath  the  arachnoid  may  be 
very  thick  and  purulent,  completely  hiding  the  convolutions.  The  ventricles 
also  may  be  involved,  though  in  these  simple  forms  they  rarely  present  the 
distention  and  softening  which  is  so  frequent  in  the  tuberculous  meningitis. 
For  a  more  detailed  description  the  student  is  referred  to  the  sections  on 
cerebro-spinal  fever  and  tuberculous  meningitis. 

Symptoms. — The  clinical  features  of  meningitis  have  already  been  de- 
scribed at  length  in  the  diseases  just  referred  to,  and  I  shall  here  give  a  gen- 
eral summary.  I  have  already,  on  several  occasions,  called  attention  to  the 
fact  that  cortical  meningitis  is  not  to  be  recognized  by  any  symptoms  or  set  of 
symptoms  from  a  condition  which  may  be  produced  by  the  poison  of  many 
of  the  specific  fevers.  In  the  cases  of  so-called  cerebral  pneumonia,  unless  the 
base  is  involved  and  the  nerves  afi'ected,  the  disease  is  unrecognizable,  since 
identical  symptoms  may  be  produced  by  intense  engorgement  of  the  meninges. 
In  typhoid  fever,  in  which  meningitis  is  very  rare,  the  twitchings,  spasms,  and 
retractions  of  the  neck  are  almost  invariably  associated  with  cerebro-spinal 
congestion,  not  with  meningitis.  Actual  meningitis  does,  however,  occur  in 
typhoid  fever,  and,  as  Ohlmacher's  cases  show,  the  typhoid  bacilli  may  be 
present  in  the  exudate. 

A  knowledge  of  the  etiology  gives  a  very  important  clew.  Thus,  in  middle- 
ear  disease  the  development  of  high  fever,  delirium,  vomiting,  convulsions,  and 
retraction  of  the  head  and  neck  would  be  extremely  suggestive  of  meningitis 
or  abscess.  Headache,  which  may  be  severe  and  continuous,  is  the  most  com- 
mon symptom.  While  the  patient  remains  conscious  this  is  usually  the  chief 
complaint,  and  even  when  semicomatose  he  may  continue  to  groan  and  to 
place  his  hand  on  his  head.  In  the  fevers,  particularly  in  pneumonia,  there 
may  be  no  complaint  of  headache.  Delirium  is  frequently  early,  and  is  most 
marked  when  the  fever  is  high.'  Convulsions  are  less  common  in  simple  than 
in  tuberculous  meningitis.    They  were  not  present  in  a  single  instance  in  the 


DIFFUSE  DISEASES  OF   THE  NERVOUS  SYSTEM.  927 

cases  which  I  have  seen  in  pneumonia,  ulcerative  endocarditis,  or  septicsemia. 
In  the  simple  meningitis  of  children  they  may  occur.  Epileptiform  attacks 
which  come  and  go  are  highly  characteristic  of  direct  irritation  of  the  cortex. 
Eigidity  and  spasm  or  twitchings  of  the  muscles  are  more  common.  Stiffness 
and  retraction  of  the  muscles  of  the  neck  are  important  symptoms;  but  they 
are  by  no  means  constant,  and  are  most  frequent  when  the  inflammation  is 
extensive  on  the  meninges  of  the  cervical  cord.  There  may  be  trismus,  gritting 
of  the  teeth,  or  spastic  contraction  of  the  abdominal  muscles.  Vomiting  is 
a  common  symptom  in  the  early  stages,  particularly  in  basilar  meningitis. 
Constipation  is  usually  present.  In  the  late  stages  the  urine  and  faces  may  be 
passed  involuntarily.  Optic  neuritis  is  rare  in  the  meningitis  of  the  cortex, 
but  is  not  uncommon  when  the  base  is  involved.  Leube  lays  stress  on  the 
hyperaesthesia  of  the  skin  and  muscles,  especially  of  the  muscles  of  the  neck 
and  calves. 

Important  symptoms  are  due  to  lesions  of  the  nerves  at  the  base.  Stra- 
bismus or  ptosis  may  occur.  The  facial  nerve  may  be  involved,  producing 
slight  paralysis,  or  there  may  be  damage  to  the  fifth  nerve,  producing  an- 
aesthesia and,  if  the  Grasserian  ganglion  is  affected,  trophic  changes  in  the 
cornea.  The  pupils  are  at  first  contracted,  subsequently  dilated,  and  perhaps 
unequal.  The  reflexes  in  the  extremities  are  often  accentuated  at  the  begin- 
ning of  the  disease;  later  they  are  diminished  or  entirely  abolished.  Herpes 
is  common,  particularly  in  the  epidemic  form. 

Fever  is  present,  moderate  in  grade,  rarely  rising  above  103°.  In  the 
non-tuberculous  leptomeningitis  of  debilitated  children  and  in  Bright's  dis- 
ease there  may  be  little  or  no  fever.  The  pulse  may  be  increased  in  frequency 
at  first,  though  this  is  unusual.  One  of  the  striking  features  of  the  disease 
is  the  slowness  of  the  pulse  in  relation  to  the  temperature,  even  in  the  early 
stages.  Subsequently  it  may  be  irregular  and  still  slower.  The  very  rapid 
emaciation  which  often  occurs  is  doubtless  to  be  referred  to  a  disturbance  of 
the  cerebral  influence  upon  metabolism.  Kernig's  sign  has  been  described 
under  cerebro-spinal  fever.  Lumbar  puncture  is  exceedingly  valuable  for 
diagnosis.  Not  only  does  this  frequently  prove  indisputably  the  existence 
of  an  acute  meningitis,  but  the  bacteriological  examination  may  decide  as 
to  the  etiological  factor,  and  thus  yield  a  more  rational  basis  for  treat- 
ment. 

Treatment. — There  are  no  remedies  which  in  any  way  control  the  course 
of  acute  meningitis.  An  ice-bag  should  be  applied  to  the  head  and,  if  the 
subject  is  young  and  full-blooded,  general  or  local  depletion  may  be  practised. 
Absolute  rest  and  quiet  should  be  enjoined.  When  disease  of  the  ear  is 
present,  a  surgeon  should  be  early  called  in  consultation,  and  if  there  are 
symptoms  of  meningo-encephalitis  which  can  in  any  way  be  localized  trephin- 
ing should  be  practised.  An  occasional  saline  purge  will  do  more  to  relieve 
the  congestion  than  blisters  and  local  depletion.  The  warm  baths,  as  recom- 
mended by  Aufrecht  and  described  under  cerebro-spinal  fever,  should  be  given 
every  three  hours.  It  is  possible  that  recovery  may  follow  in  the  primary 
pneumococcus  form  (Fetter).  If  counter-irritation  is  deemed  essential,  the 
thermo-cautery  may  be  lightly  applied  to  the  back  of  the  neck.  Large  doses 
of  the  perchloride  of  iron,  iodide  of  potassium,  and  mercury  are  recommended 
by  some  authors. 


928  DISEASES  OF  THE  NERVOUS  SYSTEM. 

The  application  of  an  ice-cap,  attention  to  the  bowels  and  stomach,  and 
keeping  the  fever  within  moderate  limits  by  sponging,  are  the  necessary  meas- 
ures in  a  disease  recognized  as  almost  invariably  fatal,  in  which  also  the  cases 
of  recovery  are  extremely  doubtful.  Quincke's  lumbar  puncture  (see  page 
163)  may  be  used  as  a  therapeutic  measure.  Fiirbinger  in  one  case  removed 
60  cc.  of  cloudy  fluid,  in  which  tubercle  bacilli  were  found.  The  headache 
and  other  cerebral  symptoms  disappeared,  and  the  patient,  a  man  of  twenty, 
recovered.  Wallis  Ord  and  Waterhouse  report  a  case  of  recovery,  in  a  child 
of  five  years,  after  trephining  and  drainage.  In  a  recent  case  Halsted  made 
an  unsuccessful  attempt  to  irrigate  the  cerebro-spinal  meninges  in  the  manner 
suggested  by  Leonard  Hill. 

Posterior  Basic  Meningitis   (Sporadic  Cerebrospinal  Fever). 

Specially  studied  by  Gee,  Lees,  and  Barlow,  this  form  is  met  with  chiefly 
in  infants  during  the  first  year,  84  of  110  cases.  It  presents  a  marked  sea- 
sonal incidence  the  first  half  of  the  year.  Anatomically  there  is  found  inflam- 
mation with  matting  of  the  parts  over  the  posterior  part  of  the  base  of  the 
brain  from  the  optic  commissure  to  the  medulla,  and  with  distention  of  the 
lateral,  the  third,  and  sometimes  the  fourth  ventricle  with  turbid  fluid.  The 
two  most  striking  features  clinically  are  retraction  of  the  head  and  blindness. 
The  cervical  opisthotonos  is  a  most  characteristic  symptom.  Extensor  and 
flexor  spasms  of  the  limbs  also  occur.  There  are  remarkable  crises,  with  chill, 
increased  fever,  vomiting,  and  exaggeration  of  the  spasms  (Box).  The  prog- 
nosis is  bad,  but  recovery  takes  place  in  a  few  cases.  Much  discussion  has 
taken  place  as  to  the  relation  of  this  form  to  epidemic  cerebro-spinal  fever. 
Still,  Hunter,  Nuttall,  and  others  claim  that  the  organism  found  corresponds 
with  the  meningococcus,  and  with  this  view  Koplik  and  other  New  York 
observers  agree.  Houston  and  Eankin  state  that  the  organism  of  posterior 
basic  meningitis  has  much  the  same  cultural  characters,  but  differs  entirely  in 
its  opsonic  and  agglutinating  powers;  but  Arkwright,  in  a  careful  study  of 
forty-five  different  strains,  could  not  confirm  this  view. 

Chronic  Leptomeningitis. — This  is  rarely  seen  apart  from  syphilis  or  tuber- 
culosis, in  which  the  meningitis  is  associated  with  the  growth  of  the  granu- 
lomata  in  the  meninges  and  about  the  vessels.  The  symptoms  in  such  cases 
are  extremely  variable,  depending  entirely  upon  the  situation  of  the  growth. 
The  epidemic  meningitis  may  run  a  very  chronic  course.  The  posterior  basic 
meningitis  may  be  chronic.  In  the  cases  reported  by  Gee  and  Barlow  the 
duration  in  some  instances  extended  even  to  a  year  and  a  half.  Quincke's 
meningitis  serosa  is  considered  with  hydrocephalus. 

II.     SCLEROSES    OF    THE    BRAIN. 

General  Remarks. — The  supporting  tissue  of  the  central  nervous  system 
is  the  neuroglia,  derived  from  the  ectoderm,  with  distinct  morphological  and 
chemical  characters.  The  meninges  are  composed  of  true  connective  tissue 
derived  from  the  mesoderm,  a  little  of  which  enters  the  brain  and  cord  with 
the  blood-vessels.  The  neuroglia  plays  the  chief  part  in  pathological  processes 
within  the  central  nervous  system,  lout  changes  in  the  connective  tissue  ele- 


DIFFUSE  DISEASES  OF  THE  NERVOUS  SYSTEM.  929 

ments  may  also  be  important.  A  convenient  division  of  the  cerebro-spinal 
scleroses  is  into  degenerative,  inflammatory,  and  developmental  forms. 

The  degenerative  scleroses  comprise  the  largest  and  most  important  sub- 
division, in  which  provisionally  the  following  groups  may  be  made:  (a)  The 
common  secondary  degeneration  which  follows  when  nerve-fibres  are  cut  ofE 
from  their  trophic  centres  (the  severance  of  portions  of  neurones  from  the 
main  portions  containing  the  nuclei) ;  (h)  toxic  forms,  among  which  may  be 
placed  the  scleroses  from  lead  and  ergot,  and,  most  important  of  all,  the 
sclerosis  of  the  dorsal  columns,  due  in  such  a  large  proportion  of  cases  to  the 
virus  of  syphilis.  Other  unknown  toxic  agents  may  possibly  induce  degenera- 
tion of  the  nerve-fibres  in  certain  tracts.  The  systemic  paths  in  the  cord 
differ  apparently  in  their  susceptibility,  and  the  dorsal  columns  appear  most 
prone  to  undergo  this  change;  (c)  the  sclerosis  associated  with  change  in  the 
smaller  arteries  and  capillaries,  which  is  met  with  as  a  senile  process  in  the 
convolutions.  In  all  probability  some  of  the  forms  of  insular  sclerosis  are 
due  to  primary  alterations  in  the  blood-vessels;  but  it  is  not  yet  settled 
whether  the  lesion  in  these  cases  is  a  primary  degeneration  of  the  nerve  cells 
and  fibres  to  which  the  sclerosis  is  secondary,  or  whether  the  essential  factor 
is  an  alteration  in  nutrition  caused  by  lesions  of  the  capillaries  and  .smaller 
arteries. 

The  inflammatory  scleroses  embrace  a  less  important  and  less  extensive 
group,  comprising  secondary  forms  which  develop  in  consequence  of  irritative 
inflammation  about  tumors,  foreign  bodies,  haemorrhages,  and  abscess.  Histo- 
logically these  are  chiefly  mesodermic  (vascular)  scleroses,  which  arise  from 
the  connective  tissue  about  the  blood-vessels.  Possibly  a  similar  change  may 
follow  the  primary,  acute  encephalitis,  which  Striimpell  holds  is  the  initial 
lesion  in  the  cortical  sclerosis  which  is  so  commonly  found  post  mortem  in 
infantile  hemiplegia. 

The  developmental  scleroses  are  believed  to  be  of  a  purely  neurogliar  char- 
acter, and  embrace  the  new  growth  about  the  central  canal  in  syringomyelia 
and,  according  to  recent  French  writers,  the  sclerosis  of  the  dorsal  columns 
in  Friedreich's  ataxia.  It  is  stated  that  histologically  this  form  is  different 
from  the  ordinary  variety.  It  may  be,  too,  that  the  diffuse  cortical  sclerosis 
met  with  as  a  congenital  condition  without  thickening  of  the  meninges  belongs 
to  this  type.  It  is  not  improbable  that  many  forms  of  sclerosis  are  of  a  mixed 
character,  in  which  both  the  ectodertnic  glia  and  mesodermic  connective  tissue 
are  involved. 

Anatomically  we  meet  with  the  following  varieties: 

(1)  Miliary  sclerosis  is  a  term  which  has  been  applied  to  several,  different 
conditions.  Gowers  mentions  a  case  in  which  there  were  grayish-red  spots  at 
the  junction  of  the  white  and  gray  matters,  and  in  which  the  neuroglia  was 
increased.  There  is  also  a  condition  in  which,  on  the  surface  of  the  convolu- 
tions, there  are  small  nodular  projections,  varying  from  a  half  to  five  or  more 
millimetres  in  diameter.  Single  nodules  of  this  sort  are  not  uncommon; 
sometimes  they  are  abundant.  So  far  as  is  known  no  symptoms  are  produced 
l)y  them. 

(2)  Diffuse  sclerosis,  which  may  involve  an  entire  hemisphere,  or  a  single 
lobe,  in  which  case  the  term  sclerose  lohaire  has  been  applied  to  it  by  the 
French,     It  is  not  an  important  condition  in  general  medical  practice,  but 


930  DISEASES  OF   THE  NERVOUS  SYSTEM. 

occurs  most  frequently  in  idiots  and  imbeciles.  In  extensive  cortical  sclerosis 
of  one  hemisphere  the  ventricle  is  usually  dilated.*  The  symptoms  of  this 
condition  depend  upon  the  region  affected.  There  may  be  a  considerable 
extent  of  sclerosis  without  symptoms  or  without  much  mental  impairment. 
In  a  majority  of  cases  there  is  hemiplegia  or  diplegia  with  imbecilit}^  or 
idiocy. 

(3)  Tuherous  Sclerosis. — In  this  remarkable  form,  which  is  also  known  as 
hypertrophic  sclerosis,  there  are  on  the  convolutions  areas,  projecting  beyond 
the  surface,  of  an  opaque  white  color  and  exceedingly  firm.  The  sclerosis 
may  not  disturb  the  s}Tametr\'  of  the  convolution,  but  simply  cause  a  great 
enlargement,  increase  in  the  density,  and  a  change  in  the  color. 

These  three  forms  are  not  of  much  practical  interest  except  in  asylum  and 
institution  work.  The  fourth  variety  forms  a  well-characterized  disease  of  con- 
siderable importance,  namely,  multiple  sclerosis. 

(i)  Multiple  (Insular:  Disseminated)  Sclerosis  (Sclerose  en  plaques). — 
DznxiTiox. — A  chronic  affection  of  the  brain  and  cord,  characterized  by 
localized  areas  in  which  the  nerve  elements  are  more  or  less  replaced  by 
neuroglia.    This  may  occur  in.  the  brain  or  cord  alone,  more  commonly  in  both. 

The  etiology  is  obscure.  Kahler.  ]\Iarie,  and  others  assign  great  importance 
to  the  infectious  diseases,  particularly  scarlet  fever.  It  is  found  most  com- 
monly in  young  persons,  and  cases  are  not  uncommon  in  children. 

]\IoKBiD  AxATo:siT. — The  sclerotic  areas  are  widely  distributed  through 
the  brain  and  cord,  and  cases  limited  to  either  part  alone  are  almost  un- 
known. The  grayish-red  areas  are  scattered  indifferently  through  the  white 
and  gray  matter  (E.  W.  Taylor).  The  patches  are  most  abundant  in  the 
neighborhood  of  the  ventricles,  and  in  the  pons,  cerebellum,  basal  ganglia, 
and  the  medulla.  The  cord  may  be  only  slightly  involved  or  there  may  be 
very  many  areas  throughout  its  length.  The  cervical  region  is  apt  to  be 
most  affected.  The  nerve  roots  and  the  branches  of  the  cauda  equina  are 
often  attacked.  Histologically  in  the  sclerosed  patches  ihere  is  a  degeneration 
of  the  medullary  sheaths,  with  the  persistence  for  some  time  of  the  axis- 
cylinders.  These  naked  axis-cylinders  are  thought  by  some  to  be  new-formed 
nerve-fibres.  Accompanying  this  there  is  marked  proliferation  of  the  neu- 
roglia, the  fibres  of  which  are  denser  and  firmer.  Secondary  degeneration, 
although  relatively  slight,  does  occur. 

Symptoms. — The  onset  is  slow  and  the  disease  is  chronic.  Feebleness  of 
the  legs  with  irregular  pains  and  stiffness  are  among  the  earl}^  S}Tnptoms. 
Indeed,  the  clinical  picture  may  be  that  of  spastic  paraplegia  with  great 
increase  in  the  refiexes.     The  following  are  the  most  important  features : 

(a)  Volitional  Tremor  or  So-called  Intention  Tremor.  There  is  no  paraly- 
sis of  the  arms,  but  on  attempting  to  pick  up  an  object  there  is  trembling 
or  rapid  oscillation.  A  patient  may  be  unable  to  lift  even  a  glass  of  water 
to  the  mouth.  The  tremor  may  be  marked  in  the  legs,  and  in  the  head, 
which  shakes  as  he  walks.  "When  the  patient  is  recumbent  the  muscles 
may  be  perfectly  quiet.  On  attempting  to  raise  the  head  from  the  pillow, 
trembling  at  once  comes  on.      (&)   Scanning  Speech.  — The  words  are  pro- 

*In  my  monograph  on  Cerebral  Palsies  of  Children  I  have  given  a  description  of  the 

distribution  of  the  sclerosis  in  ten  specimens  in  the  museum  at  the  Elwvn  Institution. 


DIFFUSE  AND  FOCAL  DISEASES  OF  THE  SPINAL  CORD.     931 

nounced  slowly  and  separately,  or  the  individual  syllables  may  be  accentu- 
ated. This  staccato  or  syllabic  utterance  is  a  common  feature,  (c)  Nys- 
tagmus,  a  rapid  oscillatory  movement  of  both  eyes,  constitutes  an  important 
symptom. 

Sensation  is  unaffected  in  a  majority  of  the  cases.  Optic  atrophy  often 
occurs,  but  not  so  frequently  as  in  tabes.  The  sphincters,  as  a  rule,  are 
unaffected  until  the  last  stages.  Mental  debility  is  not  uncommon.  Remark- 
able remissions  occur  in  the  course  of  the  disease,  in  which  for  a  time  all 
the  symptoms  may  improve.  Vertigo  is  common,  and  there  may  be  sudden 
attacks  of  coma,  such  as  occur  in  general  paresis. 

The  symptoms,  on  the  whole,  are  extraordinarily  variable,  corresponding 
to  the  very  irregular  distribution  of  the  nodules. 

Diagnosis. — The  diagnosis  in  well-marked  cases  is  easy.  Volitional  tremor, 
scanning  speech,  and  nystagmus  form  a  characteristic  symptom-group.  With 
this  there  is  usually  more  or  less  spastic  weakness  of  the  legs.  Paralysis  agitans, 
certain  cases  of  general  paresis,  and  occasionall)^  hysteria  may  simulate  the 
disease  very  closely.  If  the  case  is  not  seen  until  near  the  end  the  diagnosis 
may  be  impossible.  Buzzard  holds  that  of  all  organic  diseases  of  the  nervous 
system  disseminated  sclerosis  in  its  early  stages  is  that  which  is  most  com- 
monly taken  for  hysteria.  The  points  to  be  relied  upon  in  the  differentiation 
are,  in  order  of  importance,  optic  atrophy,  the  nystagmus,  the  bladder  disturb- 
ances, when  present,  and  the  volitional  tremor.  The  tremor  in  hysteria  is  not 
volitional.    Unilateral  cases  are  recorded. 

Much  more  puzzling,  however,  are  the  instances  of  pseudo-scUrose  en 
plaques,  which  have  been  described  by  Westphal.  French  writers  regard  them 
as  instances  of  hysterical  tremor.  In  children  the  condition  may  with  diffi- 
culty be  separated  from  Friedreich's  ataxia. 

The  prognosis  is  unfavorable.  Ultimately,  the  patient,  if  not  carried  off 
by  some  intercurrent  affection,  becomes  bedridden. 

Treatment. — No  known  treatment  has  any  influence  on  the  progress  of 
sclerosis  of  the  brain.  Neither  the  iodides  nor  mercury  have  the  slightest 
effect,  but  a  prolonged  course  of  nitrate  of  silver  may  be  tried,  or  arsenic. 
The  X-rays  have  been  used  with  success  (Eaymond). 


D.    DIFFUSE  AND   FOCAL   DISEASES  OE  THE   SPINAL 

CORD. 

I.     TOPICAL    DIAGNOSIS. 

From  the  clinical  symptoms  presented  by  a  spinal  cord  lesion  it  is  pos- 
sible for  us  to  determine  more  or  less  accurately  not  only  its  segmental  level  but 
also  the  transverse  extent  of  the  segmental  involvement.  The  effects  of  an 
injury  or  of  disease  processes  may  be  circumscribed  and  involve  the  gray  matter 
of  the  segment  or  the  tracts  running  through  it  only  in  part ;  it  may  be  more 
extensive  and  involve  the  cord  in  a  given  level  in  its  entire  transverse  ex- 
tent; finally,  there  are  cases  in  which  only  one  lateral  half  of  the  cord  is 
implicated.  It  is  well  for  the  student  to  have  a  definite  routine  to  follow  in 
making  his  examinations,  for  each  factor  may  be  helpful  in  determining  the 


932  DISEASES  OF  THE  NERVOUS  SYSTEM. 

site  and  character  of  the  lesion.  Some  of  the  more  important  points  to 
observe  are  the  following:  (1)  subjective  sensations,  particularly  the  char- 
acter and  seat  of  pain,  if  any  be  present,  such  as  the  radiating  pains  of 
dorsal  root  compression;  (2)  the  patient's  attitude,  as  the  position  of  the 
arms  in  cervical  lesions,  the  character  of  the  respiration,  whether  diaphrag- 
matic, etc.;  (3)  motor  symptoms,  the  groups  of  paralyzed  muscles  and  their 
electrical  reaction;  (4)  the  sensory  symptoms,  including  tests  for  tactual,  ther- 
mic, and  dolorous  impressions,  for  muscle  sense,  bone  sensation,  etc.;  (5)  the 
condition  of  the  reflexes,  both  the  tendon  and  the  skin  reflexes  as  well  as 
those  for  the  pupil,  the  bladder  and  rectum,  etc.;  (6)  the  surface  temperature 
and  condition  of  moisture  or  dryness  of  the  skin,  which  gives  an  indication 
of  vaso-motor  paralysis.  The  table  on  pages  871-873  and  the  figures  on  pages 
878  and  879  will  be  useful  while  making  an  examination. 

Focal  Lesions. — We  have  seen  that  a  lesion  involving  a  definite  part  of  the 
gray  matter  of  the  spinal  cord,  owing  to  destruction  of  the  cell  bodies  of  the 
lower  motor  neurones  and  consequent  degeneration  of  their  axis-cylinder  proc- 
esses, is  accompanied  by  a  loss  of  power  to  perform  certain  definite  movements. 
Thus  a  disease,  such  as  anterior  poliomyelitis,  which  is  confined  to  the  gray 
matter,  gives  as  its  only  symptom  a  characteristic  flaccid  paralysis,  and  the  seat 
of  the  lesion  is  revealed  by  the  muscles  involved.  If  from  injury  or  disease 
a  lesion  involves  more  than  the  gray  matter  and,  for  example,  if  the  neigh- 
boring fibres  of  the  pyramidal  tract  be  affected  there  may  be  in  addition  a 
spastic  paralysis  of  the  muscles  whose  centres  lie  in  the  lower  levels  of  the 
cord.  The  degree  of  such  a  paralysis  depends  upon  the  intensity  of  the 
lesion  of  the  pyramidal  tract  and  may  vary  from  a  slight  weakness  in  dorsal/ 
flexion  of  the  ankle  to  an  absolute  paralysis  of  all  the  muscles  below  the 
lesion.  Again,  if  the  afferent  tracts  of  the  cord  are  affected  sensory  symptoms 
may  be  added  to  the  motor  palsy.  There  may  be  disturbances  of  pain  and\^ 
temperature  sense  alone  or  touch  also  may  be  affected.  This,  however,  is 
more  rare  except  in  serious  lesions.  The  upper  border  of  disturbed  sensation 
often  indicates  most  clearly  the  level  of  the  disease,  especially  when  this  is 
in  the  thoracic  region  where  the  corresponding  level  of  motor  paralysis  is 
not  easily  demonstrated.  It  is  unusual  for  cutaneous  anaesthesia  in  organic 
lesions  of  the  cord  to  extend  above  the  level  of  the  second  rib  and  the  tip 
of  the  shoulder,  for  this  represents  the  lower  border  of  the  skin-field  of 
the  fourth  cervical  (see  sensory  charts),  and  as  the  chief  center  for  the  dia- 
phragm lies  in  this  segment,  a  lesion  at  this  level  sufficiently  serious  to 
cause  sensory  disturbances,  would  probably  occasion  motor  paralyses  as  well 
and  would  entirely  shut  off  the  movements  necessary  for  respiration.  It  is 
to  be  noted  that  the  demonstrable  upper  border  of  the  anaesthetic  field  may 
not  quite  reach  that  which  represents  the  level  of  the  lesion.  This  is  due  to 
the  functional  overlapping  of  the  segmental  skin- fields  (Sherrington)  and 
applies  more  to  touch  than  to  pain  and  temperature.  There  is  often  a  narrow 
zone  of  hypersesthesia  above  the  anaesthetic  region. 

Complete  Transverse  Lesions. — When  the  transverse  lesion  is  total  and 
the  lower  part  of  the  cord  is  cut  off  entirely  from  all  influences  from  above, 
there  is  complete  sensory  and  motor  paralysis  up  to  the  segmental  level  of 
the  injury,  and  the  tendon  reflexes,  whose  centres  lie  below,  are  lost  instead 
of  being  exaggerated,  as  they  are  apt  to  be  in  case  the  lesion  is  a  focal  one. 


DIFFUSE  AND  FOCAL  DISEASES  OF   THE  SPINAL  CORD.     933 

The  symptomatology  of  total  transverse  lesions  in  man  has  thus  been  given 
by  Collier.  (1)  Total  flaccid  paralysis  of  muscles  below  the  level  of  the  lesion. 
(Spastic  paralysis  indicates  that  the  lesion  is  incomplete.)  (3)  Permanent 
abolition  of  the  knee-jerk  and  other  deep  reflexes  supplied  by  the  lower  seg- 
ments of  the  cord.  (3)  A  rapid  wasting  of  the  paralyzed  muscles  with  a  loss 
of  the  faradic  excitability.  (4)  The  sphincters  lose  their  tone  and  there  is 
dribbling.  (5)  There  is  total  ansBsthesia  to  the  level  of  the  lesion  (the  zone 
of  hypersesthesia  is  rare).  (6)  The  only  sign  of  self-action  remaining  is  in 
the  occasional  presence,  though  in  reduced  degree,  of  certain  skin  reflexes 
such  as  the  plantar  reflex  with  its  dorsal  flexor  response  in  the  great  toe. 

Unilateral  Lesions. — The  motor  symptoms,  which  follow  lesions  limited 
to  one  lateral  half  of  the  cross-section  of  the  spinal  cord,  are  confined  to 
one  side  of  the  body;  they  are  on  the  same  side  as  the  lesion.  At  the  level 
of  the  lesion,  owing  to  destruction  of  cell  bodies  of  the  lower  system  of 
neurones,  there  will  be  found  flaccid  paralysis  and  atrophy  of  those  muscles 
whose  centres  of  innervation  happen  to  lie  at  this  level.  Owing  to  degeneration 
of  the  pyramidal  tract,  the  muscles  whose  centres  lie  at  lower  levels  are  also 
paralyzed,  but  they  retain  their  normal  electrical  reactions,  become  spastic, 
and  do  not  atrophy  to  any  great  degree. 

Owing  to  the  early  crossing  of  the  afferent  paths  in  the  cord,  the  sensory 
symptoms  are  peculiar.  On  the  side  of  the  lesion — the  paralyzed  side — corre- 
sponding to  the  segment  or  segments  of  the  cord  involved,  there  is  a  zone 
of  anaesthesia  to  all  forms  of  sensation,  but  below  this  the  sensitivity  remains 
normal  or  may  be  increased,  for  there  is  often  hypersesthesia.  The. muscle 
sense,  however,  is  impaired.  On  the  side  opposite  to  the  lesion  and  nearly 
up  to  its  level  there  is  complete  loss  of  perception  for  pain  and  temperature 
and  there  is  more  or  less  dulling  of  tactual  sense  as  well. 

The  following  table,  slightly  modified  from  Gowers,  illustrates  the  dis- 
tribution of  these  symptoms  in  a  complete  hemi-lesion  of  the  cord: 

Cord. 


Zone  of  cutaneous  hyperassthesia. 
Zone  of  cutaneous  anaesthesia. 
Lower  segment  type  of  paralysis 
with  atrophy. 

Lesion. 

>. 

Upper  segment  type  of  paralysis. 
Hypersesthesia  of  skin. 
Muscular  sense  impaired. 
Reflex  action   first  lessened  and 

then  increased. 
Surface  temperature  raised. 

Muscular  power  normal. 

Loss  of  sensibility  of  skin  to  pain 

and  temperature. 
Muscular  sense  normal. 
Reflex  action  normal. 
Temperature   same  as  that  above 

lesion. 

This  combination  of  symptoms  was  first  recognized  by  Brown- Sequard, 
after  whom  it  has  been  named.  It  is  common  in  syphilitic  diseases  of  the 
cord,  may  follow  tumors,  stab-wounds,  and  is  not  infrequently  associated  with 
syringomyelia  and  haemorrhages  into  the  cord.  It  is  only  in  exceptional  cases, 
of  course,  that  the  lesion  is  absolutely  limited  to  the  hemi-section  of  the 
cord  and  the  symptoms  consequently  may  vary  somewhat  in  degree. 


934  DISEASES  OF   THE  NERVOUS  SYSTEM. 

The  explanation  of  the  disturbance  in  sensation  is  not  entirely  satisf actor}', 
and  can  not  be  until  our  knowledge  of  the  paths  of  sensory  conduction  is 
more  accurate.  These  cases  have  convinced  most  clinicians  that  in  man  the 
paths  for  touch,  pain,  and  temperature  cross  the  middle  line  soon  after 
entering  the  spinal  cord,  and  proceed  toward  the  brain  in  the  opposite 
side,  while  that  for  muscular  sense  remains  in  the  dorsal  columns  of  the 
same  side.  Anatomy  lends  some  support  to  this  view,  and  it  is  the  explanation 
usually  given.  The  experiments  on  animals  have  thrown  some  doubt  on  this 
view,  especially  those  of  Mott  on  monkeys,  which  seem  to  indicate  that  the 
sensory  paths  for  the  most  part  remain  on  the  same  side  of  the  cord. 


U.    AFFECTIONS    OF    THE    BLOOD-VESSELS. 

1.    COXGESTIOX. 

Apart  from  actual  myelitis,  we  rarely  see  post-mortem  evidences  of  con- 
gestion of  the  spinal  cord,  and  when  we  do,  it  is  usually  limited  either  to  the 
gray  matter  or  to  a  definite  portion  of  the  organ.  There  is  necessarily, 
from  the  posture  of  the  body  post  mortem,  a  greater  degree  of  vascularity 
in  the  dorsal  portion  of  the  cord.  The  white  matter  is  rarely  found  con- 
gested, even  when  inflamed;  in  fact,  it  is  remarkable  how  uniformly  pale 
this  portion  of  the  cord  is.  The  gray  matter  often  has  a  reddish-pink  tint, 
but  rarely  a  deep  reddish  hue,  except  when  myelitis  is  present.  If  we  know 
little  anatomically  of  conditions  of  congestion  of  the  cord,  we  know  less 
clinically,  for  there  are  no  features  in  any  way  characteristic  of  it. 

2.  Ax^iiiA. 

So,  too,  with  this  state.  There  may  be  extreme  grades  of  anemia  of 
the  cord  without  symptoms.  In  chlorosis,  for  example,  there  are  rarely 
symptoms  pointing  to  the  cord,  and  there  is  no  reason  to  suppose  that  such 
sensations  as  heaviness  in  the  limbs  and  tingling  are  especially  associated 
with  ansmia. 

There  are,  however,  some  very  interesting  facts  with  reference  to  the 
profound  anaemia  of  the  cord  which  follows  ligature  of  the  aorta.  In  ex- 
periments made  in  Welch's  laboratory  by  Herter,  it  was  found  that  within 
a  few  moments  after  the  application  of  the  ligature  to  the  aorta  paraplegia 
came  on.  Paralysis  of  the  sphincters  developed,  but  less  rapidly.  Eecent 
observations  made  b}'  Halsted  on  occlusion  of  the  abdominal  aorta  in  dogs 
have  shown  that  paraplegia  occurs  in  a  large  percentage  of  cases,  many  of 
which,  however,  may  recover  as  the  collateral  circulation  is  established.  In' 
the  fatal  cases  Gilman  found  extensive  alterations  in  the  cell  bodies  of 
the  lower  part  of  the  cord  with  degenerations.  This  condition  is  of  interest 
in  connection  with  the  occasional- rapid  development  of  a  paraplegia  after 
profuse  hemorrhage,  usually  from  the  stomach  or  uterus.  It  may  come 
on  at  once  or  at  the  end  of  a  week  or  ten  days,  and  is  probably  due  to 
an  anatomical  change  in  the  nerve  elements  similar  to  that  produced  in 
Herter's  experiments.  The  degeneration  of  the  dorsal  columns  of  the  cord 
in  pernicious   auEemia  has   already  been  described.  ■      - 


DIFFUSE  AND  FOCAL  DISEASES  OF  THE  SPINAL  CORD.    935 


3,  Embolism  and  Thrombosis. 

Blocking  of  the  spinal  arteries  by  emboli  rarely  occurs.  It  may, be  pro- 
duced experimentally,  and  Money  found  that  it  was  associated  with  chorei- 
form movements.  Thrombosis  of  the  smaller  vessels  in  connection  with  endar- 
teritis plays  an  important  part  in  many  of  the  acute  and  chronic  changes 
in  the  cord. 

4.  Endarteritis. 

It  is  remarkable  how  frequently  in  persons  over  fifty  the  arteries  of  the 
spinal  cord  are  found  sclerotic.  The  following  forms  may  be  met  with: 
(1)  A  nodular  peri-arteritis  or  endarteritis  associated  with  syphilis  and 
sometimes  with  gummata  of  the  meninges;.  (3)  an  arteritis  obliterans,  with 
great  thickening  of  the  intima  and  narrowing  of  the  lumen  of  the  vessels, 
involving  chiefly  the  medium  and  larger-sized  arteries.  Miliary  aneurisms 
or  aneurisms  of  the  larger  vessels  are  rarely  found  in  the  spinal  cord.  In 
the  classical  work  of  Leyden  but  a  single  instance  of  the  latter  is  mentioned. 

5.    HEMORRHAGE  INTO  THE   SpINAL  MeMBRANES  ;   H^MATORRHACHIS. 

In  meningeal  apoplexy,  as  it  is  called,  the  blood  may  lie  between  the 
dura  mater  and  the  spinal  canal — extra-meningeal  haemorrhage — or  within 
the  dura  mater — intra-meningeal  hsemorrhage. 

(a)  Extra-meningeal  haemorrhage  occurs  usually  as  a  result  of  traumatism; 
The  exudation  may  be  extensive  without  compression  of  the  cord.  The 
blood  comes  from  the  large  plexuses  of  veins  which  may  surround  the  dura. 
The  rupture  of  an  aneurism  into  the  spinal  canal  may  produce  extensive 
and  rapidly  fatal  haemorrhage. 

(6)^  Intra-meningeal  haemorrhage  is  a  less  frequent  result  of  trauma,  but 
in  general  is  perhaps  rather  more  common.  It  is  rarely  extensive  from  causes 
acting  directly  on  the  spinal  meninges  themselves.  Scattered  hemorrhages 
are  not  infrequent  in  the  acute  infectious  fevers,  and  I  have  twice,  in 
malignant  small-pox,  seen  much  extravasation.  Bleeding  may  occur  also 
in  death  from  convulsive  disorders,  such  as  epilepsy,  tetanus,  and  strychnia 
poisoning,  and  has  been  recorded  in  association  with  difficult  parturition. 
The  most  extensive  haemorrhages  occur  in  cases  in  which  the  blood  comes 
from  rupture  of  an  aneurism  at  the  base  of  the  brain,  either  of  the  basilar 
or  vertebral  artery.  In  several  cases  of  this  kind  I  have  found  a  large 
amount  of  blood  in  the  spinal  meninges.  In  ventricular  apoplexy  the  blood 
may  pass  from  the  fourth  ventricle  into  the  spinal  meninges.  There  is 
a  specimen  in  the  medical  museum  of  McGill  College  of  the  most  extensive 
intraventricular  haemorrhage,  in  which  the  blood  passed  into  the  fourth 
ventricle,  and  descended  beneath  the  spinal  arachnoid  for  a  considerable 
distance.  In  cranial  fractures,  particularly  those  of  the  base  of  the  skull, 
the  resultant  haemorrhage  almost  always  finds  its  way  into  the  subarachnoid 
space  about  the  cord  and  may  be  demonstrated  by  the  withdrawal  of  bloody 
fluid  by  a  lumbar  puncture.  The  procedure  is  of  considerable  diagnostic  value. 
On  the  other  hand,  haemorrhage  into  the  spinal  meninges  may  possibly  ascend 
into  the  brain. 


936  DISEASES  OF  THE  NERVOUS  SYSTEM, 

Symptoms. — The  symptoms  in  moderate  grades  may  be  slight  and  in- 
definite. In  the  non-traumatic  cases  the  haemorrhage  may  cither  come  on 
suddenly  or  after  a  day  or  two  of  uneasy  sensations  along  the  spine.  As 
a  rule,  the  onset  is  abrupt,  with  sharp  pain  in  the  back  and  symptoms  of 
iri;itation  in  the  course  of  the  nerves.  There  may  be  muscular  spasms,  or 
paralysis  may  come  on  suddenly,  either  in  the  legs  alone  or  both  in  the 
legs  and  arms.  In  some  instances  the  paralysis  develops  more  slowly  and 
is  not  complete.  There  is  no  loss  of  consciousness,  and  there  are  no  signs 
of  cerebral  disturbance.  The  clinical  picture  naturally  varies  with  the  site 
of  the  haemorrhage.  If  in  the  lumbar  region,  the  legs  alone  are  involved, 
the  reflexes  may  be  abolished,  and  the  action  of  the  bladder  and  rectum  is 
impaired.  If  in  the  thoracic  region,  there  is  more  or  less  complete  paraplegia, 
the  reflexes  are  usually  retained,  and  there  are  signs  of  disturbance  in  the 
thoracic  nerves,  such  as  girdle  sensations,  pains,  and  sometimes  eruption 
of  herpes.  In  the  cervical  region  the  arms  as  well  as  the  legs  may  be  involved ; 
there  may  be  difficulty  in  breathing,  stiffness  of  the  muscles  of  the  neck, 
and  occasionally  pupillar}^  symptoms. 

The  prognosis  depends  much  upon  the  cause  of  the  hgemorrhage.  Ee- 
covery  may  take  place  in  the  traumatic  cases,  and  in  those  associated  with 
the  infectious  diseases. 

6.    HEMORRHAGE    INTO    THE    SpINAL   CoRD;    HeMATOMYELIA. 

Being  most  frequently  a  result  of  traumatism,  an  intraspinal  hsemorrhage 
is  more  common  in  males,  and  during  the  active  period  of  life.  Cases  have 
been  known  to  follow  cold  or  exposure;  it  occurs  also  in  tetanus  and  other 
convulsive  diseases,  and  haemorrhage  may  be  associated  with  tumors,  with 
syringomyelia  or  myelitis.  A  direct  injury  to  the  spine,  however,  from 
blows  or  from  falls,  is  by  far  the  most  common  cause.  Thorburn  was  among 
the  first  to  point  out  that  acute  flexures  of  the  neck,  often  without  attendant 
fracture  or  dislocation  of  the  vertebrae,  was  a  form  of  accident  that  most 
commonly  preceded  these  haemorrhages.  The  level  of  the  lesion,  for  this 
reason,  is  most  frequently  in  the  lower  cervical  region.  Twelve  cases  of 
this  type  have  been  seen  during  the  past  few  years  in  Halsted's  service. 

Anatomical  Condition. — The  extent  of  the  haemorrhage  may  vary  from 
a  small  focal  extravasation  to  one  which  finds  its  way  in  columnar  fashion 
a  considerable  distance  up  and  down  the  cord.  The  bleeding  primarily 
takes  place  into  the  gray  matter,  and  this  as  a  rule  suffers  most,  but  the 
surrounding  medullated  tracts  may  be  thinned  out  and  lacerated.  In  a 
ease  which  occurred  at  the  Montreal  General  Hospital  under  Wilkins  the 
hsemorrhage  occupied  a  position  opposite  the  region  of  the  fifth  and  sixth 
cervical  nerves,  and  on  transverse  section  the  cord  was  occupied  by  a  dark-red 
clot  measuring  12  by  5  mm.,  around  which  the  white  substance  formed  a 
thin,  ragged  wall.  The  clot  could  be  traced  upward  as  far  as  the  second 
cervical,  and  downward  as  far  as  the  fourth  thoracic  segment. 

Symptoms. — Usually  one  side  of  the  cord  is  involved  much  more  than 
the  other,  so  that  a  type  of  the  Brown- Sequard  syndrome  is  very  commonly 
observed.  The  symptoms  are  sudden  in  onset,  and  leave  the  patient  with 
hyperaesthesia  and  a  paralysis  which  becomes  spastic  and  is  most  marked 
on  one  side,  while  anaesthesia,  chiefly  to  pain  and  temperature,  are  most 


DIFFUSE  AND  FOCAL  DISEASES  OF  THE  SPINAL  CORD.     937 

marked  on  the  opposite  side  of  the  body.  Often  a  most  distressing  hyper- 
sesthesia,  usually  a  "pins  and  needles"  sensation,  may  be  present  for 
many  days,  but  there  is  rarely  any  acute  pain  of  the  radiating  or  root 
type.  As  hsematomyelia  is  most  frequent  in  the  lower  cervical  region,  in 
addition  to  the  symptoms  just  mentioned  a  brachial  type  of  palsy  is  commonly 
seen,  with  flaccid  and  atrophic  paralysis  of  the  muscles  innervated  from 
the  lowest  cervical  and  first  thoracic  segments.  The  haemorrhage  may  occur 
in  segments  farther  down  the  cord,  the  lumbar  enlargement  being  affected 
next  in  frequency  to  the  lower  cervical.  The  segmental  level  of  the  paralysis 
necessarily  would  vary  accordingly. 

The  condition  may  prove  rapidly  fatal,  particularly  if  the  extravasation 
is  bilateral  and  extends  high  enough  in  the  cord  to  involve  the  centres  for 
the  diaphragm.  More  frequently  there  is  a  more  or  less  complete  recovery 
with  a  residual  palsy  of  the  upper  extremity  and  a  partial  anaesthesia,  corre- 
sponding to  the  level  of  the  lesion,  and  some  spasticity  of  the  leg. 

Diagnosis. — The  diagnosis  of  the  traumatic  cases  is  comparatively  easy, 
and  it  is  important  to  recognize  them,  as  they  are  often  needlessly  subjected 
to  operation  under  the  belief  that  they  are  instances  of  acute  compression. 
The  residual  symptoms  in  old  cases  may  closely  simulate  those  seen  in  syringo- 
myelia. 

7.  Caisson"  Disease   (Diver's  Paralysis;  Compressed  Air  Disease). 

This  remarkable  affection,  found  in  divers  and  in  workers  in  caissons,  is 
characterized  by  a  paraplegia,  more  rarely  a  general  palsy,  which  supervenes 
on  returning  from  the  compressed  atmosphere  to  the  surface. 

The  disease  has  been  carefully  studied  by  the  French  writers,  by  Leyden 
and  Schultze  in  Germany,  and  in  America  particularly  by  A.  H.  Smith. 
It  has  been  made  the  subject  of  a  special  monograph  by  Snell.  The  pressure 
must  be  more  than  that  of  three  atmospheres.  The  symptoms  are  especially 
apt  to  come  on  if  the  change  from  the  high  to  the  ordinary  atmospheric 
pressure  is  quickly  made.  They  may  supervene  immediately  on  leaving  the 
caisson,  or  they  may  be  delayed  for  several  hours.  Pains  of  the  most  atrocious 
character  about  the  knees,  elbows,  or  other  joints,  without  swelling,  as  a  rule, 
pain  and  swelling  in  the  muscles,  epigastric  pain,  and  vomiting  are  the  most 
common  symptoms.  Headache,  giddiness,  and  paralysis  are  less  frequent. 
Paraplegia  occurred  in  15  per  cent  of  Dr.  Smith's  cases  and  in  61  per  cent 
of  the  St.  Louis  cases.  Monoplegia  and  hemiplegia  are  rare.  In  the  most 
extreme  instances  the  attacks  resemble  apoplexy;  the  patient  rapidly  becomes 
comatose  and  death  occurs  in  a  few  hours.  In  the  case  of  paraplegia  the 
outlook  is  usually  good,  and  the  paralysis  may  pass  off  in  a  day,  or  may  con- 
tinue for  several  weeks  or  even  for  months. 

Several  careful  autopsies  have  been  made.  In  Leyden's  case  death  occurred 
on  the  fifteenth  day,  and  in  the  thoracic  portion  of  the  cord  there  were  nu- 
merous foci  of  ha?morrhage  and  signs  of  an  acute  myelitis.  In  Schultze's 
case  death  occurred  in  two  and  a  half  months,  and  a  disseminated  myelitis 
was  found  in  the  thoracic  region.  In  both  cases  there  were  fissures,  and  ap- 
pearances as  if  tissue  had  been  lacerated.  In  a  case  examined  on  the  third 
day  Assuring  and  laceration  were  found,  and  this  condition  has  been  deter- 
mined by  Boycott  to  be  the  esseuticil  lesion  in  experimental  anilMls,    Jt  lam 


938  DISEASES  OF   THE  NERVOUS  SYSTEM. 

been  suggested  that  the  symptoms  are  due  to  the  liberation  in  the  spinal  cord 
of  bubbles  of  nitrogen  which  have  been  absorbed  by  the  blood  under  the  high 
pressure,  and  the  condition  found  at  the  autopsies  just  referred  to  is  held  to 
favor  this  view. 

Death  is  rare;  it  occurred  in  12  of  76  cases  at  the  St.  Louis  bridge,  in 
3  of  the  110  cases  at  the  Brooklyn  bridge.  In  the  important  work  on  the 
Firth  of  Forth  bridge  and  the  Blackvell  tunnel  there  were  no  fatalities  from 
this  cause. 

The  most  successful  treatment  is  recompression.  A  medical  air  lock  should 
be  provided  at  the  works,  well  heated  and  filled  with  bunks,  etc.  The  recom- 
pression stops  the  pain  and  relieves  the  symptoms.     Morphia  may  be  required. 

III.     COMPRESSION    OF    THE    SPINAL    CORD. 

(Compression  Myelitis.) 

Definition. — Interruption  of  the  functions  of  the  cord  by  slow  compression. 

Etiology. — Caries  of  the  spine,  new  growths,  aneurism,  and  parasites  are 
the  important  causes  of  slow  compression.  Caries,  or  Pott's  disease,  as  it  is 
usually  called,  after  the  surgeon  who  first  described  it,  is  in  the  great  majority 
of  instances  a  tuberculous  affection.  In  a  few  cases  it  is  due- to  s}'philis  and 
occasionally  to  extension  of  disease  from  the  phar^mx.  It  is  most  common  in 
early  life,  but  may  occur  after  middle  age.  It  follows  trauma  in  a  few  cases. 
Compression  occasionally  results  from  aneurism  of  the  thoracic  aorta  or  the 
abdominal  aorta,  in  the  neighborhood  of  the  cceliac  axis.  Malignant  growtTis 
frequently  cause  a  compression  paraplegia.  A  retroperitoneal  sarcoma  or 
the  lymphadenomatous  growths  of  Hodgkin's  disease  may  invade  the  vertebrse. 
More  commonly,  however,  the  involvement  is  secondary  to  scirrhus  of  the 
breast.  Of  parasites,  the  echinococcus  and  the  cysticercus  occasionally  occur 
in  the  spinal  canal. 

Symptoms. — These  may  be  considered  as  they  affect  the  bones,  the  nerves, 
and  the  cord. 

(1)  Yeetebeal. — In  malignant  diseases  and  in  aneurism,  erosion  of  the 
bodies  may  take  place  without  producing  any  deformity  of  the  spine.  Fatal 
haemorrhage  may  follow  erosion  of  the  vertebral  artery.  In  caries,  on  the 
other  hand,  it  is  the  rule  to  find  more  or  less  deformity,  amounting  often  to 
angular  curvature.  The  compression  of  the  cord,  however,  is  rarely  if  ever 
the  direct  result  of  this  bony  kj-phosis  but  is  due  to  the  thickening  of  the  dura 
and  the  presence  of  caseous  and  inflammatory  products  between  this  mem- 
brane and  the  bodies  of  the  diseased  vertebras.  The  spinous  processes  of  the 
affected  vertebrae  are  tender  on  pressure,  and  pain  follows  jarring  movements 
or  twisting  of  the  spine.  There  may  be  extensive  tuberculous  disease  without 
much  deformit}",  particularly  in  the  cervical  region.  In  the  case  of  aneurism 
or  tumor  pain  is  a  constant  and  agonizing  feature. 

(2)  JSTerve-eoot  Symptoms. — These  result  from  compression  of  the  nerve 
roots  as  they  pass  out  between  the  vertebrae.  In  caries,  even  when  the  disease 
is  extensive  and  the  deformity  great,  radiating  pains  from  compression  involve- 
ment of  the  roots  are  rare.  Pains  are  more  common  in  cancer  of  the  spine 
secondary  to  that  of  the  breast,  and  in  such  cases  may  be  agonizing.    There 


DIFFUSE  AND  FOCAL  DISEASES  OF  THE  SPINAL  CORD.     939 

may  be  acutely  painful  areas — the  ancestliesia  dolorosa — in  regions  of  the  skin 
which  are  anaesthetic  to  tactile  and  painful  impressions.  Trophic  disturb- 
ances may  occur,  particularly  herpes.  Pressure  on  the  ventral  roots  may  give 
rise  to  wasting  of  the  muscles  supplied  by  the  affected  nerves.  This  is  most 
noticeable  in  disease  of  the  cervical  or  lumbar  regions. 

(3)  Cord  Symptoms. —  (a)  Cervical  Region. — Not  infrequently  the  caries 
is  high  up  between  the  axis  and  the  atlas  or  between  the  latter  and  the  oc- 
cipital bone.  In  such  instances  a  retropharyngeal  abscess  may  be  present, 
giving  rise  to  difficulty  in  swallowing.  There  may  be  spasm  of  the  cervical 
muscles,  the  head  may  be  fixed,  and  movements  may  either  be  impossible 
or  cause  great  pain.  In  a  case  of  this  kind  in  the  Montreal  General  Hos- 
pital movement  was  liable  to  be  followed  by  transient,  instantaneous  paraly- 
sis of  all  four  extremities,  owing  to  compression  of  the  cord.  In  one  of  these 
attacks  the  patient  died. 

In  the  lower  cervical  region  there  may  be  signs  of  interference  with  the 
cilio-spinal  centre  and  dilatation  of  the  pupils.  Occasionally  there  is  flushing 
of  the  face  and  ear  of  one  side  or  unilateral  sweating.  Deformity  is  not 
so  common,  but  healing  may  take  place  with  the  production  of  a  callus 
of  enormous  breadth,  with  complete  rigidity  of  the  neck. 

(&)  Thoracic  Region. — The  deformity  is  here  more  marked  and  pressure 
symptoms  are  more  common.  The  time  of  onset  of  the  paralysis  varies 
very  much.  It  may  be  an  early  symptom,  even  before  the  curvature  is 
manifest,  and  it  is  noteworthy  that  Pott  first  described  the  disease  that 
bears  his  name  as  ''  a  palsy  of  the  lower  limbs  which  is  frequently  found 
to  accompany  a  curvature  of  the  spine.''  More  commonly  the  paralysis  is 
late,  occurring  many  months  after  the  curvature  has  developed.  The  para- 
plegia is  slow  in  its  development;  the  patient  at  first  feels  weak  in  the 
legs  or  has  disturbance  of  sensation,  numbness,  tingling,  pins  and  needles. 
The  girdle  sensation  may  be  marked,  or  severe  pains  in  the  course  of  the 
intercostal  nerves.  Motion  is,  as  a  rule,  more  quickly  lost  than  sensation. 
The  paraplegia  is  usually  of  the  spastic  type,  with  exaggeration  of  the  reflexes. 
Bastian's  symptom — abolition  of  the  reflexes — is  rarely  met  with  in  compres- 
sion from  caries  as  the  transverse  nature  of  the  lesion  is  rarely  complete.  The 
paraplegia  may  persist  for  months,  or  even  for  more  than  a  year,  and  recovery 
still  be  possible. 

(c)  Lumbar  Region. — In  the  lower  dorsal  and  lumbar  regions  the  symp- 
toms are  practically  the  same,  but  the  sphincter  centres  are  involved  and 
the  reflexes  are  not  exaggerated. 

Diagnosis. — Caries  is  by  far  the  most  frequent  cause  of  slow  compression 
of  the  cord,  and  when  there  are  external  signs  the  recognition  is  easy.  There 
are  cases  in  which  the  exudation  in  the  spinal  canal  between  the  dura  and 
the  bone  leads  to  compression  before  there  are  any  signs  of  caries,  and  if 
the  root  symptoms  are  absent  it  may  be  extremely  difficult  to  arrive  at  a 
diagnosis.  Janeway  has  called  attention  to  persistent  lumbago  as  a  symptom 
of  importance  in  masked  Pott's  disease,  particularly  after  injury.  Brown- 
Sequard's  paralysis  is  more  common  in  tumor  and  in  injuries  than  in  caries. 
Pressure  on  the  nerve  roots,  too,  is  less  frequent  in  caries  than  in  malignant 
disease.  The  cervical  form  of  pachymeningitis  also  produces  a  pressure 
paralysis,  the  symptoms  of  which  have  already  been  detailed.     Pressure  from 


940  DISEASES  OF  THE  NERVOUS  SYSTEM. 

secondary  carcinoma  is  naturall}'  suggested  when  spinal  symptoms  follow 
within  a  few  years  after  an  operation  for  cancer  of  the  breast.  In  paraplegia 
following  tumor  of  the  vertebra  secondary  to  cancer  of  the  breast^  and  in 
the  erosion  of  the  spine  by  retroperitoneal  growths,  the  suffering  is  most 
intense.  The  condition  has  been  well  termed  paraplegia  dolorosa.  I  have 
seen  two  cases  in  which  the  breast  tumor  had  not  been  recognized. 

Treatment. — In  compression  by  aneurism  or  metastatic  tumors  the  con- 
dition is  hopeless.  In  the  former  the  pains  are  often  not  very  severe,  but 
in  the  latter  morphia  is  always  necessary.  On  the  other  hand,  compression 
by  caries  is  often  successfully  relieved  even  after  the  paralysis  has  persisted 
for  a  long  period.  When  caries  is  recognized  early,  rest  and  support  to 
the  spine  by  the  various  methods  now  used  by  surgeons  may  do  much  to 
prevent  the  onset  of  paraplegia.  When  paralysis  has  developed,  rest  with 
extension  gives  the  best  hope  of  recovery.  It  is  to  be  remembered  that 
restoration  may  occur  after  compression  of  the  cord  has  lasted  for  many 
months,  or  even  more  than  a  year.  Cases  have  been  cured  by  recumbency 
alone,  enforced  for  weeks  or  months;  the  extradural  and  inflammatory 
products  are  absorbed  and  the  caries  heals.  In  earlier  days  brilliant  results 
were  obtained  in  these  cases  by  suspension,  a  method  introduced  by  J.  K. 
Mitchell  in  1826,  and  pursued  with  remarkable  success  by  his  son,  Weir  Mitchell. 
During  my  association  with  the  Infirmary  for  Xervous  Diseases  I  had  numerous 
opportunities  of  witnessing  the  really  remarkable  effects  of  persistent  sus- 
pension, even  in  apparently  desperate  and  protracted  cases.  In  recent  years 
the  suspension  methods  in  the  erect  posture  have  been  largely  superseded 
by  those  of  hyperextension  during  recumbency  with  the  application  of  plaster 
jackets  to  hold  the  body  and  spine  immovable  in  the  improved  position. 
Forcible  correction  of  the  deformity  under  anaesthesia  as  sometimes  advo- 
cated is  not  to  be  recommended;  but  the  gentler  partial  corrections,  perhaps 
repeated  several  times  with  a  few  weeks'  interval,  often  lead  to  a  rapid  disap- 
pearance of  paralyses  through  the  lessening  of  the  angular  deformity  of  the 
vertebra.  In  protracted  cases  after  these  methods  have  been  given  a  fair 
trial,  laminectomy  may  become  advisable,  and  has  in  many  instances  been 
successful  in  relieving  paralyses  when  bloodless  methods  have  failed. 

The  general  treatment  of  caries  is  that  of  tuberculosis — fresh  air,  good 
food,  cod-liver  oil,  and  arsenic. 

Lesioxs  of  the  Cauda  Equina  akd  Conus  Medullaeis. 

The  spinal  cord  extends  only  to  the  second  lumbar  vertebra.  Injury, 
tumors,  and  caries  at  or  below  this  level  involve  not  the  cord  itself,  but  the 
bundle  of  nerves  known  as  the  cauda  equina  and  the  terminal  portion  of 
the  cord,  the  conns  medullaris.  Much  attention  has  been  given  to  lesions 
of  this  part.  The  whole  subject  is  admirably  discussed  in  Thorburn's  work. 
Fractures  and  dislocations  are  common  in  the  lumbo-sacral  region,  tumors 
not  infrequently  involve  the  filaments  of  the  cauda  equina,  and  some  of 
the  nerves  are  often  entangled  in  the  cicatrix  of  a  spina  bifida. 

A  lesion  limited  to  the  conus  medullaris  is  rare.  A  myelitis  or  a  focal 
hgematomyelia  may  be  limited  to  this  site  with  symptoms  referable  to  a 
lesion  of  the  lowest  sacral  segments — anaesthesia  over  the  buttocks,  perinaeum, 
and  genitalia,  paralysis  of  the  levator  ani  and  the  vesical  and  anal  sphincters. 


DIFFUSE  AND  FOCAL  DISEASES  OF  THE  SPINAL  CORD.     941 

Such  a  focalized  lesion  has  heen  known  to  follow  a  lumbar  puncture  made 
between  the  first  and  second  lumbar  vertebraj. 

In  a  fracture  or  dislocation  of  the  first  lumbar  vertebra  the  conus  medul- 
laris  may  be  compressed  together  with  the  lowest  sacral  nerves  given  ofE 
from  it.  It  is  rare,  however^  in  traumatic  cases  for  the  tip  of  the  cord  to 
suffer  injury  alone  without  simultaneous  involvement  of  the  nerve  roots  com- 
])rising  the  cauda  equina  from  the  second  lumbar  down.  In  fracture  or 
dislocation  of  the  fifth  lumbar  vertebra  the  sacral  roots  may  alone  be  involved. 
Thus  in  a  case  which  I  have  reported  the  patient  fell  from  a  bridge  and 
had  paralysis  of  the  legs  and  of  the  bladder  and  rectum.  When  seen  sixteen 
years  after  the  injury,  there  was  slight  weakness,  with  wasting  of  the  left 
leg;  there  w-as  complete  loss  of  the  function  in  the  ano-vesical  and  genital 
centres,  and  anaesthesia  in  a  strip  at  the  back  part  of  the  thigh  (in  the 
distribution  of  the  small  sciatic),  and  of  the  perinsum,  scrotum,  and  penis. 
The  urethra  was  also  insensitive. 

It  is  sometimes  very  difficult  to  differentiate  between  a  lesion,  possibly 
at  the  first  lumbar  vertebra,  involving  the  lower  part  of  the  spinal  cord 
and  one  in  the  sacral  region  which  compromises  those  peripheral  nerves  of  the 
Cauda  equina  that  are  given  off  from  the  same  segment.  This  is  particu- 
larly so  in  the  case  of  tumors,  for  in  fractures  or  caries  there  may  be  some 
palpable  indication  of  the  seat  of  trouble.  In  cauda  equina  lesions,  however, 
pressure  upon  the  nerve  roots  is  supposed  to  affect  motion  much  more  markedly 
than  sensation,  and  this  discrepancy  may  be  helpful  since  in  the  cord  lesions 
themselves  the  motor  and  sensory  disturbances  are  more  apt  to  have  a  corre- 
spondingly segmental  distribution. 

The  table  and  figures  given  in  the  general  introduction  wall  be  found 
useful  in  determining  the  nerve  fibres  and  segments  involved  in  these  cases 
of  injury  of  the  cauda  equina. 

IV.     TUMORS    OF    THE    SPINAL    CORD    AND    ITS 
MEMBRANES. 

Morbid  Anatomy. — Xew^  growths  may  develop  in  the  cord  or  in  its  mem- 
branes, or  may  extend  into  them  from  the  spine.  These  invading  growths 
are  the  more  common  and  have  been  touched  upon  in  a  previous  section. 
Here  the  primary  spinal  growths  onty  wall  be  considered. 

■  Schlesingers  tabulation  in  1898  of  400  cases  shows  that  meningeal  tumors 
are  considerably  more  common  than  medullary  or  true  cord  tumors.  Solitary 
tubercles  are  b}'  far  the  most  frequent  medullary  growths.  The  meningeal 
tumors  may  be  either  intra-  or  extradural  and  the  intradural  sarcomata 
or  fibromata — it  is  often  difficult  to  tell  under  which  of  these  terms  they 
should  be  classified — are  by  far  the  most  common.  This  is  important  because 
these  particular  growths  remain  for  a  long  time  non-infiltrating  and  offer 
most  favorable  opportunities  for  surgical  treatment.  In  the  extradural  space 
echinococcus  cysts  are  in  some  countries  frequently  found.  They  are  usually 
multiple,  and  indeed,  most  of  the  other  forms  of  tumor  may  be  multiple.  A 
lipoma,  psammoma,  myxoma,  neuroma,  and  other  varieties  of  growth  may 
be  met  mth.  Gummata  and  gliosarcomata  are  not  infrequent  and  usually 
involve  both  the  cord  and  the  meninges. 


942  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Tumors  are  more  commonly  situated  on  the  lateral  and  dorsal  surfaces 
of  the  cord,  but  there  is  no  level  of  the  spine  in  which  they  may  not  occur. 

The  effects  of  tumor  on  the  functions  of  the  cord  are  varied.  Slow  com- 
pression is  usuall}'^  produced  by  growths  external  to  the  cord,  and  it  is  remark- 
able what  a  high  grade  of  compression  the  cord  will  bear  without  serious  inter- 
ference with  its  functions.  In  cases  of  prolonged  interruption  of  function 
ascending  and  descending  degenerations  occur.  Tumors  developing  within  the 
cord  may  lead  to  syringomyelia. 

Symptoms. — These  will  naturally  vary  a  good  deal  with  the  segment  in- 
volved and  with  the  degree  of  pressure  and  the  extent  of  implication  of  the 
nerve  roots.  Xeuralgic  pains  which  persist  over  a  particular  territory,  and  a 
slowly  progressive  paralysis  which  may  at  iirst  suggest  a  Bro-^Ti-Sequard 
s}"iidrome,  should  always  make  one  suspect  a  spinal  growth. 

The  symptoms  of  the  commoner  intradural  tumors  are  as  follows :  Eadiat- 
ing  (root)  pains  from  the  level  of  the  lesion;  segmental  atrophy  from  pressure 
on  the  ventral  horns;  weakness  of  the  leg,  going  on  to  paralj'sis,  at  first  only 
on  the  side  occupied  by  the  growth,  and  due  to  pyramidal  tract  involvement; 
sensory  disturbances  on  the  opposite  side,  first  affecting  pain  and  temperature 
sense;  with  increase  of  symptoms  the  crossed  type  of  paralysis  is  lost  and  motor 
palsy  occurs  on  both  sides  with  great  increase  of  reflexes;  even  in  advanced 
cases  the  sensory  paratysis  rarely  becomes  quite  complete,  since  some  tactual 
transmission  from  the  lower  sacral  segments  usually  persists ;  spasmodic,  pain- 
ful, jerking  movements  of  the  lower  extremities  are  ver}'  characteristic  of  the 
advanced  cases.  These  sj-mptoms  will  vary  naturally  with  the  character  of 
the  growth,  its  segmental  level,  place  of  origin,  and  other  factors,  but  in  no 
other  disease  is  there  the  same  coincidence  of  a  gradual  compression  paraplegia 
and  persistent  radiating  pain.  In  some  cases  pain  may  be  elicited  by  deep 
pressure  alongside  the  spinous  processes  at  the  level  of  the  growth,  and  the 
patient,  b}*  sudden  exertion,  or  by  straining,  coughing,  or  sneezing,  may  greatly 
increase  it. 

Diagnosis. — Wlien  constant  and  severe  root  pains  are  associated  with  a 
progressive  parah'sis,  the  diagnosis  may  be  easily  made.  Caries  may  cause 
identical  symptoms,  but  the  radiating  pains  are  rarely  so  severe.  Cervical 
meningitis  simulates  tumor  very  closely,  and  in  realit}^  produces  identical 
effects,  but  the  very  slow  progress  and  the  bilateral  character  from  the  outset 
may  be  sufficient  to  distinguish  it.  In  chronic  transverse  myelitis  the  s3Tnp- 
toms,  according  to  Gowers,  may  resemble  tumor  very  closely  and  present  radi- 
ating pains,  a  sense  of  constriction,  and  progressive  paralysis.  S}Tingomyelia, 
too,  may  give  a  similar  picture,  A  radiogram  may  be  of  diagnostic  aid  in 
case  the  vertebrse  are  infiltrated  by  the  growth. 

The  nature  of  the  tumor  can  rarely  be  indicated  with  precision.  With  a 
marked  sj'philitic  histor}'  gumma  may  naturally  be  suspected,  or  vrith  coex- 
isting tuberculous  disease,  a  solitary  tubercle. 

Treatment. — If  the  possibility  of  syphilitic  infection  is  present  the  iodide 
of  potassium  should  be  given  in  large  and  increasing  doses.  For  the  severe 
pains  counter-irritation  is  sometimes  beneficial,  particularly  the  thermo- 
cautery; morphia  is,  however,  often  necessary.  A  successful  laminectomy 
offers  the  only  hope  of  relief  in  case  the  lesion  prove  to  be  non-syphilitic. 
During  the  seventeen  years  since  Horsley's  first  brilliant  operation  there  haye 


DIFFUSE  AND  FOCAL  DISEASES  OF  THE  SPINAL  CORD.     943 

been  numerous  cases  of  successful  extirpation  of  spinal  cord  tumors.  The 
intradural  fibrosarcomata  are  the  most  favorable  cases  and  complete  restora- 
tion of  function  in  the  cord  may  follow  the  removal  of  the  tumor.  In  the 
infiltrating  growths  the  nerve  roots  may  be  divided,  or,  as  has  been  suggested, 
even  the  cord  itself  sectioned  for  the  relief  of  the  agonizing  pain,  but  ultimate 
cure  is  hopeless  in  malignant  growths  of  this  character. 

V.     SYRINGOMYELIA. 

Definition. — A  gliomatous  new  growth  about  the  central  canal  of  the  spinal 
cord,  with  cavity  formation. 

Etiology  and  Morbid  Anatomy. — Syringomyelia  must  be  distinguished 
from  dilatation  of  the  central  canal — hydromyelus — slight  grades  of  which  are 
not  very  uncommon  either  as  a  congenital  condition  or  as  a  result  of  the 
pressure  of  tumors.  The  cavity  of  syringomyelia  has  a  variable  extent  in  the 
cord,  sometimes  running  the  entire  length,  but  in  many  cases  involving  only 
the  cervical  and  thoracic  regions  or  a  more  limited  area.  It  is  usually  in  the 
dorsal  portion  of  the  cord  and  may  extend  only  into  one  dorsal  cornu.  The 
transverse  section  may  be  oval  or  circular  or  narrow  and  fissure-like.  It  varies 
at  different  levels.  The  condition  is  now  regarded  as  a  gliosis,  a  development 
of  embryonal  neurogliar  tissue  in  which  hsemorrhage  or  degeneration  takes 
place  with  the  formation  of  cavities. 

Of  190  cases,  133  were  in  men,  57  in  women' (Schlesinger).  A  large 
majority  of  the  cases  begin  before  the  thirtieth  year.  The  disease  has  been 
met  with  in  three  members  of  the  same  family. 

Symptoms. — The  clinical  features  are  extremely  complex.  In  the  classical 
form  there  are  irregular  pains,  chiefly  in  the  cervical  region ;  muscular  atroph}'' 
develops,  which  may  be  confined  to  the  arms,  or  sometimes  extends  to  the  legs. 
The  reflexes  are  increased  and  a  spastic  condition  develops  in  the  legs.  Ulti- 
mately the  clinical  picture  may  be  that  of  an  amyotrophic  lateral  sclerosis.  The 
tactile  sensation  is  usually  normal  and  the  muscular  sense  is  retained,  but  pain- 
ful and  thermic  sensations  are  not  recognized,  or  there  may  be  in  rare  instances 
complete  angesthesia  of  the  skin  and  of  the  mucous  membranes  (Dejerine). 
This  combination  of  loss  of  painful  and  thermic  sensations  with  paralysis  of 
an  amyotrophic  type  is  characteristic,  but  not  pathognomonic  of  the  disease. 
The  special  senses  are  usually  intact  and  the  sphincters  uninvolved.  Trophic 
troubles  are  not  uncommon.  Owing  to  the  loss  of  the  pain  and  heat  sensations, 
the  patients  are  apt  to  injure  themselves.  Scoliosis  also  may  be  present  in 
these  cases.  The  loss  of  painful  and  thermic  impressions  is  due  to  the  fact 
that  these  pass  to  the  brain  in  the  peri-ependymal  gray  matter,  particularly 
that  portion  in  the  dorsal  roots,  which  is  almost  constantly  involved  in  syringo- 
myelia. The  tactile  sensation  is  retained  because  the  postero-lateral  columns 
are  uninvolved. 

Schlesinger,  in  his  monograph  (1895),  recognizes  the  following  types: 
(1)  With  the  classical  features  above  described,  which  may  begin  in  the 
cervical  or  lumbar  regions;  (3)  a  motor  type,  with  the  picture  of  an  amyo- 
trophic or  a  spastic  paralysis — the  sensation  may  be  undisturbed  for  years; 
(3)  with  predominant  sensory  features,  simulating  hysterical  hemiplegia,  or 
with  general  pain  and  temperature  anaesthesia;  (4)  with  pronounced  trophic 


944  DISEASES  OF   THE  NERVOUS  SYSTEM. 

disturbances — to  this  type  belong  the  cases  described  as  Morvan's  disease,  an 
afEection  characterized  by  neuralgic  pains,  cutaneous  anaesthesia,  and  painless, 
destructive  whitlows;  and  (5)  the  tabetic  type,  either  a  combination  of  the 
symptoms  of  tabes  in  the  lower,  and  of  syringomyelia  in  the  upper  extremities, 
or  a  pure  tabetic  symptom-complex,  due  to  invasion  of  the  dorsal  columns  by 
the  gliosis  (Oppenheim).  Arthropathies  occur  in  about  10  per  cent  of  the 
cases. 

Diagnosis. — In  typical  cases  the  diagnosis  is  easy.  The  combination  of  an 
amyotrophic  paralysis,  the  picture  of  progressive  muscular  atrophy  of  the 
Aran-Duchenne  type,  with  retention  of  tactile  and  loss  of  thermic  and  painful 
sensation,  is  probably  pathognomonic  of  the  disease.  Of  affections  with  which 
it  may  be  confounded,  anaesthetic  leprosy  is  the  most  important,  since  the 
anaesthesia  and  the  wasting  may  closely  simulate  it;  but,  as  a  rule,  in  leprosy 
trophic  changes  are  more  or  less  marked.  There  is  often  loss  of  phalanges 
and  there  is  no  characteristic  dissociation  of  sensory  impressions. 

VI.    ACUTE    MYELITIS. 

Etiology. — Acute  myelitis  results  from  many  causes,  and  may  affect  the 
cord  in  a  limited  or  extended  jDortion — the  gray  matter  chiefly,  or  the  gray 
and  white  matter  together.  It  is  met  with:  (a)  As  an  independent  affection 
following  exposure  to  cold,  or  exertion,  and  leading  to  rapid  loss  of  power 
with  the  symptoms  of  an  acute  ascending  paralysis,  (h)  As  a  sequel  of  the 
infectious  diseases,  such  as  small-pox,  typhus,  measles,  and  gonorrhoea,  (c)  As 
a  result  of  traumatism,  either  fracture  of  the  spine  or  very  severe  muscular 
effort.  Concussion  without  fracture  may  produce  it,  but  this  is  rare.  Acute 
myelitis,  for  instance,  sca,rcely  ever  follows  railway  accidents,  (d)  In  diseases 
of  the  bones  of  the  spine,  either  caries  or  cancer.  This  is  a  more  common  cause 
of  localized  acute  transverse  myelitis  than  of  the  diffuse  affection,  (e)  In 
disease  of  the  cord  itself,  such  as  tumors  and  syphilis;  in  the  latter,  either  in 
association  with  gummata,  in  which  case  it  is  usually  a  late  manifestation ;  or 
it  may  follow  within  a  year  or  eighteen  months  of  the  primary  affection. 

Morbid  Anatomy. — In  localized  acute  myelitis  affecting  white  and  gray 
matter,  as  met  with  after  accident  or  an  acute  compression,  the  cord  is  swollen, 
the  pia  injected,  the  consistence  greatly  reduced,  and  on  incising  the  mem- 
brane an  almost  diffluent  material  may  escape.  In  less  intense  grades,  on  section 
at  the  affected  area,  the  distinction  between  the  gray  and  white  matter  is  lost, 
or  is  extremely  indistinct.  The  tissue  may  be  injected,  or,  as  is  often  the  case, 
haemorrhagic.  It  is  particularly  in  these  forms,  due  to  extension  of  disease 
from  without  or  to  acute  compression,  that  we  find  definite  involvement  of 
the  white  matter.  In  other  instances  the  gray  matter  is  chiefly  affected.  There 
may  be  localized  areas  throughout  the  cord  in  which  the  gray  matter  is  reduced 
in  consistence  and  haemorrhagic,  the  so-called  red  softening.  There  may  be 
definite  cavity  formations  in  these  foci.  In  some  cases  of  disseminated  or 
focal  myelitis  the  meninges  also  are  involved  and  there  is  a  myelomeningitis. 
And,  lastly,  there  are  instances  in  which,  throughout  a  long  section  of  the 
cord,  sometimes  through  the  lumbar  and  the  greater  part  of  the  thoracic,  or 
in  the  thoracic  and  cervical  regions,  there  is  a  diffuse  myelitis  of  the  gray 


DIFFUSE  AND  FOCAL  DISEASES  OF  THE  SPINAL  CORD.     945 

Histologically  the  nerve  fibres  are  much  swollen  and  irregularly  distorted, 
the  axis-cylinders  are  beaded,  the  myelin  droplets  are  abundant,  and  the 
laminated  bodies  known  as  corpora  amylacea  may  be  seen.  Granular  fatty 
cells  are  also  numerous  and  there  may  be  leucocytes  and  red  blood-corpuscles. 
Changes  in  the  blood-vessels  are  striking;  the  smaller  veins  are  distended  and 
may  show  varicosities.  The  perivascular  lymph  spaces  contain  numerous  leu- 
cocytes, and  the  smaller  arteries  themselves  are  frequently  the  seat  of  hyaline 
thrombi.  The  ganglion  cells  are  swollen  and  irregular  in  outline,  the  proto- 
plasm is  extremely  granular  and  vacuolated,  and  the  nuclei,  though  usually 
invisible,  may  show  signs  of  division,  and  the  processes  of  the  cells  are  not  seen. 

In  cases  which  persist  for  some  time  we  have  an  opportunity  of  seeing 
the  later  stages  of  acute  myelitis.  The  acute,  inflammatory,  hypersemic  or 
red  softening  is  succeeded  by  stages  in  which  the  affected  area  becomes 
more  yellow  from  gradual  alteration  of  the  blood-pigment,  and  finally  white 
in  color  from  the  advancing  fatty  degeneration.  In  cases  of  compression 
myelitis,  a  sclerosis  may  gradually  be  produced  with  the  anatomical  picture 
of  a  chronic  diffuse  myelitis. 

Symptoms, —  (a)  Acute  Diffuse  Myelitis. — This  form  may  follow  ex- 
posure to  cold,  or  occurs  in  connection  with  syphilis  or  one  of  the  infectious 
diseases,  or  is  seen  in  a  typical  manner  in  the  extension  from  injuries  or 
from  tumor.  The  onset,  though  scarcely  so  abrupt  as  in  hsemorrhage,  may 
be  sudden;  a  person  may  be  attacked  on  the  street  and  have  difficulty  in 
getting  home.  In  some  instances,  the  onset  is  preceded  by  pains  in  the 
legs  or  back,  or  a  girdle  sensation  is  present.  It  may  be  marked  by  chills, 
occasionally  by  convulsions;  fever  is  usually  present  from  the  beginning — 
at  first  sight,  but  subsequently  it  may  become  high. 

The  motor  functions  are  rapidly  lost,  sometimes  as  quickly  as  in  Landry's 
ascending  paralysis.  The  paraplegia  may  be  complete,  and,  if  the  myelitis 
extends  to  the  cervical  region,  there  may  be  impairment  of  motion,  and 
ultimately  complete  loss  of  power  in  the  upper  extremities  as  well.  The 
sensation  is  lost,  but  there  may  at  first  be  hypersesthesia.  The  reflexes  in 
the  initial  stage  are  increased,  but  in  acute  central  myelitis,  unless  limited 
in  extent  to  the  thoracic  and  cervical  regions,  the  reflexes  are  usually  abolished. 
The  rectum  and  bladder  are  paralyzed.  Trophic  disturbances  are  marked; 
the  muscles  waste  rapidly;  the  skin  is  often  congested,  and  there  may  be 
localized  sweating.  The  temperature  of  the  affected  limbs  may  be  lowered. 
Acute  bed-sores  may  develop  over  the  sacrum  or  on  the  heels,  and  sometimes 
a  multiple  arthritis  is  present.  In  these  acute  cases  the  general  symptoms 
become  greatly  aggravated,  the  pulse  is  rapid,  the  tongue  becomes  dry ;  there 
is  delirium,  the  fever  increases,  and  may  reach  107°  or  108°. 

The  course  of  the  disease  is  variable.  In  very  acute  cases  death  follows 
in  from. five  to  ten  days.  The  cases  following  the  infectious  diseases,  par- 
ticularly the  fevers  and  sometimes  syphilis,  may  run  a  milder  course. 

The  diagnosis  of  this  variety  of  acute  myelitis  is  rarely  difficult.  In 
common  with  the  acute  ascending  paralysis  of  Landry,  and  with  certain 
cases  of  multiple  neuritis,  it  presents  a  rapid  and  progressive  motor  paraly- 
sis. From  the  former  it-  is  distinguished  by  the  more  marked  involvement 
of  sensation,  the  trophic  disturbances,  the  paralysis  of  bladder  and  rectum, 
the  rapid  wasting,  the  electrical  changes,  and  the  fever.  From  acute  cases 
61 


946  DISEASES  OF   THE  NERVOUS  SYSTEM, 

of  multiple  neuritis  it  may  be  more  difficult  to  distinguish,  as  the  sensory 
features  in  these  eases  may  be  marked,  though  there  is  rarely,  if  ever,  in 
multiple  neuritis  complete  anaesthesia;  the  wasting,  moreover,  is  more  rapid 
in  myelitis.  The  bladder  and  rectum  are  rarely  involved — though  in  ex- 
ceptional cases  they  may  be — and,  most  important  of  all,  the  trophic  changes, 
the  development  of  bullae,  bed-sores,  etc.,  are  not  seen  in  multiple  neuritis. 

(&)  Acute  Traxsverse  Myelitis. — The  symptoms  naturally  differ  with 
the  situation  of  the  lesion. 

(1)  Acute  transverse  myelitis  in  the  ilioracic  region,  the  most  common 
situation,  produces  a  very  characteristic  picture.  The  sjToptoms  of  onset 
are  variable.  There  may  be  initial  pains  or  numbness  and  tingling  in  the 
legs.  The  paralysis  may  set  in  quickly  and  become  complete  within  a 
few  days;  but  more  commonly  it  is  preceded  for  a  day  or  two  by  sensations 
of  pain,  heaviness,  and  dragging  in  the  legs.  The  paralysis  of  the  lower 
limbs  is  usually  complete,  and  if  at  the  level,  say,  of  the  sixth  thoracic 
vertebra,  the  abdominal  muscles  are  involved.  Sensation  may  be  partially 
or  completely  lost.  At  the  onset  there  may  be  numbness,  tingling,  or  even 
h3'per8esthesia  in  the  legs.  At  the  level  of  the  lesion  there  is  often  a  zone  of 
hyperassthesia,  which  is  discovered  by  passing  a  test-tube  containing  hot 
water  along  the  spine,  when  the  sensation  of  warmth  changes  to  one  of 
actual  pain,  A  girdle  sensation  may  occur  early,  and  when  the  lesion  is  in 
this  situation  it  is  usually  felt  between  the  ensiform  and  umbilical  regions. 
The  reflex  functions  are  variable.  There  may  at  first  be  abolition  of  the 
reflexes;  subsequently,  those  which  pass  through  the  segments  lower  than  the 
one  affected,  may  be  exaggerated  and  the  legs  may  take  on  a  condition  of  spastic 
rigidity.  It  does  not  always  happen,  however,  that  the  reflexes  are  increased 
here,  for  in  a  total  transverse  lesion  of  the  cord,  they  are  usually  entirely  lost, 
as  first  pointed  out  b}^  Bastian.  That  this  is  not  due  to  the  preliminary  shock 
is  shown  by  the  fact  that  the  abolition  of  the  reflexes  may  be  permanent.  The 
muscles  become  extremely  flabby,  waste,  and  lose  their  faradic  excitability,  and 
the  sphincters  lose  their  tone.  The  temperature  of  the  paralyzed  limbs  is  vari- 
able. It  may  at  first  rise,  then  fall  and  become  subnormal.  Lesions  of  the  skin 
are  not  uncommon,  and  bed-sores  are  apt  to  form.  There  is  at  first  retention  of 
urine  and  subsequently  spastic  incontinence.  If  the  lumbar  centres  are  in- 
volved, there  are  from  the  outset  vesical  symptoms.  The  urine  is  alkaline  in 
reaction  and  may  rapidly  become  ammoniacal.  The  bowels  are  constipated 
and  there  is  usually  incontinence  of  the  faeces.  Some  writers  attribute  the  cys- 
titis associated  with  transverse  myelitis  to  disturbed  trophic  influence. 

The  course  of  complete  transverse  myelitis  depends  a  good  deal  upon  its 
cau5e.  Death  may  result  from  extension.  Segments  of  the  cord  may  be  com- 
pletely and  permanently  destroyed,  in  which  case  there  is  persistent  paraplegia. 
The  pyramidal  fibres  below  the  lesion  undergo  the  secondary  degeneration,  and 
there  is  an  ascending  degeneration  of  the  dorsal  median  columns.  If  the 
lower  segments  of  the  cord  are  involved  the  legs  may  remain  flaccid.  In  some 
instances  a  transverse  myelitis  of  the  thoracic  region  involves  the  ventral  horns 
above  and  below  the  lesion,  producing  flaccidity  of  the  muscles,  with  wasting, 
fibrillar  contractions,  and  the  reaction  of  degeneration.  More  commonly, 
however,  in  the  cases  which  last  many  months  there  is  more  or  less  rigidity  of 
the  muscles  with  spasm  or  persistent  contraction  of  the  flexors  of  the  knee. 


DIFFUSE  AND  FOCAL  DISEASES  OF   THE  BRAIN.  947 

(2)  Transverse  Myelitis  of  the  Cervical  Region. — If  the  lesion  is  at  the 
level  of  the  sixth  or  seventh  cervical  nerves,  there  is  paralysis  of  the  upper 
extremities,  more  or  less  complete,  sometimes  sparing  the  muscles  of  the 
shoulder.  Gradually  there  is  loss  of  sensation.  The  paralysis  is  usually  com- 
plete below  the  point  of  lesion,  but  there  are  rare  instances  in  which  the  arms 
only  are  affected,  the  so-called  cervical  paraplegia.  In  addition  to  the  symp- 
toms already  mentioned  there  are  several  which  are  more  characteristic  of 
transverse  myelitis  in  the  cervical  region,  such  as  the  occurrence  of  vomiting, 
hiccough,  and  slow  pulse,  which  may  sink  to  20  or  30,  pupillary  changes — 
myosis — sometimes  attacks  of  dysphagia,  dyspnoea,  or  syncope. 

Treatment  of  Acute  Myelitis. — In  the  rapidly  developing  form  due  either 
to  a  diffuse  inflammation  in  the  gray  matter  or  to  transverse  myelitis,  the 
important  measures  are  scrupulous  cleanliness,  care  and  watchfulness  in 
guarding  against  bed-sores,  the  avoidance  of  cystitis,  either  by  systematic 
catheterization  or,  if  there  is  incontinence,  by  a  carefully  adjusted  bed  urinal, 
or  the  use  of  antiseptic  cotton-wool  repeatedly  changed.  In  an  acute  onset 
in  a  healthy  subject  the  spine  may  be  cupped.  Counter-irritation  is  of  doubt- 
ful advantage.  Chapman's  ice-bag  is  sometimes  useful.  No  drugs  have  the 
slightest  influence  upon  an  acute  myelitis,  and  even  in  subjects  with  well- 
marked  syphilis  neither  mercury  nor  iodide  of  potassium  is  curative.  Tonic 
remedies,  such  as  quinine,  arsenic,  and  strychnia,  may  be  used  in  the  later 
stages.  When  the  muscles  have  wasted,  massage  is  beneficial  in  maintaining 
their  nutrition.  Electricity  should  not  be  used  in  the  early  stages  of  myelitis. 
It  is  of  no  value  in  the  transverse  myelitis  in  the  thoracic  region  with  retention 
of  the  nutrition  in  the  muscles  of  the  leg. 


E.    DIFFUSE  AND  FOCAL  DISEASES  OF  THE  BRAIN. 

I.    TOPICAL    DIAGNOSIS. 

Only  certain  regions  of  the  brain  give  localizing  symptoms.  These  are  the 
cortical  motor  centres  and  the  associated  sensory  centres,  the  speech  centres, 
the  centres  for  the  special  senses,  and  the  tracts  which  connect  these  cortical 
areas  with  each  other  and  with  other  parts  of  the  nervous  system. 

The  following  is  a  brief  summary  of  the  effects  of  lesions  from  the  cortex 
to  the  spinal  cord : 

1.  The  Cerebral  Cortex. —  {a)  Destructive  lesions  of  the  motor  cortex  cause 
paralysis  in  the  muscles  of  the  opposite  side  of  the  body.  The  paralysis  is  at 
first  flaccid,  but  the  spastic  condition  subsequently  develops.  The  extent  of 
the  paralysis  depends  upon  that  of  the  lesion.  It  is  apt  to  be  limited  to  the 
muscles  of  the  head  or  of  an  extremity,  giving  rise  to  the  cerebral  monoplegias. 
One  group  of  muscles  may  be  much  more  affected  than  others,  especially  in 
lesions  of  the  highly  differentiated  area  for  the  upper  extremity.  It  is  un- 
common to  find  all  the  muscle  groups  of  an  extremity  equally  involved  in 
cortical  monoplegia.  Very  rarely  through  small  bilaterally  symmetrical  lesions 
monoplegia  -of  the  tongue  may  result  without  paralysis  of  the  face.  A  lesion 
may  involve  centres  lying  close  together  or  overlapping  one  another,  thus  pro- 
ducing associated  monoplegias — e.  g.,  paralysis  of  the  face  and  arm,  or  of  the 


948  DISEASES  OF  THE  NERVOUS  SYSTEM. 

arm  and  leg,  but  not  of  the  face  and  leg  without  involvement  of  the  arm. 
Very  rarely  the  whole  motor  cortex  is  involved,  causing  paralysis  of  the  opposite 
side — cortical  hemiplegia.  Usually  in  such  instances  there  is  marked  recovery, 
so  that  only  a  monoplegia  persists. 

Adjoining  and  posterior  to  the  motor  area  is  believed  to  be  the  region  of 
the  cortex  in  which  the  impulses  concerned  in  general  bodily  sensation  (cutane- 
ous sensibility,  muscle  sense,  visceral  sensations)  first  arrive  (the  somaesthetic 
area).  Combined  with  the  muscular  weakness  there  is  usually  some  disturb- 
ance of  sensations,  particularly  of  those  of  the  muscular  sense.  In  lesions  of 
the  superior  parietal  lobe  the  stereognostic  sense  is  very  often  affected.  For 
example,  when  a  coin  or  a  knife  is  placed  in  the  hand  of  the  affected  limb,  the 
patient's  eyes  being  closed,  it  is  not  recognized,  owing  to  inappreciation  of 
the  form  and  consistence  of  the  object,  and  this  even  though  the  slightest 
tactile  stimulus  applied  to  the  fingers  or  surface  of  the  hand  is  felt  and  may 
be  correctly  localized.  The  sense  of  touch,  pain,  and  temperature  may  be 
lowered,  but  usually  not  markedly  unless  the  superior  and  inferior  parietal 
lobules  are  involved  in  subcortical  lesions.  Parsesthesias  and  vaso-motor  dis- 
turbances are  common  accompaniments  of  paralyses  of  cortical  origin. 

(6)  Irritative  lesions  cause  localized  spasms  as  described  on  page  883. 
The  most  varied  muscle  groups  corresponding  to  particular  movement  forms 
may  be  picked  out.  If  the  irritation  be  sudden  and  severe,  typical  attacks  of 
Jacksonian  epilepsy  may  occur.  These  convulsions  are  often  preceded  and 
accompanied  by  subjective  sensory  impressions.  Tingling  or  pain,  or  a  sense 
of  motion  in  the  part,  is  often  the  signal  symptom  (Seguin),  and  is  of  great 
importance  in  determining  the  seat  of  the  lesion. 

Lesions  are  often  both  destructive  and  irritative,  and  we  then  have  com- 
binations of  the  symptoms  produced  by  each.  For  instance,  certain  muscles 
may  be  paralyzed,  and  those  represented  near  them  in  the  cortex  may  be  the 
seat  of  localized  convulsions,  or  the  paralyzed  limb  itself  may  be  at  times 
subject  to  convulsive  spasms,  or  muscles  which  have  been  convulsed  may  be- 
come paralyzed.  The  close  observation  of  the  sequence  of  the  symptoms  in 
such  cases  often  makes  it  possible  to  trace  the  progress  of  a  lesion  involving 
the  motor  cortex.  In  these  cases  the  most  frequent  cause  is  a  developing  tumor, 
though  sometimes  local  thickenings  of  the  membranes  of  the  brain,  small  ab- 
scesses, minute  heemorrhages,  or  fragments  of  a  fractured  skull  must  be  held 
responsible. 

In  another  section  lesions  involving  the  centres  for  the  special  senses  are 
considered,  and  we  shall  simpl}''  refer  to  them  here.  The  symptoms  caused 
by  lesions  of  the  speech  centres  will  be  described  under  aphasia,  and  it  is 
only  necessary  to  note  here  the  near  situation  of  the  motor  speech  area  (Broca's 
centre)  in  the  left  inferior  frontal  convolution  to  the  centres  for  the  face  and 
tongue  on  that  side,  and  the  nearness  of  the  supposed  centre  for  writing  to 
that  of  the  hand  and  arm,  and  to  state  that  motor  aphasia  is  often  associated 
with  paralysis  of  the  right  side  of  the  face  and  the  right  arm.  Accompanying 
the  paralysis,  following  a  Jacksonian  fit,  of  the  right  face  or  arm  there  is  often 
a  transient  motor  aphasia. 

According  to  Flechsig,  the  sensori-motor  centres  are  limited  to  tolerably 
circumscribed  areas  in  the  cortex,  which  differ  from  other  portions  in  that  they 
are  provided  with  projection  fibres  which  connect  them  with  lower  centres. 


DIFFUSE  AND  FOCAL  DISEASES  OF  THE  BRAIN.  949 

The  remaining  areas  of  the  cortex,  amounting,  he  believes,  to  about  two-thirds 
of  the  whole,  are  devoid  of  projection  fibres  and  are  concerned  entirely  in 
associative  activities.  These  latter  areas,  the  "  association  centres  "  of  Flech- 
sig,  are  three  in  number:  (1)  The  anterior  association  centre,  including  the 
whole  of  the  frontal  lobe  in  front  of  the  somgesthetic  area;  (2)  the  middle 
association  centre,  corresponding  to  the  cortex  of  the  island  of  Eeil;  and  (3) 
the  large,  posterior  association  centre,  including  the  prsecuneus,  the  superior 
and  inferior  parietal  lobules,  the  supramarginal  and  angular  gyri,  and  the 
whole  of  the  temporal  and  occipital  lobes  except  the  auditory  and  visual  sen- 
sory areas. 

Flechsig  attributes  the  higher  psychic  functions,  especially  those  connected 
with  the  personality  of  the  individual,  to  the  anterior  association  centres,  while 
the  intellectual  activities  which  have  to  do  with  knowledge  of  the  external 
world  he  believes  correspond  to  the  functions  of  the  large  posterior  association 
centre.  Whether  these  views  be  true,  and,  if  so,  in  how  far  they  may  be  applied 
practically  in  the  localization  of  diseases,  especially  of  the  mind,  the  future 
has  to  decide. 

2.  Centrum  Semiovale. — Lesions  in  this  part  may  involve  either  projection 
fibres  (motor  or  sensory)  or  association  fibres.  If  involvement  of  the  motor 
path  cause  paralysis,  this  has  the  distribution  of  a  cortical  palsy  when  the 
lesion  is  near  the  cortex,  and  of  a  paralysis  due  to  a  lesion  of  the  internal 
capsule  when  it  is  near  that  region.  These  lesions  of  the  motor  fibres  may 
be  associated  with  symptoms  due  to  interruption  in  the  other  systems  of  fibres 
running  in  the  centrum  semiovale ;  there  may  be  sensory  disturbances — hemi- 
anesthesia and  hemianopia — and  if  the  lesion  is  in  the  left  hemisphere  one 
of  the  different  forms  of  aphasia  may  accompany  the  paralysis. 

3.  Corpus  Callosum. — This  may  be  congenitally  absent  without  symptoms. 
An  acute  lesion  involving  a  large  portion  of  the  corpus  callosum  may,  how- 
ever, yield  symptoms  suggestive  of  its  localization  in  this  region.  In  the  case 
recorded  by  Reinhard,  in  which  the  situation  of  the  lesion  was  suspected  ante 
mortem,  there  was  a  disturbance  of  equilibration  (without  vertigo)  and  of 
the  synergetic  movements  of  both  halves  of  the  body.  The  autopsy  revealed 
a  gliosarcoma  which  had  destroyed  the  posterior  three-fourths  of  the  corpus 
callosum.  In  Bristowe's  4  cases  there  existed,  as  symptoms  common  to  all, 
pain  in  the  head  and  partial  or  complete  hemiplegia,  with  gradual  extension 
of  the  paralysis  to  the  opposite  side  of  the  body.  Toward  the  end  of  life  there 
was  disturbance  of  speech,  difficulty  in  deglutition,  incontinence  of  urine  and 
fasces,  and  dementia.  Here  the  symptoms  have  in  them  nothing  that  can  be 
looked  upon  as  pathognomonic ;  indeed,  many  of  the  phenomena  were  doubtless 
dependent  upon  involvement  of  the  projection  and  association  fibres  of  the 
centrum  semiovale. 

In  animals  in  which  the  corpus  callosum  has  been  cut  experimentally  pro- 
gressive emaciation  has  been  mentioned  as  a  characteristic  phenomenon. 

4.  Internal  Capsule  (Fig.  4). — Through  this  pass  within  a  rather  narrow 
area  all,  or  nearly  all,  of  the  projection  fibres  (both  motor  and  sensory)  which 
are  connected  with  the  cerebral  cortex.  It  is  divided  into  an  anterior  limb,  a 
knee,  and  a  posterior  limb,  the  latter  consisting  of  a  thalamo-lenticular  por- 
tion (its  anterior  two-thirds)  and  a  retro-lenticular  portion  (its  posterior 
third).    In  considering  the  effects  of  a  given  focal  lesion  involving  the  fibres 


950  DISEASES  OF  THE  NERVOUS  SYSTEM. 

of  the  internal  capsule,  it  is  not  to  be  forgotten  that  the  relations  of  the  two 
limbs  of  the  capsule  to  one  another  and  to  the  knee  vary  considerably  in  dif- 
ferent horizontal  planes.  Much  of  the  confusion  in  the  bibliography  is  de- 
pendent upon  neglect  to  describe  the  horizontal  level  of  the  lesion,  as  well  as 
its  situation  in  an  antero-posterior  direction.  The  principal  bundle  passing 
through  the  anterior  limb  of  the  capsule  is  that  which  connects  the  frontal  gyri 
and  the  medial  bundle  in  the  base  of  the  peduncle  (crus)  with  the  nuclei  of 
the  pons.  These  fibres  are  centrifugal,  and  innervate  chiefly  the  lower  motor 
nuclei  governing  bilaterally  innervated  muscles,  especially  those  of  the  eyes, 
head,  neck,  and  probably  those  of  the  mouth,  tongue,  and  larynx.  In  lower 
horizontal  planes  these  fibres  are  situated  near  the  knee  of  the  capsule.  It  is 
the  region  of  the  knee  of  the  capsule  which  transmits  especially  the  fibres  pass- 
ing from  the  cerebral  cortex  to  the  nuclei  of  the  facial,  hypoglossal,  and  third 
nerves.  '  The  path  which  supplies  the  nuclei  governing  the  muscles  used  in 
speech  passes  through  the  knee. 

The  pyramidal  tract  goes  through  the  thalamo-lenticular  portion  of  the 
capsule.  The  motor  fibres  are  arranged  according  to  definite  muscle  groups, 
or  rather  movement  forms,  those  for  the  movements  of  the  arm  being  anterior 
to  those  for  the  leg.  The  number  of  fibres  for  a  given  muscle  group  corre- 
sponds rather  to  the  degree  of  complexity  of  the  movements  than  to  the  size 
of  the  muscles  concerned.  Thus  the  areas  for  the  fingers  and  toes  are  rela- 
tively large. 

The  fibres  to  the  somgesthetic  area  of  the  cortex — that  is,  those  from  the 
ventro-lateral  group  of  nuclei  of  the  thalamus  and  the  tegmental  radiations — 
carrying  impulses  concerned  in  general  bodily  sensation,  pass  upward  through 
the  posterior  part  of  the  thalamo-lenticular  portion  of  the  capsule.  Some  of 
these  fibres  pass  through  the  anterior  two-thirds  of  the  posterior  limb  along- 
side of  the  fibres  of  the  pyramidal  tract. 

Through  the  retro-lenticular  portion  of  the  posterior  limb,  opposite  the 
posterior  third  of  the  lateral  surface  of  the  thalamus,  pass  ( 1 )  the  fibres  carry- 
ing impulses  concerned  in  the  sensations  of  the  opposite  visual  field  (optic 
radiation  from  the  lateral  geniculate  body  to  the  visual  sense  area  in  the 
occipital  cortex)  ;  (2)  the  fibres  carrying  impulses  concerned  in  auditory  sen- 
sations (radiation  from  the  medial  geniculate  body  to  the  auditory  sense  area 
in  the  cortex  of  the  temporal  lobe) ;  (3)  the  fibres  (probably  centrifugal) 
connecting  the  cortex  of  the  temporal  lobe  with  the  nuclei  of  the  pons. 

With  this  preliminary  knowledge  concerning  the  internal  capsule,  it  is  not 
difficult  to  understand  the  symptoms  which  result  when  it  is  diseased. 

Since  here  all  the  fibres  of  the  upper  motor  segment  are  gathered  together 
in  a  compact  bundle,  a  lesion  in  this  region  is  apt  to  cause  complete  hemi- 
plegia of  the  opposite  side,  followed  later  by  contractures;  and  if  the  lesion 
involves  the  hinder  portion  of  the  posterior  limb  there  is  also  hemiansesthesia, 
including  even  the  special  senses  (Fig.  4).  As  a  rule,  however,  lesions  of 
the  internal  capsule  do  not  involve  the  whole  structure.  The  disease  usually 
affects  mainly  either  the  anterior  or  posterior  portions,  and  even  in  instances 
in  which  at  first  the  symptoms  point  to  total  involvement,  there  is  a  disap- 
pearance often  of  a  large  part  of  the  phenomena  after  a  short  time.  Thus 
when  the  pyramidal  tract  is  destroyed  (lesion  of  the  thalamo-lenticular  por- 
tion of  the  capsule)  the  arm  may  be  affected  more  than  the  leg,  or  vice  versa. 


DIFFUSE  AND  FOCAL  DISEASES  OF  THE  BRAIN.  951 

The  facial  paralysis  is  usually  slight,  though  if  the  lesion  be  well  forward 
in  the  capsule  the  paralysis  of  the  face  and  tongue  may  be  marked. 

Hemiansesthesia  alone  without  involvement  of  the  motor  fibres,  due  to  dis- 
ease of  the  capsule,  is  rare.  There  is  usually  also  at  least  partial  paralysis 
of  the  leg.  When  the  retro-lenticular  portion  of  the  capsule  is  destroyed  the 
hemianaesthesia  is  accompanied  by  hemianopsia,  disturbances  of  hearing,  and 
sometimes  of  smell  and  taste.  The  occurrence  of  hemichorea,  marked  tremor, 
or  hemiathetosis  after  a  capsular  hemiplegia  points  to  the  involvement  of  the 
thalamus  or  of  the  hypothalamic  region  in  the  lesion. 

Charcot  and  others  have  described  cases  in  which  as  a  result  of  disease  of 
the  internal  capsule  there  has  been  paralysis  of  the  face  and  leg  without 
involvement  of  the  arm.  In  such  instances  the  lesion  is  linear,  extending  from 
the  posterior  part  of  the  anterior  limb  of  the  internal  capsule  backward  and 
lateralward  to  the  leg  region  in  the  posterior  limb  of  the  capsule,  the  region 
for  the  arm  escaping. 

Capsular  lesions  when  pure  are  not  usually  accompanied  by  aphasic 
symptoms,  alexia,  or  agraphia.  A  "  subcortical "  motor  aphasia  may  result 
if  the  lesion  is  bilaterial,  as  in  pseudo-bulbar  paralysis,  or  if  on  the  left 
side  it  is  so  extensive  as  to  destroy  the  fibres  connecting  Broca's  convolu- 
tion with  the  opposite  hemispheres,  as  well  as  the  pyramidal  fibres  on  the 
same  side. 

5.  Crura  (Cerebral  Peduncles). — From  this  level  through  the  pons,  me- 
dulla, and  cord  the  upper  and  lower  motor  segments  are  represented,  the  first 
by  the  fibres  of  the  pyramidal  tracts  and  by  the  fibres  which  go  from  the  cere- 
bral cortex  to  the  nuclei  of  the  cerebral  nerves,  the  latter  by  the  motor  nuclei 
and  the  nerve  fibres  arising  from  them.  Lesions  often  affect  both  motor 
segments,  and  produce  paralyses  having  the  characteristics  of  each.  Thus  a 
single  lesion  may  involve  the  pyramidal  tract  and  cause  a  spastic  paralysis 
on  the  opposite  side  of  the  body,  and  also  involve  the  nucleus  or  the  fibres 
of  one  of  the  cerebral  nerves,  and  so  produce  a  lower  segment  paralysis  on 
the  same  side  as  the  lesion — crossed  paralysis.  In  the  crus  the  third  and 
fourth  cerebral  nerves  run  near  the  pyramidal  tract,  and  a  lesion  of  this  region 
is  apt  to  involve  them  or  their  nuclei,  causing  partial  paralysis  of  the  muscles 
of  the  eye  on  the  same  side  as  the  lesions,  combined  with  a  hemiplegia  of  the 
opposite  side  (Fig.  1,  3). 

The  optic  tract  also  crosses  the  crus  and  may  be  involved,  giving  hemi- 
anopsia in  the  opposite  halves  of  the  visual  fields. 

If  the  tegmentum  be  the  seat  of  a  lesion  which  does  not  involve  the  base 
of  the  peduncle  (or  pes)  there  may  be  disturbances  of  cutaneous  and  mus- 
cular sensibility,  ataxia,  disturbances  of  hearing,  or  oculo-motor  paralysis.  An 
oculo-motor  paralysis  of  one  side,  accompanied  by  a  hemi-ataxia  of  the  opposite 
side,  appears  to  be  especially  characteristic  of  a  tegmental  lesion. 

6.  Corpora  Quadrigemina. — Anatomical  studies  point  to  the  view  that  the 
superior  colliculus  (anterior  quadrigeminal  body)  represents  the  most  impor- 
tant subcortical  central  organ  for  the  control  of  the  eye-muscle  nuclei.  This 
is  supported  to  a  certain  extent  by  clinical  evidence,  though  as  yet  but  few 
cases  have  been  carefully  studied.  Sight  is  only  slightly,  if  at  all,  disturbed 
when  the  superior  colliculus  is  destroyed.  The  pupil  is  usually  widened,  and 
the  pupillary  reaction,  both  to  light  and  on  accommodation,  interfered  with. 


952  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Apparently  actual  paralysis  of  the  eye  muscles  does  not  occur  unless  the  nucleus 
of  the  third  nerve  ventral  to  the  aqueduct  he  also  injured. 

The  inferior  collicuTus  (posterior  quadrigeminal  body),  on  the  other  hand, 
has  been  shown  by  anatomical  study  to  be  an  important  way-station  in  the 
auditory  conduction-path.  A  large  part  of  the  lateral  lemniscus  ends  in  its 
nucleus,  and  from  it  emerge  medullated  fibres  which  pass  through  the  brachium 
quadrigeminum  inf erius  to  the  medial  geniculate  body.  Thence  a  large  bundle 
runs  through  the  retro-lenticular  portion  of  the  internal  capsule  to  the  auditory 
sense  area  in  the  cortex  of  the  temporal  lobe. 

Weinland  has  collected  19  cases  of  tumors  of  the  corpora  quadrigemina 
from  the  bibliography;  in  9  of  these  auditory  disturbances  were  especially 
noted.  Since  the  central  auditory  path  of  each  side  receives  impulses  from 
both  ears,  lesion  of  the  coUiculus  on  one  side  may  dull  the  hearing  on  both 
sides,  though  the  opposite  ear  is  usually  the  more  defective.  Lesion  of  the 
inferior  coUiculus  may  be  accompanied  by  disturbance  of  mastication,  owing 
to  paralysis  of  the  descending  (mesencephalic)  root  of  the  trigeminus.  The 
fourth  nerve  may  also  be  involved.  The  ataxia  which  sometimes  accompanies 
lesions  of  the  corpora  quadrigemina  is  probabl}"  to  be  referred  to  disturbance 
in  conduction  in  the  medial  lemniscus. 

7.  Pons  and  Medulla  Oblongata. — Lesions  involving  the  pyramidal  tract, 
together  with  any  one  of  the  motor  cerebral  nerves  of  this  region,  cause  crossed 
paralysis.  A  lesion  in  the  lower  part  of  the  pons  is  apt  to  cause  a  lower- 
segment  paralysis  of  the  face  on  the  same  side  (destruction  of  the  nucleus  of 
the  facial  nerve  or  of  its  root  fibres)  and  a  spastic  paralysis  of  the  arm  and 
leg  on  the  opposite  side  (injury  to  pyramidal  tract)  (Fig.  1,  4).  The  abdu- 
cens,  the  motor  part  of  the  trigeminus,  and  the  hypoglossus  nerves  may  also 
be  paralyzed  in  the  same  manner.  When  the  central  fibres  to  the  nucleus 
of  the  hypoglossus  are  involved  a  peculiar  form  of  anarthria  results.  If  the 
nucleus  itself  be  diseased,  swallowing  is  interfered  with. 

When  the  sensory  fibres  of  the  fifth  nerve  are  interrupted,  together  with 
the  sensor}'  tract  (the  medial  lemniscus  or  fillet)  for  the  rest  of  the  body,  which 
has  already  crossed  the  middle  line,  there  is  a  crossed  sensory  paralysis — 
i.  e.,  disturbed  sensation  in  the  distribution  of  the  fifth  on  the  side  of  the 
lesion,  and  of  all  the  rest  of  the  body  on  the  opposite  side. 

A  paralj'sis  of  the  external  rectus  muscle  of  one  eye  and  of  the  internal 
rectus  of  the  other  eye  (conjugate  paralysis  of  the  muscles  which  turn  the 
eyes  to  one  side),  in  the  absence  of  a  "forced  position"  of  the  eyeballs,  is 
highly  characteristic  of  certain  lesions  of  the  pons.  In  such  cases  the  internal 
rectus  may  still  be  capable  of  functioning  on  convergence,  or  when  the  eye 
to  which  it  belongs  is  tested  independently  of  that  in  which  the  external  rectus 
is  paralyzed.  This  form  of  paralysis  is  found,  as  a  rule,  only  when  the  lesion 
lies  just  in  front  of  the  abducens  or  involves  the  nucleus  itself,  or  includes, 
besides  the  root  fibres  of  the  abducens,  that  portion  of  the  formatio  reticularis 
that  lies  between  them  and  the  fasciculus  longitudinalis  medialis  (von  Mona- 
kow).  The  cases  of  conjugate  paralysis  just  referred  to  may  be  complicated 
by  other  disturbances  of  the  eye-muscle  movements,  in  which  case  the  inter- 
pretation of  the  symptoms  may  be  rendered  difficult.  The  facial  nerve  is  often 
involved  in  these  paralyses. 

In  lesions  of  the  pons  the  patient  often  has  a  tendency  to  fall  toward  the 


DIFFUSE  AND  FOCAL  DISEASES  OF   THE  BRAIN.  953 

side  on  which  the  lesion  is,  probably  on  account  of  implication  of  the  middle 
peduncle  of  the  cerebellum  (brachium  pontis).  Still  more  frequent  is  the 
simple  motor  hemi-ataxia  consequent  upon  lesion  of  the  medial  lemniscus,  and 
perhaps  of  longitudinal  bundles  in  the  formatio  reticularis.  This  is  often 
accompanied  by  a  dissociated  sensory  disturbance,  pain  and  temperature  being 
affected,  while  touch  remains  normal.  The  muscular  sense  may  also  be  in- 
volved. Only  when  the  lesion  is  very  extensive  are  there  disturbances  of  hear- 
ing (involvement  of  the  lateral  lemniscus  or  corpus  trapezoideum ) . 

The  symptoms  produced  by  involvement  of  the  different  cerebral  nerves 
will  be  considered  in  detail  in  another  section. 

8.  Cerebellum. — The  functions  of  this  part  of  the  brain  are  still  under 
consideration.  Luciani,  whose  monograph  is  exhaustive,  regards  it  as  "  an  end 
organ,  directly  or  indirectly  related  to  certain  peripheral  sensory  organs  and 
in  direct  efferent  relationship  with  certain  ganglia  of  the  cerebro-spinal  axis, 
and  indirectly  with  the  motor  apparatus  in  general.  It  is  functionally  homo- 
geneous, each  part  exercising  the  functions  of  the  whole,  but  having  special 
relations  to  the  muscles  of  the  corresponding  side  of  the  body  ^'  (Krauss). 

Lesions  of  the  lateral  lobes  affect  the  corresponding  side  of  the  body,  while 
lesions  of  the  middle  lobe  (vermis)  affect  both  sides.  Partial  removal  is  fol- 
lowed by  transient  muscular  weakness;  complete  removal  by  extreme  inco- 
ordination. Its  one  important  function  would  appear  to  be  the  coordination 
of  the  muscular  movements. 

In  monkeys  the  symptoms  differ  much  at  different  periods  after  the  opera- 
tion. During  the  first  five  or  six  days  irritation  phenomena  predominate. 
According  to  Luciani,  there  is  asthenia,  atony  of  the  muscles,  and  astasia 
on  the  side  of  the  body  operated  upon.  The  animal  can  not  stand  or  walk. 
All  these  symptoms  may  gradually  disappear  in  the  course  of  a  few  months. 

The  experiments  of  J.  S.  Risien  Eussell  do  not  entirely  confirm  the  obser- 
vations of  Luciani.  In  the  first  place,  the  occurrence  of  asthenia  is  not  con- 
stant, and  as  to  atony,  while  the  patellar  tendon  reflexes  are  sometimes  absent, 
they  are  as  a  rule  intact  in  pure  cerebellar  lesions.  There  may  be  even  mus- 
cular rigidity  instead  of  atony.  Eussell's  experiments  make  it  seem  likely  that 
the  cerebellar  hemisphere  of  one  side  exercises  constantly  an  inhibitory  effect 
upon  the  activities  of  the  cerebral  hemisphere  of  the  opposite  side  (probably 
by  way  of  the  brachium  conjunctivum).  Thus  after  removal  of  one  cerebellar 
hemisphere  he  found  that  movements  of  the  arm  and  leg  could  be  caused  by  a 
faradic  stimulation  of  the  contralateral  motor  area,  much  milder  than  that 
necessary  to  stimulate  the  homolateral  motor  area.  The  epileptic  seizures  fol- 
lowing the  administration  of  absinthe  were  far  greater  on  the  side  of  ablation. 
It  is  not  impossible  that  the  explanation  of  the  epileptiform  attacks  by  no 
means  rare  in  cerebellar  disease  is  here  to  be  sought. 

W.  C.  Krauss  has  analyzed  the  lesions  and  symptoms  in  100  cases  of  dis- 
ease of  this  part.  The  morbid  conditions  were  as  follows:  Sarcoma  in  22 
cases;  tubercle  in  22;  glioma  in  18;  abscess  in  10;  tumor  of  unspecified  origin 
in  13 ;  cyst  in  7 ;  and  1  case  each  of  softening,  endothelioma,  cyst  and  sarcoma, 
cancer,  gumma,  fibroma,  and  haemorrhage.  The  left  lobe  was  affected  32  times, 
the  right  lobe  32  times,  and  the  middle  lobe  17  times.  Thus  tumor  constituted 
by  far  the  most  important  affection.  There  may  be  no  symptoms  whatever 
if  it  is  in  one  hemisphere  only  and  does  not  involve  the  middle  lobe.     There 


954  DISEASES  OF   THE  NERVOUS  SYSTEM. 

are  instances  not  only  of  complete  absence  of  one  whole  hemisphere  from  arrest 
of  growth^  but  also  of  extensive  bilateral  disease,  which  throughout  life  has 
yielded  no  noticeable  symptoms.  Only  when  lesions  are  comparatively  sudden 
do  the  symptoms  resemble  the  early  experimental  states  in  animals.  Other 
portions  of  the  brain  appear  to  be  able  to  take  on  the  functions  normally 
performed  by  the  cerebellum.  The  most  common  symptoms  in  tumor  of  the 
cerebellum  are  as  follows: 

Vertigo,  which  is  more  constant  in  this  than  in  affections  of  any  other 
region  of  the  brain.  Some  believe  this  to  be  due  to  involvement  of  the  nervus 
vestibularis  or  its  nuclei  of  termination,  by  means  of  which  the  semicircular 
canals  are  connected  with  the  cerebellum.  The  symptom  was  present  in  48 
of  the  cases  of  Krauss'  collection,  not  reported  in  43.  The  vertigo  appears 
to  be  entirely  independent  of  the  ataxia.  Though  most  frequently  associated, 
either  symptom  may  be  present  without  the  other.  The  vertigo  of  cerebellar 
disease  is  often  associated  with  the  feeling  that  objects  are  revolving  about  the 
body,  or  that  the  body  itself  is  moving.  Headache  was  present  in  83  cases. 
Vomiting  occurred  in  69  cases,  not  reported  in  23.  Optic  neuritis  was  found 
in  66  cases,  not  reported  in  23.  It  is  apt  to  appear  early,  and  is  probably 
brought  about  by  the  obstructive  internal  hydrocephalus  that  commonly  results 
from  subtentorial  growths  through  pressure  on  the  aqueductus  cerebri. 

Of  symptoms  which  are  designated  as  more  particularly  cerebellar,  ataxia, 
particularly  of  the  homolateral  limbs,  is  the  most  important.  In  cerebellar 
ataxia  the  gait  is  irregular  and  staggering,  often  zigzag,  and  in  attempting  to 
walk  the  patient  sways  to  and  fro  like  a  drunken  man  (demarche  d'ivresse  of 
the  French  writers).  As  a  rule,  the  patient  walks  and  tends  to  fall  toward  the 
affected  side,  but  the  rule  is  not  certain.  The  ataxia  of  cerebellar  disease  is  to 
be  sharply  differentiated  from  the  ataxia  of  tabes  dorsalis,  from  cortical  ataxia, 
and  probably  from  the  ataxia  accompanying  diseases  of  the  tegmental  portion 
of  the  pons  and  cerebral  peduncle.  Cerebellar  ataxia  is  both  static  and  dy- 
namic. The  opening  or  closing  of  the  eyes  has  less  influence  than  in  spinal 
ataxia.  Very  important  for  differential  diagnosis  is  the  fact  that  when  the 
patient  lies  in  bed  movements  tolerably  well  coordinated  can  be  carried  out. 
The  coarse  nature  of  the  incoordination  distinguishes  cerebellar  ataxia  from 
that  due  to  lesion  of  the  cerebral  cortex.  In  the  latter  the  finer  movements 
(buttoning,  etc.)  are  especially  apt  to  be  involved,  and  there  is  usually  hemi- 
paresis  or  mono-paresis,  and  often  disturbance  of  muscular  sense  and  of  the 
stereognostic  sense  (von  Monakow).  Cerebellar  ataxia  may  depend  upon  the 
withdrawal  of  the  influence  of  the  cerebellum  upon  the  cerebrum.  Babinski 
has  pointed  out  that  the  affected  limb,  although  ataxic,  may  be  held  in  a  given 
position  more  steadily  than  normal,  and  also  that  repeated  movements  can  not 
be  as  quickly  performed  on  the  affected  as  on  the  normal  side. 

Paresis,  especially  of  the  homolateral  trunk  muscles,  manifest  in  an  in- 
ability to  perform  the  movements  of  bending,  erection,  and  lateral  flexion  of 
the  trunk,  may  be  present  (Hughlings  Jackson).  Eisien  Russell  holds  that 
the  paralysis  is  "  probably  directly  due  to  the  withdrawal  of  the  cerebellar 
influence  from  the  muscles."  A  peculiar  attitude  of  the  head  has  been  de- 
scribed, in  which  the  face  looks  upward  and  is  turned  away  from  the  side 
occupied  by  the  growth,  Deflciency  in  power  of  the  limbs  on  the  same  side 
is  frequent. 


DIFFUSE  AND  FOCAL  DISEASES  OF   THE  BRAIN.  955 

Other  less  constant  but  suggestive  symptoms  are  neuralgic  pains  in  the 
region  of  the  neck  and  occiput;  blocking  of  the  venae  Galeni  and  dilatation 
of  the  lateral  ventricles,  causing  in  children  hydrocephalus;  pressure  on  the 
mid-brain,  pons,  or  medulla  oblongata,  producing  paralysis  of  the  cerebral 
nerves  (most  commonly  the  sixth  cranial),  rhythmical  contractions  of  the  head 
or  extremities,  nystagmus  (particularly  when  looking  toward  the  side  of  the 
lesion),  tremor,  anarthria,  auditory  or  visual  disturbances.  There  may  be 
glycosuria,  and  bilateral  rigidity  from  pressure  on  the  motor  paths.  Sudden 
death  may  occur. 

The  reflexes,  though  variable,  are  apt  to  be  increased  on  the  side  of  the 
lesion,  and  if  internal  hydrocephalus  develops  they  may  be  exaggerated  on  both 
sides.  When  the  cerebellar  disease  involves  other  structures  directly,  or  indi- 
rectly through  action  at  a  distance,  the  reflexes  may  be  abolished. 

Symptoms  of  general  mental  disturbance  may  accompany  cerebellar  dis- 
ease, but  they  are  not  characteristic.  There  is  often  irritability,  enfeebled 
memory,  and  toward  the  end  sopor  and  coma. 

II.    APHASIA. 

Speech  disorders  give  important  information  as  to  the  position  of  lesions 
of  the  nervous  system,  and  it  is  for  this  reason  that  they  are  considered  here. 

The  studies  of  Boulliaud,  Dax,  Broca,  Bastian,  Kussmaul,  Lichtheim, 
Marie,  and  others  have  done  much  to  widen  our  knowledge  of  this  very  diffi- 
cult subject.  The  student  is  referred  to  the  works  of  these  authors,  and 
especially  to  the  recent  monograph  of  Moutier. 

As  in  all  other  voluntary  movements  speech  requires  not  only  a  motor  but 
a  sensory  apparatus,  and  we  have,  as  composing  the  speech  mechanism,  a 
sensory  or  receptive  part  as  well  as  a  motor  or  emissive  part.  These  two  parts 
are  associated  with  the  higher  centres  underlying  the  intellectual  process,  and 
are  controlled  by  them. 

The  muscles  which  are  used  in  the  production  of  articulate  speech  are  many 
and  widely  distributed ;  thus,  the  respiratory  muscles,  the  muscles  of  the  larynx, 
the  pharynx,  the  tongue,  the  lips,  and  those  which  move  the  Jaws,  are  all 
brought  into  play  during  speech.  These  muscles  are  all  active  in  other  less 
complicated  movements;  for  instance,  respiration,  crying,  sucking,  etc.,  and 
these  comparatively  simple  movements  are  represented  in  the  gray  matter  of 
the  lower  motor  segment  in  the  pons,  medulla,  and  spinal  cord.  The  asso- 
ciation of  neurones  upon  which  these  movements  depend  is  made  during  foetal 
life,  and  is  in  good  working  order  at  the  time  of  birth. 

As  the  child's  brain  grows  and  takes  control  of  the  spinal  centres  through 
the  medium  of  the  pyramidal  tracts,  other  more  complex  movements  are  de- 
veloped and  special  neurones  are  set  apart  for  this  purpose.  There  is,  then, 
a  re-representation  (Hughlings  Jackson)  of  the  finer  movements  of  these  mus- 
cles in  the  upper  motor  segment.  They  are  localized  in  the  central  convolu- 
tions about  the  lower  part  of  the  Eolandic  fissure.  All  these  muscles  except 
those  of  the  tongue  and  lips  are  used  bilaterally,  and  so  their  movements  on 
each  side  of  the  body  are  represented  on  both  sides  of  the  brain. 

This  group  of  movements,  which  are  in  part  congenital  and  in  part  ac- 
quired during  the  early  months  of  life,  is  that  from  which  the  delicate  move- 


956  DISEASES  OF  THE  NERVOUS  SYSTEM. 

meats  of  articulate  speech  are  developed.  The  structures  upon  whicli  tliese 
movements  depend  make  the  primary  or  elementary  speech  mechanism. 

The  cortical  centres  are  in  the  lower  third  of  the  central  convolution  on 
both  sides  of  the  brain.  They  are  bilaterally  acting  centres,  and  a  lesion 
limited  to  either  one  should  not  produce  marked  or  permanent  defects  in 
speech.  This  is  true  for  the  right  side,  but  on  the  left  Broca's  convolution 
and  the  insula  are  so  closely  situated  that  they  are  usually  injured  at  the  same 
time,  and  motor  aphasia  results. 

The  Path  &0111  Cortex  to  Lower  Motor  Centres. — This  is  made  up  of  the 
motor  fibr^  which  go  to  the  nuclei  of  the  pons  and  medulla,  and  in  the 
internal  eapsole  is  situated  near  the  knee.  As  in  the  cortex,  a  unilateral 
lesion  here  causes  only  slight  disturbances  of  speech  due  to  difficult  articula- 
tion, following  weakness  of  the  opposite  side  of  the  face  and  tongue.  On  the 
left  gide,  if  the  lesion  is  so  near  the  cortex  as  to  involve  the  fibres  which 
connect  Broea's  convolution  with  the  primary  speech  mechanism,  subcortical 
motor  aphasia  is  produced.  Bilateral  lesions  (usually  in  the  internal  capsule, 
but  at  tiines  in  the  c-ortex)  cause  speechlessness,  with  jjaralysis  of  the  muscles 
of  articalation — ^pseudo-bulbar  paralysis.  To  these  sjDeech  defects  Bastian 
gives  the  name  Aphemia. 

The  lower  segment  of  the  primary  speech  mechanism  is  made  up  of  the 
motor  nuclei  in  the  medulla,  etc.,  and  the  peripheral  nerves  arising  from  them. 
L^ons  here,  if  extensive  enough — as,  for  instance,  in  progressive  bulbar  paral- 
ysis— may  cause  speechlessness — anarthria  (Bastian)  ;  but  usually  they  are 
more  limited,  giving  various  disturbances  of  articulation. 

As  the  child  learns  to  speak  there  is  developed  in  the  cortex  of  the  brain 
an  association  of  centres  which  takes  control  of  the  primary  speech  mechanism. 
The  child  is  constantly  heariag  objects  called  by  names,  and  he  learns  to  asso- 
ciate certain  sounds  with  the  look,  feel,  taste,  etc.,  of  certain  things.  When 
he  hears  such  a  sound  he  gets  a  more  or  less  clear  mental  picture  of  the 
object,  or,  in  other  words,  he  has  developed  certain  auditory  memories.  These 
memories  of  the  sounds  of  words  are  stored  in  what  is  called  the  auditory 
speech  centre.  This  centre,  which  in  the  majority  of  people  is  the  controlling 
speech  centre,  is  situated  in  the  first  temporal  convolution  on  the  left  side  in 
light-handed  people,  and  on  the  right  side  in  those  who  are  left-handed. 
Yarions  theories  have  been  advanced  to  explain  the  predominance  of  the  left 
hemisphere  in  the  speech  mechanism,  and  Weber  believes  that  it  is  dependent 
upon  the  development  of  the  writing  centre  in  the  left  motor  cortex  in  associa- 
tion with  the  centre  for  the  right  hand.  The  afferent  impressions  arising  in 
the  ears  reach  the  tem]>oral  lobes,  those  from  each  ear  going  to  both  sides  of 
the  hrain.  From  each  of  these  primary  auditory  centres  impulses  are  sent 
to  the  auditory  speech  centre  in  the  left  hemisphere.  The  child  endeavors, 
and  by  repeated  efforts  learns,  to  make  the  sounds  that  he  hears,  and  he  first 
becomes  able  to  repeat  words,  then  to  speak  voluntarily.  To  do  this,  he  has 
had  to  learn  certain  very  delicate  movements,  and  so  there  has  been  developed 
a  special  motor  centre  for  speech  in  which  these  movements  are  localized. 

The  Motor  Speech  Centre. — This  has  been  placed  in  Broea's  convolution, 
""' T  -  ^"  :'  :  \rt  of  the  left  third  frontal  convolution,  but  the  older  views  as 
::  '.'..-z  .  :ion  of  aphasia,  jsarticularly  the  motor  variety  and  its  associa- 

tion with  this  convolution,  have  been  criticised  by  Marie,  whose  views  may 


DIFFUSE  AND  FOCAL  DISEASES  OF  THE  BRAIN.  957 

be  studied  at  leugtli  in  tlie  exbanstive  monograph  of  Moutier.  Marie  believes 
that  the  pure  motor  aphasia  of  writers,  anarthria,  results  from  a  lesion  involv- 
ing the  left  lenticular  nucleus  and  the  adjacent  zone,  which  he  detines  as  fol- 
lows :  In  a  horizontal  section  of  the  brain,  the  transverse  line  dra\\Ti  from 
the  anterior  angle  of  the  insula  to  a  corresponding  point  of  the  lateral  ven- 
tricle gives  the  anterior  border;  a  line  from  the  posterior  angle  of  the  insula 
to  a  corresponding  point  of  the  lateral  ventricle  gives  the  posterior  limit. 
Included  in  this  zone  are  more  than  one-half  of  the  thalamus,  both  limbs  of 
the  internal  capsule,  the  greater  part  of  the  caudate  nucleus,  the  lenticular 
nucleus,  and  the  island  of  Eeil  with  the  sulijacent  white  matter.  In  a  lesion 
of  this  lenticular  zone  articulate  speech  alone  is  affected;  internal  speech  is 
preserved,  and  the  patient  reads  and  writes  and  understands  sj)oken  speech. 
On  the  other  hand,  a  lesion  of  the  "  zone  of  "Wernicke "  causes  the  sensor)'' 
aphasia,  word  deafness  and  word  blindness.  According  to  Marie  the  zone  of 
"Wernicke  consists  of  the  supramarginal  and  angular  gyii  and  the  feet  of  the 
first  two  temporal  convolutions.  When  both  these  regions  are  affected  there 
is  loss  of  spontaneous  speech,  spoken  language  is  not  understood,  and  the 
patient  can  neither  read  nor  write. 

Marie's  position  has  been  much  discussed,  and  many  of  the  most  distin- 
guished neurologists  have  come  to  the  rescue  of  the  old  view  which  accepts 
Broca's  convolution  as  the  motor  speech  centre.  Dejerine,  Mills  and  Spiller 
have  published  most  carefully  studied  cases  which  go  far  to  show  that  the  third 
left  frontal,  Broca's  convolution,  with  the  insula  forms  the  cortical  motor  cen- 
tre for  speech.  They  agree,  however,  that  lesions  of  the  left  lenticular  zone 
interfere  with  the  movements  which  make  speech  possible.  These  motor  sjDeech 
areas  are  connected  by  commissural  fibres  through  the  corpus  callosum  with 
the  corresponding  areas  of  the  right  frontal  lobe,  and  these  latter  can  control 
the  speech  movements  when  the  more  direct  path  in  the  left  p3Tamidal  tract 
has  been  interrupted. 

The  motor  speech  centres  and  the  corresponding  area  in  the  right  brain 
are  connected  either  directty  by  special  motor  fibres  with  the  bulbar  nuclei, 
or,  as  is  more  probable,  indirectly,  through  the  medium  of  the  cortical  cen- 
tres of  the  primary  speech  mechanism  in  the  lower  part  of  the  Eolandic  region 
on  both  sides. 

The  speech  centres  are  in  close  connection  with  the  rest  of  the  brain  cor- 
tex, and  in  this  wa}'  they  take  part  in  the  general  mental  activities,  of  which, 
indeed,  the  speech  processes  form  a  large  part.  Some  authors  have  assumed 
that  the  several  sensory  elements  which  go  to  make  a  concept  are  brought 
together  in  a  sjjecial  region  of  the  brain,  and  here,  as  it  were,  united  by  a 
name.  This  is  called  "  the  centre  for  concepts,"  or  "  naming  centre  "  (Broad- 
bent),  but  most  vrriters  have  followed  Bastian  in  considering  that  the  suppo- 
sition of  such  a  centre  is  unnecessary. 

The  mechanism  which  has  been  described  is  that  which  is  developed  in 
uneducated  jDeople  and  in  children  before  they  have  learned  to  read  and  write, 
and  is  of  primary  importance  in  all  speech  processes.  As  the  cliild  learns  to 
read  he  associates  certain  visual  impressions  with  the  speech  memories  he  has 
already  acquired,  and  he  then  adds  to  his  concepts  the  visual  memories  of 
written  or  printed  s}Tiibols.  Tliese  memories  are  stored  in  the  visual  speech 
centre. 


958  .        DISEASES  OF  THE  NERVOUS  SYSTEM. 

The  Visual  Speech  Centre. — This  is  placed  by  nearly  all  authors  in  the 
angular  and  supramarginal  convolutions  on  the  left  side,  where  visual  im- 
pressions from  both  occipital  lobes  are  combined  in  speech  memories.  Yon 
Monakow  believes  that  there  is  no  such  special  centre,  but  that  visual  speech 
memories  are  dependent  upon  the  direct  connection  of  the  general  visual  cen- 
tres in  both  occipital"  lobes  with  the  speech  sphere.  That  speech  defects  result 
from  injury  to  the  angular  and  supramarginal  convolutions,  he  admits;  but 
he  thinks  these  are  due  to  an  interruption  of  fibre  tracts  which  lie  beneath 
and  not  to  a  destruction  of  a  cortical  centre.  The  distinction  is,  therefore,  of 
more  theoretical  than  practical  importance. 

In  learning  to  write,  the  child  develops  certain  delicate  movements  of  the 
arm  and  hand,  and  thus  acquires  another  method  of  externalizing  his  speech 
activities.  Whether  or  not  this  requires  the  development  of  a  separate  writing 
centre,  apart  from  the  general  Eolandic  arm  centre,  or  is  brought  about  by  an 
evolution  of  the  latter  through  the  medium  of  Broca's  convolution,  is  a  vexed 
question.  Gordinier  has  recorded  a  remarkable  case  of  total  agraphia,  with 
no  sensory  or  motor  speech  aphasia,  in  which  a  tumor  occupying  the  foot  of 
the  second  left  frontal  convolution  was  found  at  autopsy.  However  this  may 
be,  these  movements  are  learned  under  the  influence  of  visual  impressions  in 
association  with  the  other  speech  memories,  although  there  is  a  more  direct 
path,  which  is  used  in  copying  unknown  characters.  Just  as  the  movements 
of  articulate  speech  are  constantly  under  the  control  of  auditory  memories,  so 
are  the  movements  of  writing  regulated  by  visual  memories;  but  in  this  case 
the  other  speech  memories  are  of  great  importance. 

With  the  development  of  the  associations  which  underlie  reading  and 
writing,  the  speech  mechanism  may  be  said  to  be  complete,  although  its  activ- 
ities are  capable  of  practically  endless  extension,  as  when  music  or  foreign 
languages  are  learned. 

It  will  be  seen  that  the  cortical  speech  centres — the  speech  sphere  of  the 
French — occupy  the  part  of  the  brain  near  the  Sylvian  fissure,  and  that  they 
all  receive  their  blood  from  the  Sylvian  artery.  Speaking  broadly,  the  pos- 
terior part  of  this  region  is  sensory  and  the  anterior  is  motor.  The  sensory 
areas  are  near  the  optic  radiation  and  the  motor  are  near  the  general  motor 
tracts,  and  so  with  lesions  of  the  posterior  part,  hemianopia  is  apt  to  be  asso- 
ciated with  the  speech  disturbance  while  hemiplegia  occurs  with  disease  of 
the  anterior  areas.  These  associations  often  help  to  distinguish  a  sensory  from 
a  motor  aphasia,  but  each  type  has  special  characteristics  which  must  be 
studied. 

Sensoey  Aphasia,  due  to  Lesions  of  the  Posteeior  Paet  oe  the  Speech 
Aeea,  oe  to  Fibres  going  to  this  Eegion. 

Auditory  Aphasia. — Most  people  in  mentally  recalling  words  do  so  by 
means  of  their  auditory  speech  inemories — i.  e.,  they  think  of  the  sound  of 
the  words,  and,  in  voluntary  speech,  it  is  probable  that  the  will  acts  on  the 
motor  centre  indirectly  through  the  auditory  centre.  This  centre  is  also 
necessary  for  reading  in  such  persons.  There  are  certain  persons,  however,  in 
whom  the  mental  processes  are  carried  on  by  visual  memories,  and  in  these 
rare  "  visuals  "  the  visual  speech  centres  take  the  predominant  place  in  speech 
usually  occupied  by  the  auditory  centres. 


DIFFUSE  AND  FOCAL  DISEASES  OF  THE  BRAIN.  959 

Complete  abolition  of  all  the  auditory  speech  memories  by  destruction  of 
the  first  temporal  convolution  causes  the  most  extensive  disturbances  of  speech. 
Such  a  person  is  unable  to  comprehend  speech,  either  spoken  or  printed.  Vol- 
untary speech  is  much  disturbed,  and  although  at  first  he  may  talk,  his  speech 
is  nothing  but  a  jargon  of  misplaced  words,  and  he  soon  becomes  speechless. 
Writing  is  also  lost,  and  he  can  neither  repeat  words  nor  write  at  dictation. 
He  may  be  able  to  copy. 

Lesions  are  often  only  partial,  and  the  resultant  disturbance  may  be  simply 
a  difficulty  in  speech  due  to  the  loss  of  nouns  or  to  the  transposition  of  words 
(paraphasia),  the  writing  showing  the  same  defect.  The  patient  usually 
understands  what  he  hears  and  reads,  and  can  repeat  words  and  write  at 
dictation.  This  is  the  condition  Bastian  calls  "  amnesia  verbalis.^^  The  con- 
dition may  be  so  pronounced  that  voluntary  speech  and  writing  are  nearly  lost, 
even  when  the  auditory  memories  can  still  be  aroused  by  new  afferent  impres- 
sions and  he  is  able  to  understand  what  is  said  to  him  and  what  he  reads.  He 
can  usually  repeat  and  read  aloud. 

The  afferent  paths,  which  reach  the  auditory  speech  centre  from  the  two 
primary  auditory  centres,  may  be  destroyed.  A  lesion  to  do  this  must  be  in 
the  white  matter  beneath  the  first  temporal  convolution  on  the  left  side.  Such 
a  lesion  would  block  all  auditory  impressions  coming  to  the  centre,  and  the 
patient  would  not  be  able  to  understand  anything  that  was  said  to  him,  could 
not  repeat  words  nor  write  from  dictation.  As  the  cortical  centres  are  not 
disturbed,  and  the  auditory  speech  memories  are  still  present,  there  is  no  dis- 
turbance of  voluntary  speech  or  writing,  and  the  patient  can  read  perfectly. 
This  is  pure  word-deafness  or  subcortical  sensory  aphasia. 

Visual  Aphasia. — Destruction  of  the  visual  centre  in  the  angular  and 
supramarginal  convolutions  causes  a  loss  of  the  visual  speech  memories,  and  the 
patient  is  unable  to  read  printed  or  written  characters.  He  is  unable  to  write 
— i,  e.,  there  is  agraphia — and  he  can  not  copy.  His  understanding  of  spoken 
words  is  good,  and  voluntary  speech  is  normal  or  only  slightly  paraphasic. 

A  subcortical  lesion  involving  the  afferent  fibres  going  to  the  visual  speech 
centre  causes  pure  word-blindness  (subcortical  alexia) — i.  e.,  there  is  inability 
to  understand  written  or  printed  words.  Voluntary  speech  and  writing  are 
good.  The  patient  can  not  read  his  own  writing  except  by  aid  of  muscle- 
sense  impression,  in  retracing  the  letters,  either  voluntary  or  passively.  Asso- 
ciated with  this  is  always  hemianopia. 

Word-deafness  and  word-blindness  are  often  combined,  and  at  times  it 
is  not  only  the  tracts  that  connect  the  primary  auditory  and  visual  centres 
with  the  speech  spheres,  but  also  those  which  associate  them  with  the  other 
sensory  centres  in  the  formation  of  concepts,  that  are  diseased.  In  this  case 
the  patient  has  lost  not  only  his  auditory  and  visual  speech  memories,  but  also 
all  of  his  memories  which  have  to  do  with  hearing  and  sight,  and  he  has  mind- 
deafness  and  mind-blindness — i.  e.,  he  is  unable  to  recognize  objects  when  he 
hears  or  when  he  sees  them.  Further  than  this,  there  may  be  a  dissociation 
of  all  the  sensory  centres  from  each  other  or  from  the  higher  psychical  centre, 
which  is  practically  the  same  thing,  in  which  case  the  patient  is  entirely  unable 
to  recognize  objects  and  to  use  them  properly — i.  e.,  he  has  apraxia.  Apraxia 
may  occur  alone,  but  is  usually  associated  with  forms  of  aphasia.  A  sensory 
and  a  motor  type  have  been  described. 


960  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Motor  Aphasia. — Lesions  of  the  motor  sijeecli  zone,  jiossibly  in  rare  cases 
of  Broca's  convolution  alone,  more  conmionly  of  a  wider  area,  cause  loss  of 
the  power  of  speech.  The  patient  may  be  absolutely  dumb,  or  he.  may  have 
retained  one  or  two  words  or  phrases,  which  is  believed  to  be  due  to  the  activ- 
ity of  the  corresponding  region  of  the  right  brain.  He  will  make  no  effort 
to  repeat  words.  His  mind  is  comparatively  clear,  and  he  understands  what 
is  said  to  him  and  is  able  to  read,  although  there  is  usually  some  difficulty  in 
this  due  to  the  lack  of  motor  speech  memories.  He  will  not  be  able  to  indi- 
cate that  he  has  a  mental  picture  of  words.  This  is  tested  by  asking  him  to 
squeeze  the  observer's  hand  or  to  make  expiratory  efforts  as  many  times  as 
there  are  syllables  in  a  well-known  name. 

Voluntary  writing  is  usually  lost  in  cortical  motor  aphasia,  and  many 
authors  believe  that  writing  movements  are  controlled  from  this  centre. 
Others,  who  believe  that  there  is  a  special  writing  centre,  contend  that  a 
lesion  strictly  limited  to  the  motor  speech  centre  would  not  cause  agraphia, 
and  cite  cases  which  seem  to  support  their  view.  If  there  is  much  disturb- 
ance of  internal  speech,  writing  will  be  impaired. 

Subcortical  motor  aphasia  is  described  as  due  to  the  destruction  of  the 
fibres  which  join  Broca's  convolution  to  the  primary  speech  mechanism. 
Lesions  which  have  produced  this  type  of  aphasia  have  been  in  the  white  mat- 
ter of  the  left  hemisjjhere  near  Broca's  convolution.  These  would  be  within 
Marie's  speech  zone.  There  is  complete  loss  of  the  power  of  speech  without 
any  disturbance  of  internal  speech.  The  patient's  mental  processes  are  not 
disturbed,  and  he  can  write  perfectly  if  the  hand  is  not  paralyzed. 

Cases  of  aphasia  are  rarely  simple,  and  it  is  often  impossible  to  classify 
them  accurately.  The  problems  involved  are,  in  reality,  exceedingly  com- 
plicated, and  the  student  must  not  for  a  moment  suppose  that  cases  are  as 
straightforward  as  the  various  diagrams  at  first  sight  would  appear  to  indi- 
cate. A  majority  of  them  are  very  complex,  but  with  patience  the  diagnosis 
of  the  different  varieties  can  often  be  worked  out.  The  following  tests  should 
be  applied  in  each  case  of  aphasia,  after  the  presence  or  absence  of  paralysis 
has  been  determined  and  whether  the  patient  is  right-handed  or  left-handed: 
(1)  The  power  of  recognizing  the  nature,  uses,  and  relations  of  objects — ■ 
i.  e.,  whether  apraxia  is  present  or  not;  (2)  the  power  to  recall  the  name  of 
familiar  objects  seen,  smelted,  or  tasted,  or  of  a  sound  when  heard,  or  of  an 
object  touched;  (3)  the  power  to  understand  spoken  words;  (4)  the  capa- 
bility of  understanding  printed  or  written  language ;  ( 5 )  the  power  of  appre- 
ciating and  understanding  musical  tunes;  (6)  the  power  of  voluntary  speech 
— in  this  it  is  to  be  noted  particularly  whether  he  misplaces  words  or  not; 
(7)  the  power  of  reading  aloud  and  of  understanding  what  he  reads;  (8) 
the  power  to  write  voluntarily  and  of  reading  what  he  has  written;  (9)  the 
power  to  copy;  (10)  the  power  to  write  at  dictation;  and  (11)  the  power 
of  repeating  words.  Stone  and  Douglas  have  recently  described  (Brain,  1902) 
a  form  of  familial  disease  under  the  name  of  hereditary  aphasia. 

The  medico-legal  aspects  of  aphasia  are  of  great  importance.  No  general 
principle  can  be  laid  down,  but  each  case  must  be  considered  on  its  merits. 
Langdon,  in  reviewing  the  whole  question,  concludes :  "  Sanity  established, 
any  legal  document  should  be  recognized  when  it  can  be  proved  that  the 
person  making  it  can  understand  fully  its  nature  by  any  receptive  channel 


DIFFUSE  AND  FOCAL  DISEASES  OF  THE  BRAIN.  961 

(viz.,  hearing,  vision,  or  muscular  sense),  and  can,  in  addition,  express  assent 
or  dissent  with  certainty  to  proper  witnesses,  whether  this  expression  be  by- 
spoken  speech,  written  speech,  or  pantomime." 

Prognosis  and  Treatment  of  Aphasia. — In  young  persons  the  outlook  is 
good,  and  the  power  of  speech  is  gradually  restored  apparently  by  the  educa- 
tion of  the  centres  on  the  opposite  side  of  the  brain.  In  adults  the  condition 
is  less  hopeful,  particularly  in  the  cases  of  complete  motor  aphasia  with  right 
hemiplegia.  The  patient  may  remain  speechless,  though  capable  of  under- 
standing everything,  and  attempts  at  re-education  may  be  futile.  Partial 
recovery  may  occur,  and  the  patient  may  be  able  to  talk,  but  misplaces  words. 
In  sensory  aphasia  the  condition  may  be  only  transient,  and  the  different  forms 
rarely  persist  alone  without  impairment  of  the  powers  of  expression. 

The  education  of  an  aphasic  person  requires  the  greatest  care  and  patience, 
particularly  if,  as  so  often  happens,  he  is  emotional  and  irritable.  It  is  best 
to  begin  by  the  use  of  detached  letters,  and  advance,  not  too  rapidly,  to 
words  of  only  one  syllable.  Children  often  make  rapid  progress,  but  in  adults 
failure  is  only  too  frequent,  even  after  the  most  painstaking  efforts.  In  the 
cases  of  right  hemiplegia  with  aphasia  the  patient  may  be  taught  to  write 
with  the  left  hand.  Mills  has  lately  called  particular  attention  to  the  benefit 
of  this  treatment. 

III.    AFFECTIONS    OF    THE    BLOOD-VESSELS. 

1.  Cerebral  Circulation. 

There  is  much  that  is  still  indefinite  in  the  physiology  of  the  circulation 
of  the  brain,  but  that  which  is  known  is  of  the  greatest  practical  moment  to 
the  physicians.  To  the  work  of  Leonard  Hill  (see  his  summary  in  Allbutt's 
System)  I  am  much  indebted  for  many  of  the  facts  in  the  following  brief 
sketch : 

The  brain  receives  blood  from  the  internal  carotid  arteries,  the  vertebrals, 
and,  to  some  extent,  from  the  spinal  arteries.  These  anastomose  soon  after 
entering  the  skull  to  form  the  circle  of  Willis.  The  extent  of  this  intercom- 
munication is  subject  to  considerable  variation,  which  may  be  of  extreme 
importance  in  pathological  conditions.  Collected  by  the  veins,  the  blood  is 
emptied  into  large  venous  sinuses,  which  are,  to  a  great  extent,  protected  from 
pressure  changes  by  the  skull  and  dura  mater. 

The  cerebro-spinal  fluid  is  collected  in  the  meningeal  spaces  and  fills  the 
interstices  between  the  convolutions,  etc.  Under  normal  conditions  there  is 
but  a  small  quantity  of  this  fiuid  within  the  skull,  which  is  entirely  filled 
with  brain,  blood,  and  the  cerebro-spinal  fiuid.  Practically  a  closed  box,  with 
contents  uninfiuenced  by  atmospheric  pressure,  the  quantity  of  blood  within 
the  skull  under  normal  circumstances  is  almost  constant,  for  the  brain  sub- 
stance itself  can  not  be  compressed,  so  that  the  only  increase  or  decrease 
is  that  which  compensates  for  the  small  quantity  of  cerebro-spinal  fiuid  that 
can  pass  between  the  cranial  and  spinal  cavities. 

Although  the  quantity  of  blood  does  not  change  materially,  its  rapidity 

of  flow  may,  and  does,  show  marked  variations,  and  thus  the  relation  between 

arterial  and  venous  blood  is  subject  to  change.     The  circulation  within  the 

skull  not  only  differs  from  the  circulation  in  other  parts  in  its  freedom  from 

63 


962  DISEASES  OF  THE  NERVOUS  SYSTEM. 

the  effects  of  atmospheric  pressure,  but  apparently  it  is  not  under  local  vaso- 
motor control  and  is  in  an  organ  that  can  only  expand  slightly.  Although  nerve 
fibres  have  been  demonstrated  in  the  walls  of  the  small  arteries  of  the  brain, 
it  has  not  been  proved  that  they  cause  dilatation  or  contraction  under  influ- 
ences from  the  vaso-motor  centres ;  indeed,  there  is  little  experimental  evidence 
that  speaks  for,  and  much  that  speaks  against,  this  view. 

Under  ordinary  circumstances,  the  circulation  of  the  brain  follows  passively 
the  general  bodily  conditions.  When  anything  increases  the  force  with  which 
the  blood  enters  the  skull — i.  e.,  when  blood-pressure  is  raised,  either  by  in- 
crease in  the  heart's  action  or  by  general  vaso-motor  effects — more  blood  passes 
through  the  brain  in  a  given  time,  and  it  is,  as  it  were,  flooded  with  blood. 
This  active  hyperaemia  must  occur  under  many  circumstances,  but  it  is  doubt- 
ful whether  it  causes  any  symptoms;  in  fact,  it  is  difficult  to  see  how  it,  in 
itself,  can  do  anything  but  good. 

Although  without  direct  vaso-motor  control,  the  circulation  of  the  brain 
is  regulated  by  the  action  of  the  vaso-motor  centre  on  the  splanchnic  areas 
and  skin.  This  centre  itself  shares  with  the  respiratory  and  cardiac  centres 
the  same  circulatory  conditions  as  prevail  throughout  the  brain. 

Consciousness  depends  upon  a  due  blood  supplj^  to  the  brain,  particularly 
to  the  cortex,  and  life  itself  depends  upon  the  circulation  in  the  medullary 
centres.  When  the  blood  circulating  about  these  centres  is  poor  in  oxygen — 
i.  e.,  when  there  is  a  lack  of  arterial  blood — the  arterioles  within  the  splanchnic 
and  skin  areas  contract  under  vaso-motor  influences,  the  blood-pressure  is 
raised,  and  the  blood  enters  the  brain  with  unusual  force  and  supplies  the 
capillaries  with  arterial  blood.  The  extent  to  which  this  regulating  mechan- 
ism can  counteract  an  obstruction  to  the  circulation  through  these  centres 
has  been  well  shown  experimentally  by  Harvey  Gushing.  When  the  general 
intracranial  pressure  was  raised  to  arterial,  blood-pressure,  instead  of  the  circu- 
lation being  blocked  and  the  animal  dying  from  ansemia  of  the  brain,  as  had 
been  stated  by  a  number  of  authors,  he  showed  that  the  vaso-motor  centres 
responded  with  a  sufficient  rise  of  blood-pressure  to  overcome  the  impediment, 
and  so  restore  the  circulation.  With  every  repeated  increase  of  intracranial 
pressure,  there  was  an  answering  rise  of  blood-pressure,  until,  at  the  end  of 
the  experiment,  the  brain  was  acting  under  an  intracranial  pressure  much 
above  the  arterial  pressure  of  the  animal  at  the  beginning  of  the  experiment, 
and  this  pressure  had  been  correspondingly  raised  to  a  startling  extent.  The 
interesting  clinical  deductions  which  Gushing  draws  from  this  experiment 
will  be  referred  to  under  cerebral  hsemorrhage. 

When  this  regulating  mechanism  is  disturbed,  serious  results  may  follow. 
The  ordinary  fainting  fit  is  an  example :  Under  the  influence  of  emotion  the 
vaso-motor  centre  is  inhibited,  and,  in  consequence,  the  abdominal  blood- 
vessels become  dilated,  blood-pressure  falls,  and  the  heart  is  no  longer  able 
to  drive  the  blood  back  to  itself  against  the  force  of  gravity ;  the  blood  accumu- 
lates in  the  abdominal  veins,  the  heart  empties,  cerebral  circulation  fails,  and 
unconsciousness  occurs.  A  similar  condition  may  follow  the  sudden  removal 
of  something  that  has  caused  pressure  on  the  abdominal  vessels  for  a  consider- 
able time,  as  the  withdrawal  of  the  ascitic  fluid.  In  this  case  the  vaso-motor- 
control  influences  have  not  been  called  on  for  some  time,  and  the  centre  itself 
has  taken  part  in  the  general  weakened  condition  of  the  individual,  so  that 


DIFFUSE  AND  FOCAL  DISEASES  OF   THE  BRAIN.  963 

when  a  sudden  demand  is  made  upon  it  to  compensate  for  the  accustomed 
external  support  to  the  blood-vessels,  it  is  entirely  unable  to  respond,  and  the 
blood  collects  in  the  splanchnic  vessels,  the  patient  becomes  unconscious  and 
may  die,  having  bled  to  death  into  his  own  veins. 

While  under  ordinary  circumstances  the  vaso-motor  mechanism  and  the 
tonicity  of  the  muscles  of  the  abdominal  walls  compensate  perfectly  for  the 
change  from  the  horizontal  to  the  upright  position — i.  o.,  for  the  effect  of 
gravity  upon  the  column  of  venous  blood  from  the  heart  to  the  feet,  in 
asthenic  states,  as  after  severe  illness,  the  compensation  may  be  very  imper- 
fect. When  such  is  the  case,  if  the  patient  stands,  or,  at  times,  even  if  he 
sits  up  in  bed,  his  heart  beats  more  rapidly,  he  becomes  giddy  and  may  faint. 
The  change  in  the  pulse-rate,  with  a  change  in  position,  is  a  fair  indication 
of  the  vaso-motor  control,  for  the  heart  itself  endeavors  to  make  up  for  this 
incompetence. 

Chloroform  and,  to  a  less  extent,  ether  tend  to  induce  vaso-motor  paraly- 
sis, and  this  is  the  reason  why  position  is  such  an  important  factor  in  the 
safety  of  patients  during  anaesthesia.  The  splanchnic  circulation,  under  these 
circumstances,  may,  to  a  certain  extent,  be  supported  by  bandaging  the  legs 
and  abdomen  and  elevating  the  foot  of  the  bed.  Crile's  pneumatic  operating 
suit,  in  which  the  patient  is  encased  below  the  chest  in  an  inflatable  suit,  by 
means  of  which  pressure  on  the  peripheral  and  abdominal  vessels  may  be 
varied,  is  an  attempt  to  establish  an  artificial  vaso-constrictor  system  under 
the  control  of  the  operator,  which  can  compensate  for  the  paralyzing  effects 
of  the  anaesthetic,  and  obviate  the  necessity  of  considering  position. 

The  heart  itself  may  become  weak  from  various  causes  and  so  be  unable 
to  keep  the  brain  properly  supplied  with  arterial  blood.  The  extreme  example 
of  this  is  paralysis  of  the  heart  muscles  from  failure  of  the  coronary  circula- 
tion, which  is  immediately  followed  by  unconsciousness  and  death.  In  Stokes- 
Adams  disease  the  cerebral  symptoms,  attacks  of  unconsciousness,  convulsions, 
and  apoplectiform  seizures  are  due  to  cerebral  ansemia,  caused  by  the  tempo- 
rary cessation  of  the  ventricular  systole.  When  the  chest  is  forcibly  com- 
pressed the  heart  may  be  unable  to  fill  itself  with  blood,  and  so  unconscious- 
ness, or  even  death,  may  follow  from  failure  of  the  cerebral  circulation. 

Kespiration  is  an  essential  part  of  circulation;  this  is  true  not  only  in 
the  primary  sense,  that  it  is  through  this  function  that  venous  is  changed  into 
arterial  blood,  but  also  in  a  more  truly  mechanical  sense.  With  every  inspira- 
tion the  blood  is  sucked  into  the  heart  from  the  veins,  and  the  descent  of  the 
diaphragm,  by  increasing  the  pressure  on  the  abdominal  veins,  tends  to  force 
the  blood  into  the  heart.  During  expiration  the  entrance  of  the  blood  into 
the  heart  is  impeded  by  the  increase  in  the  intra-thoracic  pressure.  Eespira- 
tion  has  direct,  but  slight,  influence  upon  the  blood-pressure  within  the 
arteries. 

The  circulation  within  the  skull  is  very  intimately  related  to  respiration. 
The  blood  from  the  brain  sinuses  passes  through  the  jugular  veins  directly 
into  the  superior  vena  cava  and  the  columns  of  blood  appear  to  be  uninter- 
rupted by  competent  valves,  so  that  every  change  of  pressure  in  the  cava  is 
transmitted  directly  to  the  sinuses  and  veins  of  the  brain.  Intracranial 
pressure  has  been  shown  to  be  equal  to  venous  blood-pressure  within  the 
sinuses  and  to  follow  every  change  in  this.     The  brain  dilates  with  each  pulse- 


964  DISEASES  OF   THE  NERVOUS  SYSTEM. 

beat,  but  relatively  much  more  with  each  expiration.  In  expiration  intra- 
thoracic pressure  is  increased,  and  this  causes  an  increase  in  the  pressure 
within  the  cava,  the  jugular,  and  the  brain  sinuses.  The  blood  is,  as  it  were, 
dammed  back,  venous  congestion  occurs,  intracranial  pressure  rises,  and  the 
brain  receives  less  arterial  blood,  and  the  symptoms  of  cerebral  anaemia  may 
follow.  Under  ordinary  conditions  these  effects  are  not  so  pronounced  or 
protracted  as  to  cause  marked  symptoms,  but  at  times  they  may  be,  as  when 
a  crying  child  holds  his  breath  until  he  becomes  unconscious.  Here  the  diffi- 
culty which  the  heart  has  in  filling  itself  with  blood  under  increased  thoracic 
pressure  is  also  a  factor.  When  the  superior  vena  cava  is  alone  obstructed,  as 
by  pressure  from  a  tumor,  there  may  be  not  the  slightest  disturbance  of  the 
functions.  This  depends  upon  the  freedom  of  the  cranio-vertebral  venous 
anastomosis,  and  other  paths  which  allow  the  blood  to  reach  the  heart  through 
the  inferior  vena  cava.  Strong  respiratory  efforts  against  an  obstruction  may 
change  intrathoracic  pressure  very  greatly.  In  forced  expiration  with  the 
glottis  closed,  the  normal  negative  pressure  becomes  markedly  positive  and  may 
far  exceed  the  normal  pressure  in  the  intrathoracic  veins,  while,  if  the  glottis 
be  closed  and  a  strong  inspiratory  effort  be  made,  the  pressure  may  fall  far 
below  atmospheric  pressure.  Intracranial  haemorrhages  not  infrequently  take 
place  during  a  strong  effort  with  the  breath  held  as  when  straining  at  stool, 
or  when  lifting  a  heavy  weight,  or  during  a  severe  coughing  spell,  all  condi- 
tions in  which,  among  other  things,  the  flow  of  the  venous  blood  from  the 
brain  to  the  heart  is  impeded,  and  in  consequence  of  which  intracranial  circu- 
latory conditions  are  altered  in  the  direction  of  a  rise  of  venous  and  capillary 
pressure.  The  importance  of  preventing,  as  far  as  possible,  any  obstruction 
to  respiration  during  the  course  of  apoplexy,  will  be  referred  to  in  a  subse- 
quent paragraph. 

The  venous  outlets  from  the  skull  are  so  large  and  the  anastomoses  are  so 
free  that  they  must  all  be  obstructed  to  cause  any  marked  anemia  of  the  brain, 
and  for  this  reason  thrombosis  or  ligature  of  one  of  the  sinuses  is  not  neces- 
sarily followed  by  any  symptoms.  If  all  the  veins  in  the  neck  are  compressed 
as  by  a  tight  band  or  strong  flexion  of  the  neck,  the  circulation  may  be  impeded 
to  a  considerable  extent,  and  this  is  of  definite  importance  under  pathological 
conditions. 

Any  one  of  the  arteries  may  be  tied  before  entering  the  skull,  with  but 
little  danger,  owing  to  the  freedom  of  the  anastomosis  in  the  circle  of  Willis, 
but,  as  this  is  subject  to  variation,  the  closure  should  be  made  slowly.  With 
this  precaution,  both  carotids  may  be  tied  if  an  interval  be  allowed  between 
the  operations. 

Obliteration  of  an  artery  beyond  the  circle  of  Willis  is  always  followed  by 
a  disturbance  of  function  of  the  part  of  the  brain  supplied  by  that  artery, 
and  is  considered  under  Embolism  and  Thrombosis. 

2.  Hyperemia  and  Anemia. 

Less  and  less  stress  is  now  laid  on  active  hypergemia  as  a  cause  of  symptoms. 
As  Leube  suggests,  the  symptoms  usually  referred  to  active  hypergemia  in  the 
infectious  diseases,  or  in  association  with  hypertrophy  of  the  heart  accom- 
panying disease  of  the  kidney,  are  due  to  the  action  of  toxic  agents  rather  than 


DIFFUSE  AND  FOCAL  DISEASES  OF  THE  BRAIN.  965 

to  changes  in  the  circulation.  On  the  other  hand,  venous  stasis  and  anaemia 
of  the  brain  must  be  a  very  potent  cause  of  head  symptoms.  The  uncertainty 
which  exists  is  largely  due  to  the  fact  that  the  condition  of  the  blood-vessels 
as  seen  within  the  skull  after  death  may  bear  no  relation  to  that  which  held 
sway  during  life. 

The  anatomical  condition  of  the  brain  in  anaemia  is  very  striking.  The 
membranes  are  pale,  only  the  large  veins  are  full,  the  small  vessels  over  the 
gyri  are  empty,  and  an  unusual  amount  of  cerebro-spinal  fluid  is  present.  On 
section  both  the  gray  and  white  matter  look  extremely  pale  and  the  cut  surface 
is  moist.    Very  few  puncta  vasculosa  are  seen. 

The  effects  of  sudden  anaemia  of  the  brain  are  well  illustrated  By  the  ordi- 
nary fainting  fit,  and  have  been  described  above. 

Symptoms. — When  the  symptoms  are  the  result  of  haemorrhage,  there  are 
drowsiness,  giddiness,  inability  to.  stand ;  flashes  of  light,  dark  spots  before  the 
eyes,  and  noises  in  the  ears;  the  respiration  becomes  hurried;  the  skin  is  cool 
and  covered  with  sweat;  the  pupils  are  dilated,  there  may  be  vomiting,  head- 
ache, or  delirium,  and  gradually,  if  the  bleeding  continues,  consciousness  is 
lost  and  death  may  occur  with  convulsions.  In  the  more  chronic  forms  of 
brain  anaemia,  such  as  result  from  the  gradual  impoverishment  of  the  blood, 
as  in  protracted  illness  or  in  starvation,  the  condition  known  as  irritable  weak- 
ness results.  Mental  effort  is  difficult,  the  slightest  irritation  is  followed  by 
undue  excitement,  the  patient  complains  of  giddiness  and  noises  in  the  ears, 
or  there  may  be  hallucinations  or  delirium.  These  symptoms  are  met  with 
in  an  extreme  grade  as  a  result  of  prolonged  starvation,  and  a  very  similar 
condition  is  seen  in  certain  cases  of  arterio-sclerosis  where  the  brain  is  poorly 
nourished. 

An  interesting  set  of  symptoms,  to  which  the  term  hydrencepJialoid  was 
applied  by  Marshall  Hall,  occurs  in  the  debility  produced  by  prolonged  diar- 
rhoea in  children.  The  child  is  in  a  semi-comatose  condition  with  the  eyes 
open,  the  pupils  contracted,  and  the  fontanelle  depressed.  In  the  earlier 
period  there  may  be  convulsions.  The  coma  may  gradually  deepen,  the  pupils 
become  dilated,  and  there  may  be  strabismus  and  even  retraction  of  the  head, 
symptoms  which  closely  simulate  those  of  basilar  meningitis. 

3.  CEdema  of  the  Beain. 

In  the  pathology  of  brain  lesions  oedema  formerly  played  a  role  almost 
equal  in  importance  to  congestion.  It  occurs  under  the  following  conditions : 
In  general  atrophy  of  the  convolutions,  in  which  case  the  oedema  is  represented 
by  an  increase  in  the  cerebro-spinal  fluid  and  in  that  of  the  meshes  of  the  pia. 
In  extreme  venous  dilatation  from  obstruction,  as  in  mitral  stenosis  or  in 
tumors,  there  may  be  a  condition  of  congestive  oedema,  in  which,  in  addition 
to  great  filling  of  the  blood-vessels,  the  substance  of  the  brain  itself  is  un- 
usually moist.  The  most  acute  oedema  is  a  local  process  found  around  tumors 
and  abscesses.  The  symptoms  of  compression  following  concussion  or  con- 
tusion, as  shown  by  Cannon,  are  frequently  attributable  to  cerebral  oedema  due 
to  change  in  osmotic  pressure.  An  intense  infiltration,  local  or  general,  may 
occur  in  Bright's  disease,  and  to  it,  as  Traube  suggested,  certain  of  the  uremic 
symptoms  may  be  due. 


966  DISEASES  OF  THE  NERVOUS  SYSTEM. 

The  anatomical  changes  are  not  uiilike  those  of  anaemia.  When  the  oedema 
follows  progressive  atrophy,  the  fluid  is  chiefly  within  and  beneath  the  mem- 
branes. The  brain  substance  is  anaemic  and  moist,  and  has  a  wet,  glistening 
appearance,  which  is  very  characteristic.  In  some  instances  the  oedema  is 
more  intense  and  local,  and  the  brain  substance  may  look  infiltrated  with  fluid. 
The  amount  of  fluid  in  the  ventricles  is  usually  increased. 

The  symptoms  are  in  great  part  those  of  lessened  blood-flow,  and  are  not 
well  defined.  As  just  stated,  some  of  the  cerebral  features  of  uraemia  may 
depend  upon  it.  Cases  have  been  reported  by  Ea^Tuond,  Tenneson,  and  Der- 
cum,  in  which  unilateral  convulsions  or  paralysis  have  occurred  in  connection 
with  chronic  Bright's  disease,  and  in  which  the  condition  appeared  to  be  asso- 
ciated with  oedema  of  the  brain.  The  older  writers  laid  great  stress  upon  an 
apoplexia  serosa,  which  may  really  have  been  a  general  oedema  of  the  brain. 
Inasmuch  as  the  instances  in  which  oedema  of  the  brain  occurs  are  often  those 
in  which  there  is  also  intoxication,  or  anaemia,  or  both,  it  is  probably  impossible 
to  say  at  the  bedside  definitely  which  of  these  possible  factors  is  responsible 
for  the  symptoms  in  a  given  case. 

4.    CeEEBEAL    H-2EM0KKHAGE. 

The  bleeding  may  come  from  branches  of  either  of  the  two  great  groups 
of  cerebral  vessels — the  hasal,  comprising  the  circle  of  Willis  and  the  central 
arteries  passing  from  it  and  from  the  first  portion  of  the  cerebral  arteries,  or 
the  cortical  group,  the  anterior,  middle,  and  the  posterior  cerebral  vessels.  In 
a  majority  of  the  cases  the  haemorrhage  is  from  the  central  branches,  more  par- 
ticularly from  those  which  are  given  oS  by  the  middle  cerebral  arteries  in  the 
anterior  perforated  spaces,  and  which  supply  the  corpora  striata  and  internal 
capsules.  One  of  the  largest  of  these  branches  which  passes  to  the  third  divi- 
sion of  the  lenticular  nucleus  and  to  the  anterior  part  of  the  internal  capsule, 
the  lenticulo-striate  artery  of  Buret,  is  so  frequently  involved  in  haemorrhage 
that  it  has  been  called  by  Charcot  the  artery  of  cerebral  hcemorrhage.  Haemor- 
rhages from  this  and  from  the  lenticulo-thalamic  artery  include  more  than 
60  per  cent  of  all  cerebral  haemorrhages.  The  bleeding  may  be  into  the  sub- 
stance of  the  brain,  to  wliich  alone  the  term  cerebral  apoplexy  is  applied,  or 
into  the  membranes,  in  which  case  it  is  termed  meningeal  haemorrhage;  both, 
however,  are  usually  included  under  the  terms  intracranial  or  cerebral  haem- 
orrhage. 

Etiology. — The  conditions  which  produce  lesions  of  the  blood-vessels  play 
a  very  important  part ;  thus  the  natural  tendency  to  degeneration  of  the  vessels 
in  advanced  life  makes  apoplexy  much  more  common  after  the  fiftieth  year. 
It  may,  however,  occur  in  children  under  ten.  On  account  of  the  greater 
liability  to  arterial  disease  (associated  probably  with  muscular  exertion  and 
the  abuse  of  alcohol),  men  are  more  subject  to  cerebral  haemorrhage  than 
women.  Heredity  was  formerly  thought  to  be  an  important  factor  in  this 
affection,  and  the  apoplectic  hahitus  or  build  is  still  referred  to.  By  this  is 
meant  a  stout  plethoric  body  of  medium  size,  with  a  short  neck.  Heredity 
influences  cerebral  haemorrhage  entirely  through  the  arteries,  and  there  are 
families  in  which  these  degenerate  early,  usually  in  association  with  renal 
changes.    The  secondary  hj-pertrophy  of  the  heart  brings  with  it  serious  dan- 


DIFFUSE  AND  FOCAL  DISEASES  OF  THE  BRAIN.  -967 

gers,  which  have  already  been  discussed  in  the  section  upon  arteries.  The 
special  factors  in  inducing  arterio-sclerosis — the  abuse  of  alcohol,  immoderate 
eating,  syphilis,  and  prolonged  muscular  exertion — are  found  to  be  important 
antecedents  in  a  large  number  of  cases  of  cerebral  hasmorrhage.  Chronic  lead 
poisoning  and  gout  also  may  here  be  mentioned. 

The  endocarditis  of  rheumatism  and  other  fevers  may  indirectly  lead  to 
apoplexy  by  causing  embolism  and  aneurism  of  the  vessels  of  the  brain.  Cere- 
bral heemorrhage  occurs  occasionally  in  the  specific  fevers  and  in  profound 
alterations  of  the  blood,  as  in  leukaemia  and  pernicious  anaemia.  The  actual 
exciting  cause  of  the  haemorrhage  is  not  evident  in  the  majority  of  cases.  The 
attack  may  be  sudden  and  without  any  preliminary  symptoms.  In  other  in- 
stances violent  exertion,  particularly  straining  efforts,  or  the  excited  action  of 
the  heart  in  emotion  may  cause  a  rupture. 

Morbid  Anatomy. — The  lesions  causing  apoplexy  are  almost  invariably 
in  the  cerebral  arteries,  in  which  the  following  changes  may  lead  directly 
to  it: 

(a)  The  production  of  miliary  aneurisms,  rupture  of  which  is  the  most 
common  cause  of  cerebral  haemorrhage.  The  origin  of  the  miliary  aneurisms 
is  disputed.  Charcot  thought  they  resulted  from  changes  in  the  adventitia 
(periarteritis).  Others,  with  Eichler,  Ziegler,  and  Birch- Hirschf eld,  find  the 
primary  change  in  the  intima.  The  weight  of  opinion  at  present,  however,  is 
on  the  side  of  the  view  that  the  media  is  first  degenerated  (Eoth,  Loewenthal). 
They  occur  most  frequently  on  the  central  arteries,  but  also  on  the  smaller 
branches  of  the  cortical  vessels.  On  section  of  the  brain  substance  they  may 
be  seen  as  localized,  small  dark  bodies,  about  the  size  of  a  pin's  head.  Some- 
times they  are  seen  in  numbers  upon  the  arteries  when  carefully  withdrawn 
from  the  anterior  perforated  spaces.  According  to  Charcot  and  Bouchard,  who 
have  described  them,  they  are  most  frequent  in  the  central  ganglia.  In  apo- 
plexy after  the  fortieth  year  if  sought  for  they  are  rarely  missed.  The  actual 
miliary  aneurism,  which  by  its  rupture  has  occasioned  the  hasmorrhage,  may 
be  difficult  to  find,  but  if  one  pours  water  carefully  on  the  area  of  haemorrhage, 
or,  better  still,  submerges  the  apoplectic  mass  for  a  time,  it  will  usually  be 
found  possible  to  do  so,  and  even  to  find  the  hole  in  its  wall. 

(&)  Aneurism  of  the  branches  of  the  circle  of  Willis.  These  are  by  no 
means  uncommon,  and  will  be  considered  subsequently. 

(c)  Endarteritis  and  periarteritis  in  the  cerebral  vessels  most  commonly 
lead  to  apoplexy  by  the  production  of  aneurisms,  either  miliary  or  coarse. 
There  are  instances  in  which  the  most  careful  search  fails  to  reveal  anything 
but  diffuse  degeneration  of  the  cerebral  vessels,  particularly  of  the  smaller 
branches;  so  that  we  must  conclude  that  spontaneous  rupture  may  occur 
without  the  previous  formation  of  aneurism. 

(d)  Increased  permeability  of  the  walls  of  the  vessels  may  account  for 
haemorrhages  by  diapedesis  without  actual  rupture.  Such  haemorrhages  are 
not  uncommon  in  cases  of  contracted  kidney,  grave  anaemia,  and  various 
infections  and  intoxications. 

(e)  In  persons  over  sixty  the  hemiplegia  may  depend  upon  small  areas  of 
softening  in  the  gray  matter — the  lacunce  of  Marie — areas  varying  in  size  from 
a  pin's  head  to  a  pea  or  a  small  bean,  grayish-red  in  tint.  The  lenticular 
nucleus  is  particularly  apt  to  be  involved.     The  blood-vessels  are  always  dis- 


968.  DISEASES  OF  THE  NERVOUS  SYSTEM. 

eased.    Anatomically  this  is  believed  to  be  quite  as  important  as  the  miliary 
aneurisms. 

The  haemorrhage  may  be  meningeal,  cerebral,  or  intraventricular. 

Meningeal  licemorrhage  may  be  outside  the  dura,  between  this  membrane 
and  the  bone,  or  between  the  dura  and  arachnoid,  or  between  the  arachnoid 
and  the  pia  mater.  The  following  are  the  chief  causes  of  this  form  of  haemor- 
rhage :  Fracture  of  the  skull,  in  which  case  the  blood  usually  comes  from  the 
lacerated  meningeal  vessels,  sometimes  from  the  torn  sinuses.  In  these  cases 
the  blood  is  usually  outside  the  dura  or  between  it  and  the  arachnoid.  The 
next  most  frequent  cause  is  rupture  of  aneurisms  on  the  larger  cerebral  ves- 
sels. The  blood  is  usually  subarachnoid.  An  intracerebral  haemorrhage  may 
burst  into  the  meninges.  A  special  form  of  meningeal  hsemorrhage  is  found 
in  the  new-born,  associated  with  injury  during  birth.  And  lastly,  meningeal 
haemorrhage  may  occur  in  the  constitutional  diseases  and  fevers.  The  blood 
may  be  in  a  large  quantity  at  the  base ;  in  cases  of  ruptured  aneurism,  particu- 
larly, it  may  extend  into  the  cord  or  upon  the  cortex.  Owing  to  the  greater 
frequency  of  the  aneurisms  in  the  middle  cerebral  vessels,  the  Sylvian  fissures 
are  often  distended  with  blood. 

Intracerebral  hcemorrhage  is  most  frequent  in  the  neighborhood  of  the  cor- 
pus striatum,  particularly  toward  the  outer  section  of  the  lenticular  nucleus. 
The  hgemorrhage  may  be  small  and  limited  to  the  lenticular  body,  the  thala- 
mus, and  the  internal  capsule,  or  it  may  extend  to  the  insula.  Haemorrhages, 
confined  to  the  white  matter — the  centrum  semiovale — are  rare.  Localized 
bleeding  may  occur  in  the  crura  or  in  the  pons.  Haemorrhage  into  the  cere- 
bellum is  not  uncommon,  and  usually  comes  from  the  superior  cerebellar 
artery.  The  extravasation  may  be  limited  to  the  substance  or  may  rupture 
into  .the  fourth  ventricle.  Twice  I  have  known  sudden  death  in  girls  under 
twenty-five  to  be  due  to  cerebellar  haemorrhage. 

Ventricular  Hcemorrhage. — This  occasionally  but  rarely  is  primary,  coming 
from  the  vessels  of  the  plexuses  or  of  the  walls.  More  often  it  is  secondary, 
following  haemorrhage  into  the  cerebral  substance.  It  is  not  infrequent  in 
early  life  and  may  occur  during  birth.  Of  94  cases  collected  by  Edward 
.Sanders,  7  occurred  during  the  first  year,  and  14  under  the  twentieth  year. 
In  the  cases  which  I  have  seen  in  adults  it  has  almost  always  been  caused  by 
rupture  of  a  vessel  in  the  neighborhood  of  the  caudate  nucleus.  Tlie  blood 
may  be  found  in  one  ventricle  only,  but  more  commonly  it  is  in  both  lateral 
ventricles,  and  may  pass  into  the  third  ventricle  and  through  the  aqueduct  of 
Sylvius  into  the  fourth  ventricle,  forming  a  complete  mould  in  blood  of  the 
ventricular  system.  In  these  cases  the  clinical  picture  may  be  that  of  "^  apo- 
plexie  foudroyante." 

Subsequent  Changes. — The  blood  gradually  changes  in  color,  and  ulti- 
mately the  haemoglobin  is  converted  into  the  reddish-brown  hamatoidin.  In- 
flammation occurs  about  the  apoplectic  area,  limiting  and  confining  it,  and 
ultimately  a  definite  wall  may  be  produced,  inclosing  a  cyst  with  fluid  contents. 
In  other  instances  a  cyst  is  not  formed,  but  the  connective  tissue  proliferates- 
and  leaves  a  pigmented  scar.  In  meningeal  haemorrhage  the  effused  blood 
may  be  gradually  absorbed  and  leave  only  a  staining  of  the  membranes.  In 
other  cases,  particularly  in  infants,  when  the  effusion  is  cortical  and  abundant, 
there  may  be  localized  wasting  of  the  convolutions  and  the  production  of  a  cyst 


DIFFUSE  AND  FOCAL  DISEASES  OF   THE  BRAIN.  969 

in  the  meninges.  Possibly  certain  of  the  cases  of  porencephaly  are  caused  in 
this  way. 

Secondary  degeneration  follows,  varying  in  character  according  to  the  loca- 
tion of  the  haemorrhage  and  the  actual  damage  done  by  it  to  nerve  cells  or 
their  medullated  axones.  Thus,  in  persons  dying  some  years  after  a  cerebral 
apoplexy  which  has  produced  hemiplegia  (lesion  of  the  motor  area  in  the 
cortex  or  of  the  pyramidal  tract  leading  from  it),  the  degeneration  may  be 
traced  through  the  cerebral  peduncle,  the  ventral  part  of  the  pons,  the  pyra- 
mids of  the  medulla,  the  fibres  of  the  direct  pyramidal  tract  of  the  cord  of  the 
same  side,  and  the  fibres  of  the  crossed  pyramidal  tract  on  the  opposite  side. 
After  haemorrhages  in  the  middle  and  inferior  frontal  gyri  there  follows  degen- 
eration of  the  frontal  cerebro-cortico-pontal  path,  going  through  the  anterior 
limb  of  the  internal  capsule  and  the  medial  portion  of  the  basis  pedunculi  to 
.the  nuclei  pontis;  also  degeneration  of  the  fibres  connecting  the  nucleus  me- 
dialis  thalami,  and  the  anterior  part  of  the  nucleus  lateralis  thalami  with  the 
cortex  (Flechsig,  v.  Monakow). 

When  the  temporal  gyri  or  their  white  matter  is  destroyed  by  a  haemor- 
rhage the  lateral  segment  of  the  basis  pedunculi  degenerates  (Dejerine) .  Cere- 
bellar hemorrhage,  especially  if  it  injure  the  nucleus  dentatus,  may  lead  to 
degeneration  of  the  brachium  conjunctivum. 

The]-e  may  be  slow  degeneration  in  the  lemniscus  medialis,  extending  as 
far  as  the  nuclei  on  the  opposite  side  of  the  medulla  oblongata,  after  haemor- 
rhages in  the  central  gyri,  hypothalamic  region,  or  dorsal  part  of  the  pons. 
Hemorrhages  destroying  the  occipital  cortex,  or  subcortical  haemorrhages  in- 
juring the  optic  radiations,  occasion  slow  degeneration  (cellulipetal)  of  the 
radiations  from  the  lateral  geniculate  body,  and  after  a  time  cause  marked 
atrophy  or  even  disappearance  of  its  ganglion  cells. 

Symptoms. — These  may  be  divided  into  primary,  or  those  connected  with 
the  onset,  and  secondary,  or  those  which  develop  later,  after  the  early  mani- 
festations have  passed  away. 

Peimary  Symptoms. — Premonitory  indications  are  rare.  As  a  rule,  the 
patient  is  seized  while  in  full  health  or  about  the  performance  of  some  every- 
day action,  occasionally  an  action  requiring  strain  or  extra  exertion.  Now  and 
then  instances  are  found  in  which  there  are  sensations  of  numbness  or  tingling 
or  pains  in  the  limbs,  or  even  choreiform  movements  in  the  muscles  of  the 
opposite  side,  the  so-called  prehemiplegic  chorea.  In  other  cases  temporary 
disturbances  of  vision  and  of  associated  movements  of  the  eye-muscles  have 
been  noted,  but  none  of  the  prodromata  of  apoplexy  (the  so-called  "warn- 
ings") are  characteristic.  The  onset  of  the  apoplexy,  as  the  symptoms  of 
cerebral  haemorrhage  are  usually  called,  varies  greatly.  There  may  be  sudden 
loss  of  consciousness  and  complete  relaxation  of  the  extremities.  In  such  in- 
stances the  name  apoplectic  stroke  is  particularly  appropriate.  In  other  cases 
the  onset  is  more  gradual  and  the  loss  of  consciousness  may  not  occur  for  a 
few  minutes  after  the  patient  has  fallen,  or  after  the  paralysis  of  the  limbs 
is  manifest.  In  the  typical  apoplectic  attack  the  condition  is  as  follows: 
There  is  deep  unconsciousness;  the  patient  can  not  be  roused.  The  face  is 
injected,  sometimes  cyanotic,  or  of  an  ashen-gray  hue.  The  pupils  vary ;  usu- 
ally they  are  dilated,  sometimes  unequal,  and  always,  in  deep  coma,  inactive. 
If  the  hemorrhage  be  so  located  that  it  can  irritate  the  nucleus  of  the  third 


970  DISEASES  OF   THE  NERVOUS  SYSTEM. 

nerve  the  pupils  are  contracted  (hemorrhages  into  the  pons  or  ventricles). 
The  respirations  are  slow,  noisy,  and  accompanied  with  stertor.  Sometimes 
the  Cheyne-Stokes  rhythm  may  be  present.  The  chest  movements  on  the 
paralyzed  side  may  be  restricted,  in  rare  instances  on  the  opposite  side.  The 
cheeks  are  often  blown  out  during  expiration,  with  spluttering  of  the  lips. 
The  pulse  is  usually  full,  slow,  and  of  increased  tension.  The  temperature  may 
be  normal,  but  is  often  found  subnormal,  and,  as  in  a  case  reported  by  Bastian, 
may  sink  below  95°.  In  cases  of  basal  hsemorrhage  the  temperature,  on  the 
other  hand,  may  be  high.  The  urine  and  faeces  are  usually  passed  involun- 
tarily. Convulsions  are  not  common.  It  may  be  difficult  to  decide  whether 
the  condition  is  apoplexy  associated  with  hemiplegia  or  sudden  coma  from 
other  causes.  An  indication  of  hemiplegia  may  be  discovered  in  the  difference 
in  the  tonus  of  the  muscles  on  the  two  sides.  If  the  arm  or  the  leg  is  lifted, 
it  drops  "  dead  "  on  the  affected  side,  while  on  the  other  it  falls  more  slowly. 
Heilbroener  has  lately  pointed  out  that  the  lack  of  muscular  tone  of  the 
paralyzed  limb  may  be  determined  by  inspection.  In  this  condition  the  muscle 
mass  of  the  thigh  acts  like  a  semi-fluid  sac  and  takes  the  shape  determined  by 
gravity.  In  a  patient  lying  or  sitting  on  a  firm  support,  the  thigh  of  the 
paralyzed  limb  is  broadened  or  flattened,  while  that  on  the  normal  side  has  a 
more  rounded  contour.  Eigidity  also  may  be  present.  In  watching  the  move- 
ments of  the  facial  muscles  in  the  stertorous  respiration  it  will  be  seen  that  on 
the  paralyzed  side  the  relaxation  permits  the  cheek  to  be  blown  out  in  a  more 
marked  manner.  The  head  and  eyes  may  be  turned  strongly  to  one  side — 
conjugate  deviation.  In  such  an  event  the  turning  is  toward  the  side  of  the 
hgemorrhage. 

In  other  cases,  in  which  the  onset  is  not  so  abrupt,  the  patient  may  not 
lose  consciousness,  but  in  the  course  of  a  few  hours  there  is  loss  of  power, 
unconsciousness  gradually  develops,  and  deepens  into  profound  coma.  This 
is  sometimes  termed  ingravescent  apoplexy.  The  attack  may  occur  during 
sleep.  The  patient  may  be  found  unconscious,  or  wakes  to  find  that  the  power 
is  lost  on  one  side.  Small  haemorrhages  in  the  territory  of  the  central  arteries 
may  cause  hemiplegia  without  loss  of  consciousness.  In  old  persons  the  hemi- 
plegia may  be  slight  and  follow  a  transient  loss  of  consciousness,  and  is  usu- 
ally most  marked  in  the  leg,  which  is  dragged.  It  may  be  quite  slight  and 
difficult  to  make  out.  It  is  associated  with  other  senile  changes.  This  is  the 
form  very  often  due  to  the  presence  of  lacunar  softening. 

Usually  within  forty-eight  hours  after  the  onset  of  an  attack,  sometimes 
within  from  two  to  six  hours,  there  is  febrile  reaction,  and  more  or  less  con- 
stitutional disturbance  associated  with  inflammatory  changes  about  the  hem- 
orrhage and  absorption  of  the  blood.  The  period  of  inflammatory  reaction 
may  continue  for  from  one  week  to  two  months.  The  patient  may  die  in  this 
reaction,  or,  if  consciousness  has  been  regained,  there  may  be  delirium  or 
recurrence  of  the  coma.  At  this  period  the  so-called  early  rigidity  may  develop 
in  the  paralyzed  limbs.  The  so-called  trophic  changes  may  occur,  such  as 
sloughing  or  the  formation  of  vesicles.  The  most  serious  of  these  is  the 
sloughing  eschar  of  the  lower  part  of  the  back,  or  on  the  paralyzed  side,  which 
may  appear  within  forty-eight  hours  of  the  onset  and  is  usually  of  grave  sig- 
nificance. The  congestion  at  the  bases  of  the  lungs  so  common  in  apoplexy  is 
regarded  by  some  as  a  trophic  change. 


DIFFUSE  AND  FOCAL  DISEASES  OF  THE  BRAIN.   "        971 

Conjugate  Deviation. — In  a  right  hemiplegia  the  eyes  and  head  may  be 
turned  to  the  left  side;  that  is  to  say,  the  eyes  look  toward  the  cerebral  lesion. 
This  is  almost  the  rule  in  the  conjugate  deviation  of  the  head  and  eyes  which 
occurs  early  in  hemiplegia.  When,  however,  convulsions  or  spasm  develop  or 
the  state  of  so-called  early  rigidity  in  hemiplegia,  the  conjugate  deviation 
of  the  head  and  eyes  may  be  in  the  opposite  direction ;  that  is  to  say,  the  eyes 
look  away  from  the  lesion  and  the  head  is  rotated  toward  the  convulsed  side. 
This  symptom  may  be  associated  with  cortical  lesions,  particularly,  according 
to  some  authors,  when  in  the  neighborhood  of  the  supramarginal  and  angular 
gyri.  It  may  also  occur  in  a  lesion  of  the  internal  capsule  or  in  the  pons,  but 
in  the  latter  situation  the  conjugate  deviation  is  the  reverse  of  that  which 
occurs  in  other  cases,  as  the  patient  looks  away  from  the  lesion,  and  in  spasm 
or  convulsion  looks  toward  the  lesion. 

Hemiplegia. — In  cases  in  which  consciousness  is  restored  and  the  patient 
improves,  a  unilateral  paralysis  may  persist  due  to  the  destruction  of  the 
motor  area  or  the  pyramidal  tract  in  any  part  of  its  course.  Hemiplegia  is 
complete  when  it  involves  face,  arm,  and  leg,  or  partial  when  it  involves  only 
one  or  other  of  these  parts.  This  may  be  the  result  of  a  lesion  (a)  of  the 
motor  cortex;  (&)  of  the  pyramidal  fibres  in  the  corona  radiata  and  in 
the  internal  capsule;  (c)  of  a  lesion  in  the  cerebral  peduncle;  or  (d)  in  the 
pons  Varolii.  The  situation  of  the  lesions  and  their  effects  are  given  in  Fig.  9. 
Hgemorrhage  is  perhaps  the  most  common  cause,  but  tumors  and  spots  of 
softening  may  also  induce  it.  The  special  details  of  the  hemiplegia  may  here 
be  considered.  The  face  (except  in  lesions  in  the  lower  part  of  the  pons)  is 
involved  on  the  same  side  as  the  arm  and  leg.  This  results  from  the  fact  that 
the  facial  muscles  stand  in  precisely  the  same  relation  to  the  cortical  centres 
as  those  of  the  arm  and  leg,  the  fibres  of  the  upper  motor  segment  of  the  facial 
nerve  itora  the  cortex  decussating  just  as  do  those  of  the  nerves  of  the  limbs. 
The  signs  of  the  facial  paralysis  are  usually  well  marked.  There  may  be  a 
slight  difficulty  in  elevating  the  eyebrows  or  in  closing  the  eye  on  the  paralyzed 
side,  or  in  rare  cases  the  facial  paralysis  is  complete,  but  the  movements  may 
be  present  with  emotion,  as  laughing  or  crying.  The  facial  paralysis  is  par- 
tial, involving  only  the  lower  portion  of  the  nerve,  so  that  the  orbicularis  oculi 
and  the  frontalis  muscles  are  much  less  involved  than  the  lower  branch.  The 
hypoglossal  nerve  also  is  involved.  In  consequence,  the  patient  can  not  put 
out  the  tongue  straight,  but  it  deviates  toward  the  paralyzed  side,  inasmuch 
as  the  genio-hyo-glossus  of  the  sound  side  is  unopposed.  With  right  hemiplegia 
there  Taa.y  be  aphasia.  Even  without  marked  aphasia  difficulty  in  speaking 
and  slowness  are  common. 

The  arm  is,  as  a  rule,  more  completely  paralyzed  than  the  leg*  The  loss 
of  power  may  be  absolute  or  partial.  In  severe  cases  it  is  at  first  complete. 
In  others,  when  the  paralysis  in  the  face  and  arm  is  complete  that  of  the  leg 
is  only  partial.  The  face  and  arm  may  alone  be  paralyzed,  while  the  leg 
escapes.  Less  commonly  the  leg  is  more  affected  than  the  arm,  and  the  face 
may  be  only  slightly  involved. 

Certain  muscles  escape  in  hemiplegia,  particularly  those  associated  in 
symmetrical  movements,  as  those  of  the  thorax  and  abdomen,  a  fact  which 
Broadbent  explains  by  supposing  that  as  the  spinal  nuclei  controlling  these 
movements  on  both  sides  constantly  act  together,  they  may,  by  means  of  this 


972 


DISEASES  OF  THE  NERVOUS  SYSTEAI. 


intimate  connection,  be  stimulated  by  impulses  coming  from  only  one  side 
of  the  brain.     Hughlings  Jackson  pointed  out  that  in  quiet  respiration  the 


\.E  6 


Fig.  9. — Diagram  of  motor  path  from  left  brain.  The  apper  segment  is  black,  the  lower 
red.  The  nuclei  of  the  motor  cerebral  nerves  are  shown  on  the  right  side ;  on  the  left 
side  the  cerebral  nerves  of  that  side  are  indicated.  A  lesion  at  1  would  cause  upper 
segment  paralysis  in  the  arm  of  the  opposite  side — cerebral  monoplegia;  at  2,  upper 
segment  paralysis  of  the  whole  opposite  side  of  the  body — hemiplegia ;  at  3  (in  the  crus), 
upper  segment  paralysis  of  the  opposite  face,  arm,  and  leg,  and  lower  segment  paralysis 
of  the  eye-muscles  on  the  same  side — crossed  paralysis :  at  4  (in  the  lower  part  of  the 
pons),  upper  segment  paralysis  of  the  opposite  arm  and  leg,  and  lower  segment  paralysis 
of  the  face  and  the  external  rectus  on  the  same  side — crossed  paralysis ;  at  5,  upper  seg- 
ment paralysis  of  all  muscles  represented  below  lesion,  and  lower  segment  paralysis  of 
muscles  represented  at  level  of  lesion — spinal  paraplegia ;  at  6,  lower  segment  paralysis 
of  muscles  localized  at  seat  of  lesion — anterior  poliomyelitis.     (Van  Gehuchten,  modified.) 


DIFFUSE  AND  FOCAL  DISEASES  OF  THE  BRAIN.  973 

muscles  on  the  paralyzed  side  acted  more  strongly  than  the  corresponding 
muscles,  but  that  in  forced  respiration  the  reverse  condition  was  true.  This 
has  been  confirmed  by  Clark  and  Bury.  The  degree  of  permanent  paralysis 
after  a  hemiplegic  attack  varies  much  in  different  cases.  When  the  restitution 
is  partial,  it  is  always,  as  Wernicke  has  pointed  out,  certain  groups  of  muscles 
vhich  recover  rather  than  others.  Thus  in  the  leg  the  residual  paralysis  con- 
cerns the  flexors  of  the  leg  and  the  dorsal  flexors  of  the-  foot — i.  e.,  the  muscles 
which,  according  to  Ludwig  Mann,  are  active  in  the  second  period  of  walk- 
ing, shortening  the  leg,  and  bringing  it  forward  while  it  swings.  The  mus- 
cles which  lift  the  body  when  the  foot  rests  upon  the  ground,  those  used  in 
the  first  period  of  walking,  include  the  extensors  of  the  leg  and  the  plantar 
flexors  of  the  foot.  These  "  lengtheners  "  of  the  leg  often  recover  almost 
completely  in  cases  in  which  the  paralysis  is  due  to  lesions  of  the  pyramidal 
tract.  In  the  arms  the  residual  paralysis  usually  affects  the  muscle  groups 
which  oppose  the  thumb,  those  which  rotate  the  arm  outward,  and  the  openers 
of  the  hand. 

As  a  rule,  there  is  at  first  no  wasting  of  the  paralyzed  limbs. 

Crossed  Hemiplegia. — A  paralysis  in  which  there  is  loss  of  function  in  a 
cerebral  nerve  on  one  side  with  loss  of  power  (or  of  sensation)  on  the  opposite 
side  of  the  body  is  called  a  crossed  or  alternate  hemiplegia.  It  is  met  with 
in  lesions,  commonly  haemorrhage,  in  the  crus,  the  pons,  and  the  medulla 
(Fig.  9,  3  and  4). 

(a)  Crus. — The  bleeding  may  extend  from  vessels  supplying  the  corpus 
striatum,  internal  capsule,  and  optic  thalamus,  or  the  haemorrhage  may  be 
primarily  in  the  crus.  In  the  classical  case  of  Weber,  on  section  of  the  lower 
part  of  the  left  crus  an  oblong  clot  15  mm.  in  length  lay  just  below  the  medial 
and  inferior  surface.  The  characteristic  features  of  a  lesion  in  this  locality 
are  paralysis  of  arm,  face,  and  leg  of  the  opposite  side,  and  oculo-motor  paral- 
ysis of  the  same  side — the  syndrome  of  Weber.  Sensory  changes  have  also 
been  present.  Haemorrhage  into  the  tegmentum  is  not  necessarily  associated 
with  hemiplegia,  but  there  may  be  incomplete  paralysis  of  the  oculo-motor 
nerve,  with  disturbance  of  sensation  and  ataxia  on  the  opposite  side  of  the 
body.  The  optic  tract  or  the  lateral  geniculate  body  lying  on  the  lateral  side 
of  the  crus  may  be  compressed,  in  which  event  there  will  be  hemianopsia. 

(b)  Pons  and  Medulla. — Lesions  may  involve  the  pyramidal  tract  and  one 
or  more  of  the  cerebral  nerves.  If  at  the  lower  aspect  of  the  pons,  the  facial 
nerve  may  be  involved,  causing  paralysis  of  the  face  on  the  same  side  and 
hemiplegia  on  the  opposite  side.  The  fifth  nerve  may  be  involved,  with  the 
fillet  (the  sensory  tract),  causing  loss  of  sensation  in  the  area  of  distribution 
of  the  fifth  on  the  same  side  as  the  lesion  and  loss  of  sensation  on  the  opposite 
side  of  the  body.  The  sensory  disturbance  here  is  apt  to  be  dissociated,  of 
the  syringomyelic  type,  affecting  particularly  the  sense  of  pain  and  tem- 
perature. 

Sensory  Disturbances  resulting  from  Cerebral  Hcemorrhage. — These  are 
variable.  Hemianaesthesia  may  coexist  with  hemiplegia,  but  in  many  instances 
there  is  only  slight  numbing  of  sensation.  When  the  hemianaesthesia  is 
marked,  it  is  usually  the  result  of  a  lesion  in  the  internal  capsule  involving 
the  retrolenticular  portion  of  the  posterior  limb.  In  C.  L.  Dana's  study  of 
sensory  localization  he  found  that  anaesthesia  of  organic  cortical  origin  was 


974  DISEASES  OF  THE  NERVOUS  SYSTEM. 

always  limited  or  more  pronoimced  in  certain  parts,  as  the  face,  arm,  or  leg, 
and  was  generally  incomplete.  Total  anaesthesia  was  either  of  functional  or 
subcortical  origin.  Marked  ansesthesia  was  much  more  common  in  softening 
than  in  hfemorrhage.  Complete  hemianesthesia  is  certainly  rare  in  hsemor- 
rhage.  Disturbance  of  the  special  senses  is  not  common.  Hemianopia  may 
exist  on  the  same  side  as  the  paralysis,  and  there  may  be  diminution  in 
the  acuteness  of  the  senses  of  hearing,  taste,  and  smell.  Gowers  thinks  that 
homommious  hemianopia  of  the  halves  of  the  visual  fields  opposite  to  the 
lesion  is  very  frequent  shortly  after  the  onset,  though  often  overlooked. 

Psychic  disturbances,  variable  in  nature  and  degree,  may  result  from  cere- 
bral hsemorrhage. 

The  Reflexes  in  Apoplectic  Cases. — During  the  apoplectic  coma  all  the 
reflexes  are  abolished,  but  immediately  on  recovery  of  consciousness  they 
return,  first  on  the  non-hemiplegic  side,  later,  sometimes  only  after  weeks, 
on  the  paralyzed  side.  As  to  the  time  of  return,  especially  of  the  patellar 
reflexes,  marked  differences  are  observable  in  individual  cases.  The  deep 
reflexes  later  are  increased  on  the  paralyzed  side,  and  ankle  clonus  may  be 
present.  Plantar  stimulation  usually  gives  an  extensor  response  in  the  great 
toe  (Babinski's  reflex).  This  may  occur  very  early  and  is  an  important  indi- 
cation of  the  paralyzed  side.  The  other  superficial  reflexes  are  usually  dimin- 
ished.    The  sphincters  are  not  affected. 

The  course  of  the  disease  depends  upon  the  situation  and  extent  of  the 
lesion.  If  slight,  the  hemiplegia  may  disappear  completely  within  a  few  days 
or  a  few  weeks.  In  severe  cases  the  rule  is  that  the  leg  gradually  recovers 
before  the  arm,  and  the  muscles  of  the  shoulder  girdle  and  upper  arm  before 
those  of  the  forearm  and  hand.     The  face  may  recover  quickly. 

Except  in  the  very  slight  lesions,  in  which  the  hemiplegia  is  transient, 
changes  take  place  which  may  be  grouped  as 

SECO]sn)AET  Symptoms. — These  correspond  to  the  chronic  stage.  In  a 
case  in  which  little  or  no  improvement  takes  place  within  eight  or  ten  weeks, 
it  will  be  found  that  the  paralyzed  limbs  undergo  certain  changes.  The  leg, 
as  a  rule,  recovers  enough  power  to  enable  the  patient  to  get  about,  although 
the  foot  is  dragged.  Occasionally  a  recurrence  of  severe  s}Tnptoms  is  seen, 
even  without  a  new  hsemorrhage  having  taken  place.  In  both  arm  and  leg 
the  condition  of  secondary  contraction  or  late  rigidity  comes  on  and  is  always 
most  marked  in  the  upper  extremity.  The  arm  becomes  permanently  flexed 
at  the  elbow  and  resists  all  attempts  at  extension.  The  wrist  is  flexed  upon 
the  forearm  and  the  fingers  upgn  the  hand.  The  position  of  the  arm  and 
hand  is  very  characteristic.  There  is  frequently,  as  the  contractures  develop, 
a  great  deal  of  pain.  In  the  leg  the  contracture  is  rarely  so  extreme.  The 
loss  of  power  is  most  marked  in  the  muscles  of  the  foot,  and  to  prevent  the 
toes  from  dragging,  the  knee  in  walking  is  much  flexed,  or  more  conunonly 
the  foot  is  swung  round  in  a  half-circle. 

The  reflexes  are  at  this  stage  greatly  increased.  These  contractures  are 
permanent  and  incurable,  and  are  associated  with  a  secondary  descending 
sclerosis  of  the  motor  path.  There  are  instances,  however,  in  which  rigidity 
and  contracture  do  not  occur,  but  the  arm  remains  flaccid,  the  leg  having 
regained  its  power.  This  liemiplegie  fasque  of  Bouchard  is  found  most  com- 
monly m  children.     Among  other  secondary  changes  in  late  hemiplegia  may 


DIFFUSE  AND  FOCAL  DISEASES  OF  THE  BRAIN.  975 

be  mentioned  the  following:  Tremor  of  the  affected  limbs,  post-paialytic 
chorea,  the  mobile  spasm  known  as  athetosis,  arthropathies  in  the  joints  of 
the  affected  side,  and  muscular  atrophy.  Athetosis  and  post-hemiplegic  chorea 
will  be  considered  in  the  hemiplegia  of  children.  The  cool  surface  and  thin 
glossy  skin  of  a  hemiplegic  limb  are  familiar  to  all.  A  word  may  here  be 
said  upon  the  subject  of  muscular  atrophy  of  cerebral  origin. 

As  a  rule,  atrophy  is  not  a  marked  feature  in  hemiplegia,  but  in  some 
instances  it  does  develop.  It  has  been  thought  to  be  due  in  some  cases  to 
secondary  alterations  in  the  gray  matter  of  the  ventral  horns,  as  in  a  case 
reported  by  Charcot.  Eecently,  however,  attention  has  been  called  by  Senator, 
Quincke,  and  others  to  the  fact  that  atrophy  may  follov/  as  a  direct  result  of 
the  cerebral  lesion,  the  ventral  horns  remaining  intact.  In  Quincke's  case, 
atrophy  of  the  arm  followed  the  development  of  a  glioma  in  the  anterior  cen- 
tral convolution.  The  gray  matter  of  the  ventral  horns  was  normal.  These 
atrophies  are  most  common  in  cortical  lesions  involving  the  domain  of  the 
third  main  branch  of  the  Sylvian  artery,  and  in  central  lesions  involving  the 
lenticulo-thalamic  region.  Their  explanation  is  not  clear.  The  wasting  of 
cerebral  origin,  which  occurs  most  frequently  in  children,  and  leads  to  hemi- 
atrophy of  the  muscles  along  with  stunted  growth  of  the  bones  and  joints, 
is  to  be  sharply  separated  from  the  hemiatrophy  of  the  muscles  of  the  adult 
following  within  a  relatively  short  time  upon  the  hemiplegia. 

Diagnosis. — There  are  three  groups  of  cases  which  offer  increasing  diffi- 
culty in  recognition. 

(1)  Cases  in  which  the  onset  is  gradual,  a  day  or  two  elapsing  before 
the  paralysis  is  fully  developed  and  consciousness  completely  lost,  are  readily 
recognized,  though  it  may  be  difficult  to  determine  whether  the  lesion  is  due 
to  thrombosis  or  to  haemorrhage. 

(2)  In  the  sudden  apoplectic  stroke  in  which  the  patient  rapidly  loses 
consciousness,  the  difficulty  in  diagnosis  may  be  still  greater,  particularly 
if  the  patient  is  in  deep  coma  when  first  seen. 

The  first  point  to  be  decided  is  the  existence  of  hemiplegia.  This  may 
be  difficult,  although,  as  a  rule,  even  in  deep  coma  the  limbs  on  the  para- 
lyzed side  are  more  flaccid  and  drop  instantly  when  lifted;  whereas,  on  the 
non-paralyzed  side  the  muscles  retain  some  degree  of  tonus.  The  reflexes  may 
be  decreased  or  lost  on  the  affected  side  and  there  may  be  conjugate  devia- 
tion of  the  head  and  eyes.  Eigidity  in  the  limbs  of  one  side  is  in  favor  of  a 
hemiplegic  lesion.  It  is  practically  impossible  in  a  majority  of  these  cases 
to  say  whether  the  lesion  is  due  to  haemorrhage,  embolism,  or  thrombosis. 

(3)  Large  haemorrhage  into  the  ventricles  or  into  the  pons  may  produce 
sudden  loss  of  consciousness  with  complete  relaxation,  so  that  the  condition 
may  simulate  coma  from  uraemia,  diabetes,  alcoholism,  opium  poisoning,  or 
epilepsy. 

The  previous  history  and  the  mode  of  onset  may  give  valuable  information. 
In  epilepsy,  convulsions  have  preceded  the  coma;  in  alcoholism,  there  is  a 
history  of  constant  drinking,  while  in  opium  poisoning  the  coma  develops 
more  gradually;  but  in  many  instances  the  difficulty  is  practically  very  great, 
and  on  more  than  one  occasion  I  have  seen  mortifying  post-mortem  disclosures 
under  these  circumstances.  With  diabetic  coma  the  breath  often  smells  of 
acetone.    In  ventricular  haemorrhage  the  coma  is  sudden  and  develops  rapidly. 


976  DISEASES  OF  THE  NERVOUS  SYSTEM. 

The  hemiplegic  symptoms  may  be  transient,  quickly  giving  place  to  complete 
relaxation.  Convulsions  occur  in  many  cases,  and  may  be  the  very  symptom 
to  lead  astray — as  in  a  case  of  ventricular  hgemorrhage  which  occurred  in  a 
puerperal  patient,  in  whom,  naturally  enough,  the  condition  was  thought  to  be 
ursemic.  Eigidity  is  often  present.  In  haemorrhage  into  the  pons  convulsions 
are  frequent.  The  pupils  may  be  strongly  contracted,  conjugate  deviation  may 
occur,  and  the  temperature  is  apt  to  rise  rapidly.  The  contraction  of  the 
pupils  in  pontine  hsemorrhage  naturally  suggests  opium  poisoning.  The  dif- 
ference in  temperature  in  the  two  conditions  is  a  valuable  diagnostic  point. 
The  apoplectiform  seizures  of  general  paresis  have  usually  been  preceded  by 
abnormal  mental  symptoms,  and  the  associated  hemiplegia  is  seldom  per- 
manent. 

It  may  be  impossible  at  first  to  give  a  definite  diagnosis.  In  admissions 
to  hospitals  or  in  emergency  cases  the  physician  should  be  particularly  careful 
about  the  following  points :  The  examination  of  the  head  for  injury  or  frac- 
ture ;  the  urine  should  be  tested  for  albumin,  examined  for  sugar,  and  studied 
microscopically ;  a  careful  examination  should  be  made  of  the  limbs  with  ref- 
erence to  their  degree  of  relaxation  or  the  presence  of  rigidity,  and  the  con- 
dition of  the  reflexes;  the  state  of  the  pupils  should  be  noted  and  the  tem- 
perature taken.  The  odor  of  the  breath  (alcohol,  acetone,  chloroform,  etc.) 
should  be  remarked.  The  most  serious  mistakes  are  made  in  the  case  of 
patients  who  are  drunk  at  the  time  of  the  attack,  a  combination  by  no  means 
uncommon  in  the  class  of  patients  admitted  to  hospital.  Under  these  circum- 
stances the  case  may  erroneously  be  looked  upon  as  one  of  alcoholic  coma.  It 
is  best  to  regard  each  case  as  serious  and  to  bear  in  mind  that  this  is  a 
■condition  in  which,  above  all  others,  mistakes  are  common. 

Prognosis. — From  cortical  hsemorrhage,  unless  very  extensive,  the  recovery 
may  be  complete  without  a  trace  of  contracture.  This  is  more  common  when 
the  hsemorrhage  follows  injury  than  when  it  results  from  disease  of  the 
arteries.  Infantile  meningeal  hgemorrhage,  on  the  other  hand,  is  a  condition 
which  may  produce  idiocy  or  spastic  diplegia. 

Large  haemorrhages  into  the  corona  radiata,  and  especially  those  which 
rupture  into  the  ventricles,  rapidly  prove  fatal. 

The  hemiplegia  which  follows  lesions  of  the  internal  capsule,  the  result 
of  rupture  of  the  lenticulo-striate  artery,  is  usually  persistent  and  followed 
by  contracture.  When  the  retro-lenticular  fibres  of  the  internal  capsule  are 
involved  there  may  be  hemianaesthesia,  and  later,  especially  if  the  thalamus 
he  implicated,  hemichorea  or  athetosis.  In  any  case  of  cerebral  apoplexy  the 
following  symptoms  are  of  grave  omen:  persistence  or  deepening  of  the  coma 
during  the  second  and  third  day;  rapid  rise  in  temperature  within  the  first 
forty-eight  hours  after  the  initial  fall.  In  the  reaction  which  takes  place  on 
the  second  or  third  day,  the  temperature  usually  rises,  and  its  gradual  fall 
on  the  third  or  fourth  day  with  return  of  consciousness  is  a  favorable  indica- 
tion. The  rapid  formation  of  bed-sores,  particularly  the  malignant  decubitus 
of  Charcot,  is  a  fatal  indication.  The  occurrence  of  albumin  and  sugar,  if 
abundant,  in  the  urine  is  an  unfavorable  symptom. 

When  consciousness  returns  and  the  patient  is  improving,  the  question  is 
anxiously  asked  as  to  the  paralysis.  The  extent  of  this  can  not  be  determined 
for  some  weeks.    With  slight  lesions  it  may  pass  ofi  entirely.    If  persistent  at 


DIFFUSE  AND  FOCAL  DISEASES  OF  THE  BRAIN.  977 

the  end  of  a  month  some  grade  of  permanent  palsy  is  certain  to  remain,  and 
gradually  the  late  rigidity  supervenes. 

5.  Embolism  and  Theombosis   {Cerebral  Softening). 

(a)  Embolism. — The  embolus  usually  enters  the  carotid,  rarely  the  verte- 
bral artery.  In  the  great  majority  of  cases  it  comes  from  the  left  heart  and 
is  either  a  vegetation  of  a  fresh  endocarditis  or,  more  commonly,  of  a  recurring 
endocarditis,  or  from  the  segments  involved  in  an  ulcerative  process.  Less 
often  the  embolus  is  a  portion  of  a  clot  which  has  formed  in  the  auricular 
appendix.  Portions  of  clot  from  an  aneurism,  thrombi  from  atheroma  of  the 
aorta,  or  from  the  territory  of  the  pulmonary  veins,  may  also  cause  blocking 
of  the  branches  of  the  circle  of  Willis.  In  the  puerperal  condition  cerebral 
embolism  is  not  infrequent.  It  may  occur  in  women  with  heart-disease,  but 
in  other  instances  the  heart  is  uninvolved,  and  the  condition  has  been  thought 
to  be  associated  with  the  development  of  heart-clots,  owing  to  increased  coagu- 
lability of  the  blood.  A  majority  of  cases  of  embolism  occur  in  heart-disease, 
89  per  cent  (Saveliew).  Cases  are  rare  in  the  acute  endocarditis  of  rheuma- 
tism, chorea,  and  febrile  conditions.  It  is  much  more  common  in  the  secondary 
recurring  endocarditis  which  attacks  old  sclerotic  valves.  The  embolus  most 
frequently  passes  to  the  left  middle  cerebral  artery,  as  it  enters  the  left  carotid 
oftener  than  the  right  because  of  the  more  direct  course  of  the  blood  in  the 
former.  The  posterior  cerebral  and  the  vertebral  are  less  often  affected.  A 
large  plug  may  lodge  at  the  bifurcation  of  the  basilar.  Embolism  of  the 
cerebellar  vessels  is  rare. 

Embolism  occurs  more  frequently  in  women,  owing,  no  doubt,  to  the  greater 
frequency  of  mitral  stenosis.  Contrary  to  this  general  statement,  I^ewton 
Pitt's  statistics  of  79  cases  at  Guy's  Hospital  indicate,  however,  that  males  are 
more  frequently  affected;  or  in  this  series  there  were  44  males  and  35  females. 
Saveliew  gives  54  per  cent  in  women. 

(&)  Thrombosis. — Clotting  of  blood  in  the  cerebral  vessels  occurs  (1)  about 
an  embolus,  (2)  as  the  result  of  a  lesion  of  the  arterial  wall  (either  endar- 
teritis with  or  without  atheroma  or,  particularly,  the  syphilitic  arteritis),  (3) 
in  aneurisms  both  coarse  and  miliary,  and  (4)  very  rarely  as  a  direct  result 
of  abnormal  conditions  of  the  blood.  Thrombosis  occasionally  follows  ligation 
of  the  carotid  artery.  The  thrombosis  is  most  common  in  the  middle  cerebral 
and  in  the  basilar  arteries.  According  to  Kolisko,  softening  of  limited  areas, 
sufficient  to  induce  hemiplegia,  may  be  caused  by  sudden  collapse  of  certain 
cerebral  arteries  from  cardiac  weakness. 

Anatomical  Changes. — Degeneration  and  softening  of  the  territory  sup- 
plied by  the  vessels  is  the  ultimate  result  in  both  embolism  and  thrombosis. 
Blocking  in  a  terminal  artery  may  be  followed  by  infarction,  in  which  the 
territory  may  either  be  deeply  infiltrated  with  blood  (hgemorrhagic  infarction) 
or  be  simply  pale,  swollen,  and  necrotic  (anaemic  infarction).  Gradually  the 
process  of  softening  proceeds,  the  tissue  is  infiltrated  with  serum  and  is  moist, 
the  nerve  fibres  degenerate  and  become  fatty.  The  neuroglia  is  swollen  and 
cedematous.  The  color  of  the  softened  area  depends  upon  the  amount  of  blood. 
The  haemoglobin  undergoes  gradual  transformation,  and  the  early  red  color 
may  give  place  to  yellow.  Formerly  much  stress  was  laid  upon  the  difference 
63 


978  DISEASES  OF  THE  NERVOUS  SYSTEM. 

between  red,  yellow,  and  white  softening.  The  red  and  yellow  are  seen  chiefly 
on  the  cortex.  Sometimes  the  red  softening  is  particularly  marked  in  cases 
of  embolism  and  in  the  neighborhood  of  tumors.  The  gray  matter  shows  many 
punctiform  haemorrhages — capillary  apoplexy.  There  is  a  variety  of  yellow 
softening — the  plaques  jaunes — common  in  elderly  persons,  which  occurs  in 
the  gray  matter  of  the  convolutions.  The  spots  are  from  1  to  2  cm.  in  diam- 
eter, sometimes  are  angular  in  shape,  the  edges  cleanly  cut,  and  the  softened 
area  is  represented  by  either  a  turbid,  yellow  material,  or  in  some  instances 
there  is  a  space  crossed  by  fine  trabecule,  in  the  meshes  of  which  there  is  fluid. 
White  softening  occurs  most  frequently  in  the  white  matter,  and  is  seen  best 
about  tumors  and  abscesses.  Inflammatory  changes  are  common  in  and  about 
the  softened  areas.  When  the  embolus  is  derived  from  an  infected  focus,  as 
in  ulcerative  endocarditis,  suppuration  may  follow.  The  final  changes  vary 
very  much.  The  degenerated  and  dead  tissue  elements  are  gradually  but  slowly 
removed,  and  if  the  region  is  small  may  be  replaced  by  a  growth  of  connective 
tissue  and  the  formation  of  a  scar.  If  large,  the  resorption  results  in  the 
formation  of  a  cyst.  It  is  surprising  for  how  long  an  area  of  softening  may 
persist  without  much  change. 

The  position  and  extent  of  the  softening  depend  upon  the  obstructed  artery. 
An  embolus  which  blocks  the  middle  cerebral  at  its  origin  involves  not  only 
the  arteries  to  the  anterior  perforated  space,  but  also  the  cortical  branches,  and 
in  such  a  case  there  is  softening  in  the  neighborhood  of  the  corpus  striatum, 
as  well  as  in  part  of  the  region  supplied  by  the  cortical  vessels.  The  freedom 
of  anastomosis  between  these  branches  varies  a  good  deal.  Thus,  there  are 
instances  of  embolism  of  the  middle  cerebral  artery  in  which  the  softening 
has  involved  only  the  territory  of  the  central  branches,  in  which  case  blood  has 
reached  the  cortex  through  the  anterior  and  posterior  cerebrals.  When  the 
middle  cerebral  is  blocked  (as  is  perhaps  oftenest  the  case)  beyond  the  point 
of  origin  of  the  central  arteries,  one  or  other  of  its  branches  is  usually  most 
involved.  The  embolus  may  lodge  in  the  vessel  passing  to  the  third  frontal 
convolution,  or  in  the  artery  of  the  ascending  frontal  or  ascending  parietal; 
or  it  may  lodge  in  the  branch  passing  to  the  supramarginal  and  angular  gyri, 
or  it  may  enter  the  lowest  branch  which  is  distributed  to  the  upper  convolu- 
tions of  the  temporal  lobe.  These  are  practically  terminal  arteries,  and  in- 
stances frequently  occur  of  softening  limited  to  a  part,  at  any  rate,  of  the 
territory  supplied  by  them.  Some  of  the  most  accurate  focalizing  lesions  are 
produced  in  this  way. 

Symptoms. — Extensive  thrombotic  softening  may  exist  without  any  sjrmp- 
toms.  It  is  not  uncommon  in  the  post-mortem  examination  of  the  bodies  of 
elderly  persons  to  find  the  plaques  jaunes  scattered  over  the  convolutions.  So, 
too,  softening  may  take  place  in  the  "  silent "  regions,  as  they  are  termed, 
without  exciting  any  s3rmptoms.  When  the  central  or  cortical  branches  of  the 
middle  cerebral  arteries  are  involved  the  symptoms  are  similar  to  those  of 
haemorrhage  from  the  same  arteries.  Permanent  or  transient  hemiplegia  re- 
sults. When  the  central  arteries  are  involved  the  softening  in  the  internal 
capsule  is  commonly  followed  by  permanent  hemiplegia.  There  are  certain 
peculiarities  associated  with  embolism  and  with  thrombosis  respectively. 

In  emholism  the  patient  is  usually  the  subject  of  heart-trouble,  or  there 
exist  some  of  the  conditions  already  mentioned.    The  onset  is  sudden,  without 


DIFFUSE  AND  FOCAL  DISEASES  OF  THE  BRAIN.  979 

premonitory  symptoms.  When  the  embolus  blocks  the  left  middle  cerebral 
artery  the  hemiplegia  is  usually  associated  with  aphasia.  In  thrombosis,  on 
the  other  hand,  the  onset  is  more  gradual;  the  patient  has  previously  com- 
plained of  headache,  vertigo,  tingling  in  the  j&ngers ;  the  speech  may  have  been 
embarrassed  for  some  days;  the  patient  has  had  loss  of  memory  or  is  inco- 
herent, or  paralysis  begins  at  one  part,  as  the  hand,  and  extends  slowly,  and 
the  hemiplegia  may  be  incomplete  or  variable.  Abrupt  loss  of  consciousness 
is  much  less  common,  and  when  the  lesion  is  small  consciousness  is  retained. 
Thus,  in  thrombosis  due  to  syphilitic  disease,  the  hemiplegia  may  come  on 
gradually  without  the  slightest  disturbance  of  consciousness. 

The  hemiplegia  following  thrombosis  or  embolism  has  practically  the  char- 
acteristics, both  primary  and  secondary,  described  under  haemorrhage. 

The  following  may  be  the  effects  of  blocking  the  different  vessels:  (a) 
Vertebral. — The  left  branch  is  more  frequently  plugged.  The  effects  are  in- 
volvement of  the  nuclei  in  the  medulla  and  symptoms  of  acute  bulbar  paralysis. 
It  rarely  occurs  alone ;  more  commonly  with 

(&)  Blocking  of  the  basilar  artery.  When  this- is  entirely  occluded,  there 
may  be  bilateral  paralysis  from  involvement  of  both  motor  paths.  Bulbar 
symptoms  may  be  present;  rigidity  or  spasm  may  occur.  The  temperature 
may  rise  rapidly.    The  symptoms,  in  fact,  are  those  of  apoplexy  of  the  pons. 

(c)  The  posterior  cerebral  supplies  the  occipital  lobe  on  its  medial  surface 
and  the  greater  part  of  the  temporo-sphenoidal  lobe.  If  the  main  stem  be 
thrombosed  there  is  hemianopia  with  sensory  aphasia.  Localized  areas  of 
softening  may  exist  without  symptoms.  Blocking  of  the  main  occipital  branch 
(arteria  occipitalis  of  Duret),  or  of  the  arteria  calcarina,  passing  to  the  cuneus 
may  be  followed  by  hemianopia.  Hemiansesthesia  may  result  from  involve- 
ment of  the  posterior  part  of  the  internal  capsule.  Not  infrequently  symmet- 
rical thrombosis  of  the  occipital  arteries  of  the  two  sides  occurs,  as  in  Forster's 
well-known  case.  Still  more  frequent  is  the  occurrence  of  thrombosis  of  a 
branch  of  the  posterior  cerebral  of  one  hemisphere  and  a  branch  of  the  middle 
cerebral  of  the  other  (von  Monakow).  It  is  in  such  cases  that  the  most 
pronounced  instances  of  apraxia  are  met  with. 

(d)  Internal  Carotid. — The  symptoms  are  variable.  As  is  well  known,  the 
vessel  is  in  a  majority  of  cases  ligated  without  risk.  In  other  instances  tran- 
sient hemiplegia  follows ;  in  others  again  the  hemiplegia  is  permanent.  These 
variations  depend  on  the  anastomoses  in  the  circle  of  Willis.  If  these  are 
large  and  free,  no  paralysis  follows,  but  in  cases  in  which  the  posterior  com- 
municating and  the  anterior  communicating  vessels  are  small  or  absent,  the 
paralysis  may  persist.  In  No.  7  of  my  Elwyn  series  of  cases  of  infantile  hemi- 
plegia, the  woman,  aged  twenty-four,  when  six  years  old,  had  the  right  carotid 
ligated  for  abscess  following  scarlet  fever,  with  the  result  of  permanent  hemi- 
plegia. Blocking  of  the  internal  carotid  within  the  skull  by  thrombosis  or 
embolism  is  followed  by  hemiplegia,  coma,  and  usually  death.  The  clot  is 
rarely  confined  to  the  carotid  itself,  but  spreads  into  its  branches  and  may 
involve  the  ophthalmic  artery. 

(e)  Middle  Cerebral. — This  is  the  vessel  most  commonly  involved,  and,  as 
already  mentioned,  if  plugged  before  the  central  arteries  are  given  off,  perma- 
nent hemiplegia  usually  follows  from  softening  of  the  internal  capsule.  Block- 
ing of  the  branches  beyond  this  point  may  be  followed  by  hemiplegia,  which 


980  DISEASES  OF   THE  NERVOUS  SYSTEM. 

is  more  likel}'  to  be  transient,  involves  chiefly  tlie  arm  and  face,  and  if  the 
lesion  be  on  the  left  side  is  associated  with  aphasia.  There  ma}^  be  plugging 
of  the  individual  branches  passing  to  the  inferior  frontal  (producing  typical 
motor  aphasia  if  the  disease  be  on  the  left  side),  to  the  anterior  and  posterior 
central  gyri  (usually  causing  total  hemiplegia),  to  the  supramarginal  and 
angular  gyri  (giving  rise,  if  the  thrombosis  be  on  the  left  side,  probably  with- 
out exception  to  the  so-called  visual  aphasia  (alexia),  usually  also  to  right- 
sided  hemianopsia),  or  to  the  temporal  gyri  (in  which  event  with  left-sided 
thrombosis  word-deafness  results). 

(/)  Anterior  Cerebral. — Xo  symptoms  may  follow,  and  even  when  the 
branches  which  supply  the  paracentral  lobule  and  the  top  of  the  ascending 
convolutions  are  plugged  the  branches  from  the  middle  cerebral  are  usually 
able  to  effect  a  collateral  circulation  in  these  parts.  Monoplegia  of  the  leg 
may,  however,  result.  Hebetude  and  dulness  of  intellect  may  occur  with 
obstruction  of  the  vessel. 

There  is  unquestionably  greater  freedom  of  communication  in  the  cortical 
branches  of  the  different  arteries  than  is  usually  admitted,  although  it  is  not 
possible,  for  example,  to  inject  the  posterior  cerebral  through  the  middle  cere- 
bral, or  the  middle  cerebral  from  the  anterior;  but  the  absence  of  softening 
in  some  instances  in  which  smaller  branches  are  blocked  shows  how  complete 
may  be  the  compensation,  probably  by  way  of  the  capillaries.  The  dilatation 
of  the  collateral  branches  may  take  place  very  rapidly;  thus  a  patient  with 
chronic  nephritis  died  about  twenty-four  hours  after  the  hemiplegic  attack. 
There  were  recent  vegetations  on  the  mitral  valve  and  an  embolus  in  the  right 
middle  cerebral  artery  just  beyond  the  first  two  branches.  The  central  portion 
of  the  hemisphere  was  swollen  and  oedematous.  The  right  anterior  cerebral 
was  greatly  dilated,  and  by  measurement  its  diameter  was  found  to  be  nearly 
three  times  that  of  the  left. 

Treatment  of  Cerebral  Haemorrhage  and  of  Softening. — The  chief  difficulty 
in  deciding  upon  a  method  of  treatment  is  to  determine  whether  the  apoplexy 
is  due  to  hsemorrhage  or  to  thrombosis  "or  embolism.  The  patient  should  be 
placed  in  bed,  with  his  head  moderately  elevated  and  the  neck  free.  He  should 
be  kept  absolutely  quiet.  If  there  is  dj^spncea,  stertor,  and  signs  of  mechanical 
obstruction  to  respiration,  he  should  be  turned  on  his  side,  as  recommended 
by  Bowles.  This  procedure  also  lessens  the  liability  to  congestion  of  the  lungs. 
If  the  signs  of  intracranial  haemorrhage  are  certain,  and  if  the  arterial  tension 
is  high,  measures  may  be  taken  for  its  reduction.  Of  these  the  most  rapid 
and  satisfactory  is  venesection,  which  in  many  cases  seems  to  do  good.  How- 
ever, as  Gushing  has  shown  exj)erimentally,  a  rapid  and  increasing  rise  of 
arterial  tension,  usually  indicates  an  endeavor  of  the  vasomotor  centres  to 
counteract  an  increasing  intracranial  pressure,  in  this  case  due  to  a  continuing 
hsemorrhage.  The  indication  under  these  circumstances  is  the  relief  of  the 
intracranial  pressure  by  craniotomy  and  removal  of  the  clot,  if  this  is  possible. 
This  is  particularly  applicable  in  subdural  haemorrhage.  Horsley  and  Spencer 
have  recently,  on  experimental  grounds,  recommended  the  practice,  formerly 
employed  empirically,  of  compression  of  the  carotid,  particularly  in  the  in- 
gravescent form ;  or  even,  in  suitable  cases,  passing  a  ligature  round  the  vessel. 
An  ice-bag  may  be  placed  on  the  head  and  hot  bottles  to  the  feet.  The  bowels 
should  be  freely  opened,  either  by  calomel,  or  croton  oil  placed  on  the  tongue. 


DIFFUSE  AND  FOCAL  DISEASES  OF  THE  BRAIN.  981 

Counter-irritation  to  the  neck  or  to  the  feet  is  not  necessary.  Catheterization 
of  the  bladder  may  be  necessary,  especially  if  the  patient  remain  long  uncon- 
scious. 

Special  care  should  be  taken  to  avoid  bed-sores;  and  if  bottles  are  used 
to  the  feet,  they  should  not  be  too  hot,  since  blisters  may  be  readily  caused 
by  a  much  lower  temperature  than  in  health.  In  the  fever  of  reaction,  aconite 
may  be  indicated,  but  should  be  cautiously  used.  Stimulants  are  not  necessary, 
unless  the  pulse  becomes  feeble  and  signs  of  collapse  supervene.  No  digitalis 
is  to  be  given.  During  recovery  the  patient  should  be  still  kept  entirely  at  rest, 
even  in  the  mildest  cases  remaining  in  bed  for  at  least  fourteen  days.  The 
ice-bag  should  still  be  kept  at  the  head.  The  diet  should  be  light  and  no 
medicine  other  than  some  placebo  should  be  administered,  at  least  during  the 
first  month  after  the  haemorrhage.  Attention  should  be  paid  to  the  position 
occupied  by  the  paralyzed  limb  or  limbs,  which  if  swollen  may  be  wrapped  in 
cotton  batting  or  flannel. 

The  treatment  of  softening  from  thrombosis  or  embolism  is  very  unsatis- 
factory. Venesection  is  not  indicated,  as  it  lowers  the  tension  and  rather 
promotes  clotting.  If,  as  is  often  the  case,  the  heart's  action  is  feeble  and 
irregular,  stimulants  and  small  doses  of  digitalis  may  be  given  with,  if  neces- 
sary, ether  or  ammonia.  The  bowels  should  be  kept  open,  but  it  is  not  well 
to  purge  actively,  as  in  haemorrhage. 

In  the  thrombosis  which  follows  syphilitic  disease  of  the  arteries,  and  which 
is  met  with  most  frequently  in  men  between  twenty  and  forty  (in  whom'  the 
hemiplegia  often  sets  in  without  loss  of  consciousness),  the  iodide  of  potassium 
should  be  freely  used,  giving  from  20  to  30  grains  three  times  a  day,  or,  if 
necessary,  larger  doses.  If  the  syphilis  has  been  recent,  mercurials  by  inunc- 
tion are  also  indicated.  Practically  these  are  the  only  cases  of  hemiplegia  in 
which  we  see  satisfactory  results  from  treatment. 

Very  little  can  be  done  for  the  hemiplegia  which  remains.  The  damage 
is  too  often  irreparable  and  permanent,  and  it  is  very  improbable  that  iodide 
of  potassium,  or  any  other  remedy,  hastens  in  the  slightest  degree  ISTature's 
dealing  with  the  blood-clot. 

The  paralyzed  limbs  may  be  gently  rubbed  once  or  twice  a  day,  and  this 
should  be  systematically  carried  out,  in  order  to  maintain  the  nutrition  of  the 
muscles  and  to  prevent,  if  possible,  contractures.  The  massage  should  not, 
however,  be  begun  until  at  least  ten  days  after  the  attack.  The  rubbing  should 
be  toward  the  body,  and  should  not  be  continued  for  more  than  fifteen  minutes 
at  a  time.  After  the  lapse  of  a  fortnight,  or  in  severe  cases  a  month,  the  mus- 
cles may  be  stimulated  by  the  f aradic  current ;  f  aradic  stimulation  alternating 
with  massage,  especially  if  applied  to  the  antagonists  of  the  muscles  which 
ordinarily  undergo  contracture,  is  of  very  great  service,  even  in  cases  where 
there  can  be  but  little  hope  of  any  return  of  voluntary  movement.  'V\nien  con- 
tractures occur,  electricity  properly  applied  at  intervals  may  still  be  of  some 
benefit  along  with  the  passive  movements  and  frictions,  and  it  has  been  sug- 
gested that  tendon  transplantation,  or  indeed  cross  suture  of  nerves,  may  cause 
some  improvement. 

In  a  case  of  complete  hemiplegia,  the  friends  should  at  the  outset  be 
frankly  told  that  the  chances  of  full  recovery  are  slight..  Power  is  usually  re- 
stored in  the  leg  sufficient  to  enable  the  patient  to  get  about,  but  in  the  major- 


982  DISEASES  OF  THE  NERVOUS  SYSTEAI. 

ity  of  instances  the  finer  movements  of  the  liand  are  permanently  lost.  The 
general  health  should  be  looked  after,  the  bowels  regulated,  and  the  secretions 
of  the  skin  and  kidne3^s  kept  active.  In  permanent  hemiplegia  in  persons 
above  the  middle  period  of  life,  more  or  less  mental  weakness  is  apt  to  follow 
the  attack,  and  the  patient  may  become  irritable  and  emotional. 

And,  lastly,  when  hemiplegia  has  persisted  for  more  than  three  months  and 
contractures  have  developed,  it  is  the  duty  of  the  physician  to  explain  to  the 
patient,  or  to  his  friends,  that  the  condition  is  past  relief,  that  medicines  and 
electricity  will  do  no  good,  and  that  there  is  no  possible  hope  of  cure. 

6.    AXEUEISM    OF    THE    CeEEBEAL   AeTEEIES. 

Miliary  aneurisms  are  not  included,  but  reference  is  made  only  to  aneurism 
of  the  larger  branches.  The  condition  is  not  uncommon.  There  were  13 
instances  in  my  first  800  autopsies  in  Montreal.*  This  is  a  considerably  larger 
proportion  than  in  Newton  Pitt's  collection  from  Guy's  Hospital,  19  times  in 
9,000  inspections. 

Etiology. — Males  are  more  frequently  affected  than  females.  Of  my  12 
cases  7  were  males.  The  disease  is  most  common  at  the  middle  period  of  life. 
One  of  my  cases  was  a  lad  of  six.  Pitt  describes  one  at  the  same  age.  The 
chief  causes  are  (a)  endarteritis,  either  simple  or  syphilitic,  which  leads  to 
weakness  of  the  wall  and  dilatation;  and  (5)  embolism.  As  pointed  out  by 
Church,  these  aneurisms  are  often  found  with  endocarditis.  Pitt,  in  his  recent 
study  of  the  subject,  concludes  that  it  is  exceptional  to  find  cerebral  aneurism 
unassociated  with  fungating  endocarditis.  The  embolus  disappears,  and  dila- 
tation follows  the  secondary  inflammatory  changes  in  the  coats  of  the  vessel. 

Morbid  Anatomy. — The  middle  cerebral  branches  are  most  frequently  in- 
volved. In  my  12  cases  the  distribution  on  the  arteries  was  as  follows :  Inter- 
nal carotid,  1 ;  middle  cerebral,  5 ;  basilar,  3 ;  anterior  communicating,  3.  Ex- 
cept in  one  case  they  were  saccular  and  communicated  with  the  lumen  of  the 
vessel  by  an  orifice  smaller  than  the  circumference  of  the  sac.  In  the  154 
cases  which  make  up  the  statistics  of  Lebert,  Durand,  and  Bartholow  the  mid- 
dle cerebral  was  involved  in  44,  the  basilar  in  41,  internal  carotid  in  23,  ante- 
rior cerebral  in  14,  posterior  communicating  in  8,  anterior  communicating  in  8, 
vertebral  in  7,  posterior  cerebral  in  6,  inferior  cerebellar  in  3  (Gowers).  The 
size  of  the  aneurism  varies  from  that  of  a  pea  to  that  of  a  walnut.  The  haem- 
orrhage may  be  entirely  meningeal  with  very  slight  laceration  of  the  brain 
substance,  but  the  bleeding  may  be,  as  Coats  has  shown,  entirely  within  the 
substance. 

Symptoms. — The  aneurism  may  attain  considerable  size  and  cause  no 
symptoms.  In  a  majority  of  the  cases  the  first  intimation  is  the  rupture  and 
the  fatal  apoplexy.  Distinct  symptoms  are  most  frequently  caused  by  aneu- 
rism of  the  internal  carotid,  which  may  compress  the  optic  nerve  or  the  com- 
missure, causing  neuritis  or  paralysis  of  the  third  nerve.  A  murmur  may  be 
audible  on  auscultation  of  the  skull.  x\neurism  in  this  situation  may  give  rise 
to  irritative  and  pressure  symptoms  at  the  base  of  the  brain  or  to  hemianopsia. 
In  the  remarkable  case  reported  by  Weir  Mitchell  and  Dercum  an  aneurism 
compressed  the  chiasma  and  produced  bilateral  temporal  hemianopsia. 

*  Canada  Medical  and  Surgical  Journal,  vol.  xiv. 


DIFFUSE  AND  FOCAL  DISEASES  OF   THE  BRAIN.  983 

Aneurism  of  the  vertebral  or  of  the  basilar  may  involve  the  nerves  from 
the  fifth  to  the  twelfth.  A  large  sac  at  the  termination  of  the  basilar  may- 
compress  the  third  nerves  or  the  crura. 

The  diagnosis  is,  as  a  rule,  impossible.  The  larger  sacs  produce  the  symp- 
toms of  tumor,  and  their  rupture  is  usually  fatal. 

7.  Endarteritis. 

In  no  group  of  vessels  do  we  more  frequently  see  chronic  degenerative 
changes  than  in  those  of  the  circle  of  Willis.     The  condition  occurs  as : 

(a)  Arterio-sclerosis,  producing  localized  or  diffused  thickening  of  the 
intima  with  the  formation  of  atheromatous  patches  or  areas  of  calcification. 
In  the  later  stages,  as  seen  in  elderly  people,  the  arteries  of  the  circle  of  Willis 
may  be  dilated,  stiff,  or  almost  universally  calcified. 

(h)  Syphilitic  Endarteritis. — As  already  mentioned  under  the  section  of 
syphilis,  gummatous  endarteritis  is  specially  prone  to  attack  the  cerebral  ves- 
sels. It  has  in  itself  no  specific  characters — that  is  to  say,  it  is  impossible  in 
given  sections  to  pick  out  an  endarteritis  syphilitica  from  an  ordinary  endar- 
teritis obliterans.  On  the  other  hand,  as  already  stated,  the  nodular  peri- 
arteritis is  never  seen  except  in  syphilis. 

8.  Thrombosis  of  the  Cerebral  Sinuses  and  Veins. 

The  condition  may  be  primary  or  secondary.  Lebert  (1854)  and  Tonnele 
were  among  the  first  to  recognize  the  condition  clinically. 

Primary  thrombosis  of  the  sinuses  and  veins  is  rare.  It  occurs  (a)  in 
children,  particularly  during  the  first  six  months  of  life,  usually  in  connec- 
tion with  diarrhcea.  It  has,  in  my  experience,  been  a  rare  condition.  I  have 
never  seen  an  example  of  spontaneous  thrombosis  of  the  sinuses  in  a  child, 
and  only  two  instances,  both  in  connection  with  meningitis,  in  which  the  cor- 
tical veins  contained  clots.  Gowers  believes  that  it  is  of  frequent  occurrence, 
and  that  thrombosis  of  the  veins  is  not  an  uncommon  cause  of  infantile  hemi- 
plegia. 

(h)  In  connection  with  chlorosis  and  ansemia,  the  so-called  autochthonous 
sinus-throm,hosis.  Of  83  cases  of  thrombosis  in  chlorosis,  78  were  in  the  veins 
and  33  in  the  cerebral  sinuses.  The  longitudinal  sinus  is  most  frequently 
involved.  The  thrombosis  is  usually  associated  with  venous  thromboses  in 
other  parts  of  the  body,  and  the  patients  die,  as  a  rule,  in  from  one  to  three 
weeks,  but  both  Bristowe  and  Buzzard  report  recoveries. 

(c)  In  the  terminal  stages  of  cancer,  phthisis,  and  other  chronic  diseases 
thrombosis  may  gradually  occur  in  the  sinuses  and  cortical  veins.  To  the 
coagulum  developing  in  these  conditions  the  term  marantic  thrombus  is 
applied. 

Secondary  thrombosis  is  much  more  frequent  and  follows  extension  of 
infiammation  from  contiguous  parts  to  the  sinus  wall.  The  common  causes 
are  disease  of  the  internal  ear,  fracture,  compression  of  the  sinuses  by  tumor, 
or  suppurative  disease  outside  the  skull,  particularly  erysipelas,  carbuncle,  and 
parotitis.  In  secondary  cases  the  lateral  sinus  is  most  frequently  involved. 
Of  57  fatal  cases  in  which  ear-disease  caused  death  with  cerebral  lesions,  there 
were  33  in  which  thrombosis  existed  in  the  lateral  sinuses  (Pitt).     Tubercu- 


984  DISEASES  OF   THE  NERVOUS  SYSTEM. 

Ions  caries  of  the  temporal  bone  is  often  directly  responsible.  The  thrombus 
ma}^  be  small,  or  may  fill  the  entire  sinus  and  extend  into  the  internal  jugular 
vein.  In  more  than  one-half  of  these  instances  the  thrombus  was  suppurat- 
ing. The  disease  spreads  directly  from  the  necrosis  on  the  posterior  wall  of 
the  tjonpanum.  According  to  Yoltolini,  the  inflammation  extends  by  way  of 
the  petroso-mastoid  canal.  It  is  not  so  common  in  disease  of  the  mastoid 
cells. 

Symptoms. — Primary  tJiromhosis  of  the  longitudinal  sinus  may  occur  with- 
out exciting  sjonptoms  and  is  found  accidentall}^  at  the  post  mortem.  There 
may  be  mental  dulness  with  headache.  Convulsions  and  vomiting  may  occur. 
In  other  instances  there  is  nothing  distinctive.  In  a  patient  who  died  under 
my  care,  at  the  Philadelphia  Hospital,  of  phthisis,  there  was  a  gradual  tor- 
por, deepening  to  coma,  without  convulsions,  localizing  symptoms,  or  optic 
neuritis.  The  condition  was  thought  to  be  due  to  a  terminal  meningitis.  In 
the  chlorosis  eases  the  head  symptoms  have,  as  a  rule,  been  marked.  Ball's 
patient  was  dull  and  stupid,  had  vomiting,  dilatation  of  the  pupils,  and  double 
choked  disks.  Slight  paresis  of  the  left  side  occurred.  An  interesting  feature 
in  this  case  was  the  development  of  swelling  of  the  left  leg.  In  the  cases 
reported  by  Andrews,  Church,  Tuckwell,  Isambard  Owen,  and  Wilks  the 
patients  had  headache,  vomiting,  and  delirium.  Paralysis  was  not  present. 
In  Douglas  Powell's  case,  with  similar  symptoms,  there  was  loss  of  power  on 
the  left  side.  Bristowe  reports  a  case  of  great  interest  in  an  ansmic  girl  of 
nineteen,  who  had  convulsions,  drowsiness,  and  vomiting.  Tenderness  and 
swelling  developed  in  the  position  of  the  right  internal  jugular  vein,  and  a 
few  days  later  on  the  opposite  side.  The  diagnosis  was  rendered  definite  by 
the  occurrence  of  phlebitis  in  the  veins  of  the  right  leg.    The  patient  recovered. 

The  onset  of  such  symptoms  as  have  been  mentioned  in  an  anaemic  or 
chlorotic  girl  should  lead  to  the  suspicion  of  cerebral  thrombosis.  In  infants 
the  diagnosis  can  rarely  be  made.  Involvement  of  the  cavernous  sinus  may 
cause  oedema  about  the  eyelids  or  prominence  of  the  eyes. 

In  the  secondary  tliromhi  the  S3miptoms  are  commonly  those  of  septi- 
cgemia.  Por  instance,  in  over  70  per  cent  of  Pitt's  cases  the  mode  of  death 
was  by  pulmonary  pysemia.  Tliis  author  draws  the  following  important  con- 
elusions:  (1)  The  disease  spreads  oftener  from  the  posterior  wall  of  the 
middle  ear  than  from  the  mastoid  cells.  (2)  The  otorrhoea  is  generally  of 
some  standing,  but  not  always.  (3)  The  onset  is  sudden,  the  chief  symp- 
toms being  pyrexia,  rigors,  pains  in  the  occipital  region  and  in  the  neck, 
associated  with  a  septicemic  condition.  (4)  Well-marked  optic  neuritis  may 
be  present.  (5)  The  appearance  of  acute  local  pulmonary  mischief  or  of 
distant  suppuration  is  almost  conclusive  of  thrombosis.  (6)  The  average 
duration  is  about  three  weeks,  and  death  is  generally  from  pulmonary  pysemia. 
The  chief  points  in  the  diagnosis  may  be  gathered  from  these  statements. 

Pitt  records  an  interesting  case  of  recovery  in  a  boy  of  ten,  who  had  otor- 
rhoea for  3"ears  and  was  admitted  with  fever,  earache,  tenderness,  and  oedema. 
A  week  later  he  had  a  rigor,  and  optic  neuritis  developed  on  the  right  side. 
The  mastoid  was  explored  unsuccessfully.  The  fever  and  cllills  persisting, 
two  days  later  the  lateral  sinus  was  explored.  A  mass  of  foul  clot  was  re- 
moved and  the  jugular  vein  was  tied,  after  which  the  boy  made  a  satisfactory 
recovery. 


1 


DIFFUSE  AND  FOCAL  DISEASES  OF.  THE  BRAIN.  985 

According  to  Griesingor  there  is  often  associated  with  throinl)osis  of  the 
lateral  sinus  venous  stasis  and  painful  oedema  behind  the  ear  and  in  the  neck. 
The  external  jugular  vein  on  the  diseased  side  may  be  less  distended  than  on 
the  opposite  side,  since  owing  to  the  thrombus  in  the  lateral  sinus  the  internal 
jugular  vein  is  less  full  than  on  the  normal  side,  and  the  blood  from  the  exter- 
nal jugular  can  flow  more  easily  into  it  (Gerhardt) . 

Treatment. — In  marantic  individuals  roborants  and  stimulants  are  indi- 
cated. The  position  assumed  in  bed  should  favor  both  the  arterial  and  venous 
circulation.  The  clothing  should  not  restrict  the  neck,  and  care  should  be 
taken  to  avoid  bending  of  the  neck. 

The  internal  administration  of  potassium  iodide  and  calomel  has  been 
recommended  in  the  autochthonous  forms,  but  no  treatment  is  likely  to  be 
of  any  avail. 

The  secondary  forms,  especially  those  following  upon  disease  of  the  middle 
ear,  are  often  amenable  to  operation,  and,  especially  recently,  many  lives  have 
been  saved  by  surgical  intervention  after  extensive  sinus  thrombosis.  Mac- 
ewen's  book  on  Pyogenic  Infective  Diseases  of  the  Brain  and  Spinal  Cord 
contains  the  most  exhaustive  presentation  of  the  subject  of  sinus  thrombosis 
and  its  treatment. 

9.  Hemiplegia  in  Childeen. 

Etiology. — Of  135  cases,  60  were  in  boys  and  75  in  girls.  Eight  hemi- 
plegia occurred  in  79,  left  in  56.  In  15  cases  the  condition  was  said  to  be 
congenital. 

In  a  great  majority  the  disease  sets  in  during  the  first  or  second  year; 
thus  of  the  total  number  of  cases,  95  were  under  two.  Cases  above  the  fifth 
year  are  rare,  only  10  in  my  series.  Neither  alcoholism  nor  syphilis  in  the 
parents  appears  to  play  an  important  role  in  this  affection.  Difficult  or  abnor- 
mal labor  is  responsible  for  certain  of  the  cases,  particularly  injury  with  the 
forceps.  Trauma,  such  as  falls  or  puncturing  wounds,  is  more  rare.  The 
condition  followed  ligation  of  the  common  carotid  in  one  case. 

Infectious  diseases.  All  the  authors  lay  special  stress  upon  this  factor.  In 
19  cases  in  my  series  the  disease  came  on  during  or  just  after  one  of  the  spe- 
cific fevers.  I  saw  one  case  in  which  during  the  height  of  vaccination  con- 
vulsions developed,  followed  by  hemiplegia.  In  a  great  majority  of  the  cases 
the  disease  sets  in  with  a  convulsion,  in  which  the  child  may  remain  for  sev- 
eral hours  or  longer,  and  after  recovery  the  paralysis  is  noticed. 

Morbid  Anatomy. — In  an  analysis  which  I  have  made  of  90  autopsies 
reported  in  the  literature,  the  lesions  may  be  grouped  under  three  headings : 

(a)  Embolism,  thrombosis,  and  haemorrhage,  comprising  16  cases,  in  7  of 
which  there  was  blocking  of  a  Sylvian  artery,  and  in  9  haemorrhage.  A  strik- 
ing feature  in  this  group  is  the  advanced  age  of  onset.  Ten  of  the  cases 
occurred  in  children  over  six  years  old. 

(&)  Atrophy  and  sclerosis,  comprising  50  cases.  The  wasting  is  either  of 
groups  of  convolutions,  an  entire  lobe,  or  the  whole  hemisphere.  The  meninges 
are  usually  closely  adherent  over  the  affected  region,  though  sometimes  they 
look  normal.  The  convolutions  are  atrophied,  firm,  and  hard,  contrasting 
strongly  with  the  normal  gyri.  The  sclerosis  may  be  diffuse  and  wide-spread 
over  a  hemisphere,  or  there  may  be  nodular  projections — the  hypertrophic  scle- 
64 


986  DISEASES  OF   THE  NERVOUS  SYSTEM. 

rosis.  Some  of  the  cases  show  remarkable  unilateral  atrophy  of  the  hemi- 
sphere. In  one  of  my  cases  the  atrophied  hemisphere  weighed  169  grammes 
and  the  normal  one  653  grammes.  The  brain  tissue  may  be  a  mere  shell  over 
a  dilated  ventricle. 

(c)  PorencejDhalus,  which  was  present  in  2i  of  the  90  autopsies.  This  tejm 
was  applied  by  Heschel  (1868)  to  a  loss  of  substance  in  the  form  of  cavities 
and  cysts  at  the  surface  of  the  brain,  either  opening  into  and  bounded  by  the 
araclinoid,  and  even  passing  deeply  into  the  hemisphere,  or  reaching  to  the 
ventricle.  In  the  study  by  Audrey  of  103  cases  of  porencephalus.  hemiplegia 
was  mentioned  in  68  cases. 

Practically,  then,  in  infantile  hemiplegia  cortical  sclerosis  and  porenceph- 
alus are  the  important  anatomical  conditions.  The  primary  change  in  the 
majorit}"  of  these  cases  is  still  unknown.  Porencephalus  may  result  from  a 
defect  in  development  or  from  haemorrhage  at  birth.  The  etiology  is  clear  in 
the  limited  number  of  cases  of  haemorrhage,  embolism,  and  thrombosis,  but 
there  remains  the  large  group  in  which  the  final  change  is  sclerosis  and  atro- 
phy. What  is  the  primary  lesion  in  these  instances?  The  clinical  history 
shows  that  in  nearly  aU  these  cases  the  onset  is  sudden,  with  convulsions — 
often  with  slight  fever.  Striimpell  believes  that  this  condition  is  due  to  an 
inflammation  of  the  gray  matter — poliencephalitis — a  view  which  has  not 
been  very  widely  accepted,  as  the  anatomical  proofs  are  wanting.  Gowers  sug- 
gests that  thrombosis  may  be  present  in  some  instances.  This  might  probably 
account  for  the  final  condition  of  sclerosis,  but  clinically  thrombosis  of  the 
veins  rarely  occurs  in  healthy  children,  which  appear  to  be  those  most  fre- 
quently attacked  by  infantile  hemiplegia,  and  post-mortem  proof  is  yet  want- 
ing of  the  association  of  thrombosis  with  the  disease. 

Symptoms. —  (a)  The  oxset.  The  disease  may  set  in  suddenly  without 
spasms  or  loss  of  consciousness.  In  more  than  half  the  cases  the  child  is 
attacked  with  partial  or  general  convulsions  and  loss  of  consciousness,  which 
may  last  from  a  few  hours  to  many  days.  This  is  one  of  the  most  striking 
features  in  the  disease.  Fever  is  usually  present.  The  hemiplegia,  noticed  as 
the  child  recovers  consciousness,  is  generally  complete.  Sometimes  the  paraly- 
sis is  not  complete  at  first,  but  develops  after  subsequent  convulsions.  The 
right  side  is  more  frequently  affected  than  the  left.  The  face  is  commonly  not 
involved. 

(&)  PiESiDUAL  SYMPTOMS.  In  some  cases  the  paralysis  gradually  disap- 
pears and  leaves  scarcely  a  trace  as  the  child  grows  up.  The  leg,  as  a  rule, 
recovers  more  rapidly  and  more  fully  than  the  arm,  and  the  paralysis  ma}^  be 
scarcely  noticeable.  In  a  majority  of  cases,  however,  there  is  a  characteristic 
hemiplegic  gait.  The  paralysis  is  most  marked  in  the  arm,  which  is  usually 
wasted ;  the  forearm  is  flexed  at  right  angles,  the  hand  is  flexed,  and  the  fingers 
are  contracted.  ]\Iotion  may  be  almost  completely  lost;  in  other  instances  the 
arm  can  be  lifted  above  the  head.  Late  rigidity,  which  almost  always  develops, 
is  the  symptom  which  suggested  the  name  hemiplegia  spastica  cerehralis  to 
Heine,  the  orthopaedic  surgeon,  who  first  accurately  described  these  eases.  It 
is,  however,  not  constant.  The  limbs  may  be  quite  relaxed  even  years  after 
the  onset.  The  reflexes  are  usually  increased.  In  several  instances,  however, 
I  have  known  them  to  be  absent.     Sensation,  as  a  rule,  is  not  disturbed. 

Aphasia  is  a  not  tmcommon  symptom,  and  occurred  in  16  cases  of  my 


DIFFUSE  AND  FOCAL  DISEASES  OF   THE  BRAIN.  987 

series — a  smaller  number  than  that  given  in  the  series  of  Wallenberg,  Gau- 
dard,  and  Sachs. 

Mental  Defects. — One  of  the  most  serious  consequences  of  infantile  hemi- 
plegia is  the  failure  of  mental  development.  A  considerable  number  of  these 
cases  drift  into  the  institutions  for  feeble-minded  children.  Three  grades 
may  be  distinguished — idiocy,  which  is  most  common  when  the  hemiplegia 
has  existed  from  birth;  imbecility,  which  often  increases  with  the  develop- 
ment of  epilepsy;  and  feeble-mindedness,  a  retarded  rather  than  an  arrested 
development. 

Epilepsy. — Of  the  cases  in  my  series,  41  were  subjects  of  convulsive  seiz- 
ures, one  of  the  most  distressing  sequels  of  the  disease.  The  seizures  may  be 
either  transient  attacks  of  petit  mal,  true  Jacksonian  fits,  beginning  in  and 
confined  to  the  affected  side,  or  general  convulsions. 

Post-hemiplegic  Movements. — It  was  in  cases  of  this  sort  that  Weir 
Mitchell  first  described  the  post-hemiplegic  movements.  They  are  extremely 
common,  and  were  present  in  34  of  my  series.  There  may  be  either  slight 
tremor  in  the  affected  muscles,  or  incoordinate  choreiform  movements — the 
so-called  post-hemiplegic  chorea — or,  lastly. 

Athetosis. — In  this  condition,  described  by  Hammond,  there  are  remark- 
able spasms  of  the  paralyzed  extremities,  chiefly  of  the  fingers  and  toes,  and 
in  rare  instances  of  the  muscles  of  the  mouth.  The  movements  are  involun- 
tary and  somewhat  rhythmical ;  in  the  hand,  movements  of  adduction  or  abduc- 
tion and  of  supination  and  pronation  follow  each  other  in  orderly  sequence. 
There  may  be  hyperextension  of  the  fingers,  during  which  they  are  spread 
wide  apart.  This  condition  is  much  more  frequent  in  children  than  in  adults. 
In  the  latter  it  may  be  combined  with  hemiangesthesia,  and  the  lesion  is  not 
cortical,  but  basic  in  the  neighborhood  of  the  thalamus.  The  movements  are 
sometimes  increased  by  emotion.     They  usually  persist  during  sleep. 

■  Treatment. — The  possibility  of  injury  to  the  brain  in  protracted  labor  and 
in  forceps  cases  should  be  borne  in  mind  by  the  practitioner.  The  former 
entails  the  greater  risk.  In  infantile  hemiplegia  the  physician  at  the  outset 
sees  a  case  of  ordinary  convulsions,  perhaps  more  protracted  and  severe  than 
usual.  These  should  be  checked  as  rapidly  as  possible  by  the  use  of  the 
bromides,  the  application  of  cold  or  heat,  and  a  brisk  purge.  During  convul- 
sions' chloroform  may  be  administered  with  safety  even  to  the  youngest  chil- 
dren. When  the  paralysis  is  established  not  much  can  be  hoped  from  medi- 
cines. In  only  rare  instances  does  the  paralj^sis  entirely  disappear.  When  the 
recovery  is  partial  the  "  residual  paralysis  "  is  similar  to  that  seen  in  other 
lesions  of  the  upper  motor  segment.  Thus  in  the  lower  extremity  it  is  the 
flexors  of  the  leg  and  the  dorsal  flexors  of  the  foot  which  are  most  often  per- 
manently paralyzed  (Wernicke).  The  indications  are  to  favor  the  natural 
tendency  to  improve  by  maintaining  the  general  nutrition  of  the  child,  to 
lessen  the  rigidity  and  contractures  by  massage  and  passive  motion,  and  if 
necessary  to  correct  deformities  by  mechanical  or  surgical  measures.  Much 
may  be  done  by  careful  manipulation  and  rubbing  and  the  application  of  a 
proper  apparatus.  In  children  the  aphasia  usually  disappears.  The  epi- 
lepsy is  a  distressing  and  obstinate  symptom,  for  which  a  cure  can  rarely  be 
anticipated.  Prolonged  periods  of  quiescence  are,  however,  not  uncommon.  In 
the  Jacksonian  fits  the  bromides  rarely  do  good,  unless  there  is  much  irritabil- 


988  DISEASES  OF  THE  NERVOUS  SYSTEM. 

ity  and  excitement.  Operative  measures  in  favorable  cases  of  this  particular 
form  of  epilepsy  may  often  prove  beneficial  in  reducing  the  number  and  severity 
of  the  seizures,  but  it  is  very  unusual  for  them  to  be  completely  or  permanently 
checked.  The  liability  to  feeble-mindedness  is  the  most  serious  outlook  in  the 
infantile  cerebral  palsies.  In  many  cases  the  damage  is  irreparable,  and  idiocy 
and  imbecility  result.  With  patient  training  and  with  care  many  of  the  chil- 
dren reach  a  fair  measure  of  intelligence  and  self-reliance. 

IV.     TUMORS,    INFECTIOUS    GRANULOMATA,   AND 
CYSTS    OF    THE    BRAIN. 

The  following  are  the  most  common  varieties  of  new  growths  within  the 
cranium : 

(1)  Infectious  Granulomata. —  (a)  Tubercle^  which  may  form  large  or 
small  growths,  usually  multiple.  Tuberculosis  of  the  glands  or  bones  may 
be  coexistent,  but  the  tuberculous  disease  of  the  brain  may  occur  in  the  absence 
of  other  clinically  recognizable  tuberculous  lesions.  The  disease  is  most  fre- 
quent early  in  life.  Three-fourths  of  the  cases  occur  under  twenty,  and  one- 
half  of  the  patients  are  under  ten  years  of  age  (Gowers).  Of  300  cases  of 
tumor  in  persons  under  nineteen  collected  from  various  sources  by  Starr,  153 
were  tubercle.  The  nodules  are  most  numerous  in  the  cerebellum  and  about 
the  base. 

(&)  Sypliiloma  is  most  commonly  found  on  the  cortex  cerebri  or  about  the 
pons.  The  tumors  are  superficial,  attached  to  the  arteries  or  the  meninges, 
and  rarely  grow  to  a  large  size.  They  may  be  multiple.  The  motor  nerves 
of  the  eye  are  particularly  prone  to  sj-philitic  infiltration,  and  ptosis  and  the 
ordinary  forms  of  squint  are  common. 

(2)  Tumors. —  (c)  Glioma  and  Neuroglioma. — These  vary  greatly  in  ap- 
pearance. They  may  be  firm  and  hard,  almost  like  an  area  of  sclerosis,  or 
soft  and  very  vascrdar.  Haemorrhages  are  apt  to  occur  in  them.  They  per- 
sist remarkably  for  many  years.  Klebs  has  called  attention  to  the  occurrence 
of  elements  in  them  not  unlike  ganglion-cells.  Tumors  of  this  character  may 
contain  the  "  Spinnen "  or  spider  cells ;  enormous  spindle-shaped  cells  with 
single  large  nuclei;  cells  like  the  ganglion-cells  of  nerve-centres  with  nuclei 
and  one  or  more  processes;  and  translucent,  band-like  fibres,  tapering  at  each 
end,  which  result  from  a  vitreous  or  hyaline  transformation  of  the  large  spin- 
dle-cells. A  separate  type  is  also  recognizable,  in  which  the  cells  resemble  the 
ependymal  epithelium. 

(d)  Sarcoma  occurs  most  commonly  in  the  membranes  covering  the  hemi- 
spheres or  brain  stem,  and  for  a  long  time  may  cause  injury  by  its  compres- 
sion effects  alone.  Tumors  of  this  kind  are  particularly  common  in  the  cere- 
bello-pontine  recess.  When  sarcoma  originates  in  the  brain  substance  it  may 
become  one  of  the  largest  and  most  diffusely  infiltrating  of  intracranial 
growths.  Sarcoma  is  usually  a  primary  growth  and  occurs  next  in  frequency 
to  tubercle.  When  meningeal  in  origin,  it  is  the  form  of  tumor  most  amenable 
to  surgical  treatment. 

(e)  Carcinoma  not  infrequently  is  secondary  to  cancer  in  other  parts.  It 
is  seldom  primary.  Occasionally  cancerous  tumors  have  been  found  in  sym- 
metrical parts  of  the  brain. 


DIFFUSE  AND  FOCAL  DISEASES  OF   THE  BRAIN.  989 

(/')  Other  varieties  occur,  such  as  fibroid  growths,  which  usually  develop 
from  the  membranes;  bony  tumors,  which  grow  sometimes  from  the  falx, 
psammona,  cholesteatoma,  and  angioma.  Fatty  tumors  are  occasionally  found 
on  the  corpus  callosum. 

(3)  Cysts. —  (g)  These  occur  between  the  membranes  and  the  brain,  as 
a  result  of  hemorrhage  or  of  softening.  Porencephalus  is  a  sequel  of  con- 
genital atrophy  or  of  haemorrhage,  or  may  be  due  to  a  developmental  defect. 
Hydatid  cysts  have  been  referred  to  in  the  section  on  parasites.  An  interest- 
ing variety  of  cyst  is  that  which  follows  severe  injury  to  the  skull  in  early  life. 

Symptoms. —  (1)  General. — The  following  are  the  most  important: 
Headache,  either  dull,  aching,  and  continuous,  or  sharp,  stabbing,  and  par- 
oxysmal. It  may  be  diffused  over  the  entire  head;  sometimes  it  is  limited 
to  the  back  or  front.  When  in  the  back  of  the  head  it  may  extend  down  the 
neck  (especially  in  tumors  in  the  posterior  fossa),  and  when  in  the  front  it 
may  be  accompanied  with  neuralgic  pains  in  the  face.  Occasionally  the  pain 
may  be  very  localized  and  associated  with  tenderness  on  pressure. 

Optic  neuritis  occurs  in  four-fifths  of  all  the  eases  (Gowers).  It  should 
be  looked  for  in  every  patient  presenting  cerebral  symptoms,  for  it  may  be 
present  in  high  degree  without  impairment  of  vision.  Loss  of  visual  acuity 
usually  indicates  that  optic  atrophy  has  set  in.  It  is  usually  double,  but  occa- 
sionally is  found  in  only  one  eye.  A  growth  may  develop  slowly  and  attain 
considerable  size  without  producing  optic  neuritis.  On  the  other  hand,  it  may 
occur  with  a  very  small  tumor.  J.  A.  Martin,  from  an  extensive  analysis  of  the 
literature  with  reference  to  the  localizing  value,  concludes :  When  there  is  a 
difference  in  the  amount  of  the  neuritis  in  each  eye  it  is  more  than  twice  as 
probable  that  the  tumor  is  on  the  side  of  the  most  marked  neuritis.  It  is  con- 
stant in  tumors  of  the  corpora  quadrigemina,  present  in  89  per  cent  of  cere- 
bellar tumors,  and  absent  in  nearly  two-thirds  of  the  cases  of  tumor  of  the 
pons,  medulla,  and  of  the  corpus  callosum.  It  is  least  frequent  in  cases  of 
tuberculous  tumor;  most  common  in  cases  of  glioma  and  cystic  tumors. 

Vomiting  is  a  common  feature,  and  with  headache  and  optic  neuritis 
makes  up  the  characteristic  clinical  picture  of  cerebral  tumor.  An  important 
point  is  the  absence  of  definite  relation  to  the  meals.  A  chemical  examination 
shows  that  the  vomiting  is  independent  of  digestive  disturbances.  It  may 
be  very  obstinate,  particularly  in  growths  of  the  cerebellum  and  the  pons. 

Giddiness  is  often  an  early  symptom.  The  patient  complains  of  vertigo 
on  rising  suddenly  or  on  turning  quickly.  Mental  Disturbance. — The  patient 
may  act  in  an  odd,  unnatural  manner,  or  there  may  be  stupor  and  heaviness. 
The  patient  may  become  emotional  or  silly,  or  symptoms  resembling  hysteria 
may  develop.  Convulsions,  either  general  and  resembling  true  epilepsy  or 
localized  ( Jacksonian)  in  character.  There  may  be  slowing  of  the  pulse,  as  in 
all  cases  of  increased  intracranial  pressure. 

(2)  Localizing  Symptoms. — Focal  symptoms  often  occur,  but  it  must 
not  be  forgotten  that  these  may  be  indirectly  produced.  The  smaller  the 
tumor  and  the  less  marked  the  general  symptoms  of  cerebral  compression,  the 
more  likely  is  it  that  any  focal  symptoms  occurring  are  of  direct  origin. 

(a)  Central  Motor  Area. — The  symptoms  are  either  irritative  or  destruc- 
tive in  character.  Irritation  in  the  lower  third  may  produce  spasm  in  the 
muscles  of  the  face,  in  the  angle  of  the  mouth,  or  in  the  tongue.     The  spasm 


990  DISEASES  OF  THE  NERVOUS  SYSTEM. 

with  tingling  may  be  strictl}'  limited  to  one  muscle  group  before  extending  to 
others,  and  this  Seguin  terms  the  signal  symptom.  The  middle  third  of  the 
motor  area  contains  the  centres  controlling  the  arm,  and  here,  too,  the  spasm 
may  begin  in  the  fingers,  in  the  thumb,  in  the  muscles  of  the  wrist,  or  in  the 
shoulder.  In  the  upper  third  of  the  motor  areas  the  irritation  may  produce 
spasm  beginning  in  the  toes,  in  the  ankles,  or  in  the  muscles  of  the  leg.  In 
many  instances  the  patient  can  determine  accurately  the  point  of  origin  of 
the  spasm,  and  there  are  imjiortant  sensory  disturbances,  such  as  numbness 
and  tingling,  which  may  be  felt  first  at  the  region  affected. 

In  all  cases  it  is  important  to  determine,  first,  the  point  of  origin,  the 
signal  symptom;  second,  the  order  or  march  of  the  spasm;  and  third,  the 
subsequent  condition  of  the  parts  first  affected,  whether  it  is  a  state  of  paresis 
or  angesthesia. 

Destructive  lesions  in  the  motor  zone  cause  paralysis,  which  is  often  pre- 
ceded by  local  convulsive  seizures;  there  may  be  a  monoplegia,  as  of  the  leg, 
and  convulsive  seizures  in  the  arm,  often  due  to  irritation  in  these  centres. 
Tumors  in  the  neighborhood  of  the  motor  area  may  cause  localized  spasms  and 
subsequently,  as  the  centres  are  invaded  by  the  growth,  paralysis  occurs.  On 
the  left  side,  growths  in  the  third  frontal  or  Broca's  convolution  may  cause 
motor  aphasia. 

(&)  Prefrontal  Begion. — Xeither  motor  nor  sensory  disturbance  may  be 
present.  The  general  sjanptoms  are  often  well  marked.  The  most  striking 
feature  of  growths  in  this  region  is  mental  torpor  and  gradual  imbecility. 
Particularly  when  the  left  side  is  involved  mental  characteristics  may  be 
greatly  altered.  In  its  extension  downward  the  tumor  may  involve  on  the  left 
side  the  lower  frontal  convolution  and  produce  aphasia,  or  in  its  progress 
backward  cause  irritative  or  destructive  lesions  of  the  motor  area.  Exophthal- 
mos on  the  side  of  the  tumor  may  occur  and  be  helpful  in  diagnosis,  as  in  the 
case  reported  by  Thomas  and  Keene. 

(c)  Tumors  in  the  parieto-occipital  lohe  may  grow  to  a  large  size  without 
causing  any  symptoms.  There  may  be  word-blindness  and  mind-blindness 
when  the  angular  g}Tus  and  its  underlying  white  matter  is  involved,  and 
paraphasia.  Astereognosis  may  accompany  growths  in  the  superior  parietal 
region. 

(d)  Tumors  of  the  occipital  lohe  produce  hemianopsia,  and  a  bilateral  lesion 
may  produce  blindness.  Tumors  in  this  region  on  the  left  hemisphere  may 
be  associated  with  word-blindness  and  mind-blindness. 

(e)  Tumors  in  the  temporal  lohe  may  attain  a  large  size  without  produc- 
ing s}Tnptoms.  In  their  growth  they  involve  the  lower  motor  centres.  On 
the  left  side  involvement  of  the  first  g}Tus  and  the  transverse  temporal  gyri 
(auditory  sense  area)  may  be  associated  with  word-deafness. 

(/)  Tumors  growing  in  the  neighborhood  of  the  hasal  ganglia  produce 
hemiplegia  from  involvement  of  the  internal  capsule.  Limited  growths  in 
either  the  nucleus  caudatus  or  the  nucleus  lentiformis  of  the  corpus  striatum 
do  not  necessarily  cause  paralysis.  Tumors  in  the  thalamus  opticus  may 
also,  when  small,  cause  no  symptoms,  but  increasing  they  may  involve  the 
fibres  of  the  sensor}^  portion  of  the  internal  capsule,  producing  hemianopsia 
and  sometimes  hemiansesthesia.  Growths  in  this  situation  are  apt  to  cause 
early  optic  neuritis,  and,  growing  into  the  third  ventricle,  may  cause  a  dis- 


DIFFUSE  AND  FOCAL  DISEASES  OF   THE  BRAIN.  991 

tention  of  the  lateral  ventricles.  In  fact,  pressure  symptoms  from  this  cause 
and  paralysis  due  to  involvement  of  the  internal  capsule  are  the  chief  symp- 
toms of  tumor  in  and  about  these  ganglia.  If  the  ventrolateral  group  of 
nuclei  in  the  thalamus  be  involved  there  may  be  unilateral  disturbances  of 
cutaneous  and  muscular  sense,  hemichorea,  or  movement  ataxia. 

G-rowths  in  the  corpora  quadrigemina  are  rarely  limited,  but  most  com- 
monly involve  the  crura  cerebri  as  well.  Ocular  symptoms  are  marked.  The 
pupil  reflex  is  lost  and  there  is  nystagmus.  In  the  gradual  grovi^th  the  third 
nerve  is  involved  as  it  passes  through  the  crus,  in  which  case  there  will  be 
oculo-motor  paralysis  on  one  side  and  hemiplegia  on  the  other,  a  combination 
almost  characteristic  of  unilateral  disease  of  the  crus. 

(g)  Tumors  of  the  pons  and  medulla.  The  symptoms  are  chiefly  those 
of  pressure  upon  the  nerves  emerging  in  this  region.  In  disease  of  the  pons 
the  nerves  may  be  involved  alone  or  with  the  pyramidal  tract.  Of  53  cases 
analyzed  by  Mary  Putnam  Jacobi,  there  were  13  in  which  the  cerebral  nerves 
were  involved  alone,  13  in  which  the  limbs  were  affected,  and  26  in  which 
there  was  hemiplegia  and  involvement  of  the  nerves.  Twenty-two  of  the  latter 
had  what  is  known  as  alternate  paralysis — i.  e.,  involvement  of  the  nerves  on 
one  side  and  of  the  limbs  on  the  opposite  side.  In  4  cases  there  were  no  motor 
symptoms.  In  tuberculosis  (or  syphilis)  a  growth  at  the  inferior  and  inner 
aspects  of  the  crus  may  cause  paralysis  of  the  third  nerve  on  one  side,  and  of 
the  face,  tongue,  and  limbs  on  the  opposite  side  (syndrome  of  Weber).  A 
tumor  growing  in  the  lower  part  of  the  pons  usually  involves  the  sixth  nerve, 
producing  internal  strabismus,  the  seventh  nerve,  producing  facial  paralysis, 
and  the  auditory  nerve,  causing  deafness.  Conjugate  deviation  of  the  eyes 
to  the  side  opposite  that  on  which  there  is  facial  paralysis  also  occurs.  When 
the  motor  cerebral  nerves  are  involved  the  paralyses  are  of  the  peripheral 
type  (lower  segment  paralyses). 

Tumors  of  the  medulla  may  involve  the  cerebral  nerves  alone  or  cause 
in  some  instances  a  combination  of  hemiplegia  with  paralysis  of  the  nerves. 
Paralyses  of  the  nerves  are  helpful  in  topical  diagnosis,  but  the  fact  must  not 
be  overlooked  that  one  or  more  of  the  cerebral  nerves  may  be  paralyzed  as 
a  result  of  a  much  increased  general  intracranial  pressure.  Signs  of  irritation 
in  the  ninth,  tenth,  and  eleventh  nerves  are  usually  present,  and  produce 
difficulty  in  swallowing,  irregular  action  of  the  heart,  irregular  respiration, 
vomiting,  and  sometimes  retraction  of  the  head  and  neck.  The  hypoglossal 
nerve  is  least  often  affected.  The  gait  may  be  unsteady  or,  if  there  is  pressure 
on  the  cerebellum,  ataxic.  Occasionally  there  are  sensory  symptoms,  numbness, 
and  tingling.    Toward  the  end  convulsions  may  occur. 

Tumors  of  the  pituitary  body  are  not  uncommon,  and  are  usually  of  the 
nature  of  fibroma  or  myxoma.  They  may  accompany  acromegaly.  Landois 
and  Roy  have  reported  16  cases. 

Diagnosis. — From  the  general  symptoms  alone  the  existence  of  tumor  may 
be  determined,  for  the  combination  of  headache,  optic  neuritis,  and  vomiting 
is  distinctive.  A  gradual  increase  in  the  intensity  of  the  symptoms  is  usually 
seen.  It  must  not  be  forgotten  that  severe  headache  and  neuro-retinitis  may 
be  caused  by  Bright's  disease.  The  localization  must  be  gathered  from  the 
consideration  of  the  symptoms  above  detailed  and  from  the  data  given  in  the 
section  on  Topical  Diagnosis  of  Diseases  of  the  Brain.     Mistakes  are  most 


992  DISEASES  OF   THE  NERVOUS  SYSTEM. 

likely  to  occur  in  connection  with  uraemia,  hysteria,  and  general  paralysis; 
but  careful  consideration  of  all  the  circumstances  of  the  case  usually  enables 
the  practitioner  to  avoid  error.  Auscultatory  percussion  is  occasionally  of 
service  in  localization. 

Prognosis. — Syphilitic  tumors  alone  are  amenable  to  medical  treatment. 
Tuberculous  growths  occasionally  cease  to  grow  and  become  calcified.  The 
gliomata  and  fibromata,  particularly  when  the  latter  grow  from  the  membranes, 
may  last  for  3'ears.  I  have  described  a  case  of  small,  hard  glioma,  in  which 
the  Jacksonian  epilepsy  persisted  for  fourteen  years.  Hughlings  Jackson  has 
reported  cases  of  glioma  in  which  the  symptoms  lasted  for  over  ten  years.  The 
more  rapidly  growing  sarcomata  usually  prove  fatal  in  from  six  to  eighteen 
months.  Death  may  be  sudden,  particularly  in  growths  near  the  medulla; 
more  commonly  it  is  due  to  coma  in  consequence  of  gradual  increase  in  the 
intracranial  pressure. 

Treatment. —  (a)  Medical. — If  there  is  a  suspicion  of  syphilis  the  iodide 
of  potassium  and  mercury  should  be  given.  Xowhere  do  we  see  more  brilliant 
therapeutical  efilects  than  in  certain  cases  of  cerebral  gummata.  The  iodide 
should  be  given  in  increasing  doses.  In  tuberculous  tumors  the  outlook  is  less 
favorable,  though  instances  of  cure  are  reported,  and  there  is  post-mortem 
evidence  to  show  that  the  solitary  tuberculous  tumors  may  undergo  changes 
and  become  obsolete.  A  general  tonic  treatment  is  indicated  in  these  cases. 
The  headache  usually  demands  prompt  treatment.  The  iodide  of  potassium 
in  full  doses  sometimes  gives  marked  relief.  An  ice-cap  for  the  head  or,  in 
the  occipital  headache,  the  application  of  the  Paquelin  cautery  may  be  tried. 
The  bromides  are  not  of  much  use  in  the  headache  from  this  cause,  and,  as 
the  last  resort,  morphia  must  be  given.  For  the  convulsions  bromide  of 
potassium  is  of  little  service. 

(&)  Surgical. — Tumors  of  the  brain  have  been  successfully  removed  by 
Macewen,  Horsley,  Keen,  and  others.  The  percentage  of  cases  in  which  extir- 
pation is  possible,  however,  is  small.  Of  1,277  cases  collected  by  Starr,  only 
104  were  removable.  The  most  advantageous  cases  are  the  localized  fibromata 
and  sarcomata  growing  from  the  dura  and  only  compressing  the  brain  sub- 
stance, as  in  Keen's  remarkable  case.  Of  late  years  there  have  been  numerous 
successful  operations  with  removal  of  growths  from  the  cerebellum  and  cere- 
bello-pontine  recess.  The  safety  with  which  the  exploratory  operation  can  be 
made  warrants  it  in  all  doubtful  cases.  Even  if  the  tumor  be  inaccessible,  a 
palliative  craniectomy  may  be  indicated,  for  by  relieving  the  intracranial  ten- 
sion it  may  suffice  to  check  the  headache,  vomiting,  and  optic  neuritis. 

V.    INFLAMMATION    OF    THE    BRAIN. 

1.  x4.cuTE  Encephalitis. 

A  focal  or  diffuse  inflammation  of  the  brain  substance,  usually  of  the  gray 
■  matter  (poliencephalitis),  is  met  with  (a)  as  a  result  of  trauma;  (&)  in  cer- 
tain intoxications,  alcohol,  food  poisoning,  and  gas  poisoning;  and  (c)  follow- 
ing the  acute  infections.  The  anatomical  features  are  those  of  an  acute 
hemorrhagic  poliencephalitis,  corresponding  in  histological  details  with  acute 
polio-myelitis.     Focal  forms  are  seen  in  ulcerative  endocarditis,  in  which  the 


DIFFUSE  AND  FOCAL  DISEASES  OF   THE  BRAIN.  993 

gray  matter  may  present  deeply  haemorrliagic  areas,  firmer  than  the  surround- 
ing tissue.  In  the  fevers  there  may  be  more  extensive  regions,  involving  two 
or  three  convolutions.  This  acute  hsemorrhagic  poliencephalitis  superior  is 
thought  by  Striimpell  to  be  the  essential  lesion  in  infantile  hemiplegia.  Local- 
izing symptoms  are  usually  present,  though  they  may  be  obscured  in  the 
severity  of  the  general  infection.  The  most  typical  encephalitis  accompanies 
the  meningitis  in  cerebro-spinal  fever. 

In  acute  mania,  in  delirium  tremens,  in  chorea  insaniens,  in  the  maniacal 
form  of  exophthalmic  goitre,  and  in  the  so-called  cerebral  forms  of  the  malig- 
nant fevers  the  gray  cortex  is  deeply  congested,  moist,  and  swollen,  and  with 
the  recent  finer  methods  of  research  will  probably  show  changes  which  may 
be  classed  as  encephalitis. 

The  symptoms  are  not  very  definite.  In  severe  forms  they  are  those  of 
an  acute  infection;  some  cases  have  been  mistaken  for  typhoid  fever.  The 
onset  may  be  abrupt  in  an  individual  apparently  healthy.  Other  cases  have 
occurred  in  the  convalescence  from  the  fevers,  particularly  influenza.  One  of 
J.  J.  Putnam's  cases  followed  mumps.  The  general  symptoms  are  those  which 
accompany  all  severe  acute  affections  of  the  brain — headache,  somnolence, 
coma,  delirium,  vomiting,  etc.  The  local  symptoms  are  very  varied,  depend- 
ing on  the  extent  of  the  lesions,  and  may  be  irritative  or  paralytic.  Usually 
fatal  within  a  few  weeks,  cases  may  drag  on  for  weeks  or  months  and  recover. 

2.  Abscess  of  the  Braust, 

Etiology. — Suppuration  of  the  brain  substance  is  rarely  if  ever  primary, 
but  results,  as  a  rule,  from  extension  of  inflammation  from  neighboring  parts 
or  infection  from  a  distance  through  the  blood.  The  question  of  idiopathic 
brain  abscess  need  scarcely  be  considered,  though  occasionally  instances  occur 
in  which  it  is  extremely  difiicult  to  assign  a  cause.  There  are  three  important 
etiological  factors: 

(1)  Trauma.  Falls  upon  the  head  or  blows,  with  or  without  abrasion  of 
the  skin.  More  commonly  it  follows  fracture  or  punctured  wounds.  In  this 
group  meningitis  is  frequently  associated  with  the  abscess. 

(2)  By  far  the  most  important  infective  foci  are  those  which  arise  in 
direct. extension  from  disease  of  the  middle  ear,  of  the  mastoid  cells,  or  of  the 
frontal  sinuses.  From  the  roof  of  the  mastoid  antrum  the  infection  readily 
passes  to  the  sigmoid  sinus  and  induces  an  infective  thrombosis.  In  other 
instances  the  dura  becomes  involved,  and  a  subdural  abscess  is  formed,  which 
may  readily  involve  the  arachnoid  or  the  pia  mater.  In  another  group  the 
inflammation  extends  along  the  lymph  spaces,  or  the  thrombosed  veins,  into 
the  substance  of  the  brain  and  causes  suppuration.  Macewen  thinks  that  with- 
out local  areas  of  meningitis  the  infective  agents  may  be  carried  through  the 
lymph  and  blood  channels  into  the  cerebral  substance.  Infection  which  ex- 
tends from  the  roof  of  the  tympanic  cavity  is  most  likely  to  be  followed  by 
abscess  in  the  temporal  lobe,  while  infection  extending  from  the  mastoid  cells' 
causes  most  frequently  sinus  thrombosis  and  cerebellar  abscess. 

(3)  In  septic  processes.  Abscess  of  the  brain  is  not  often  found  in  pyae- 
mia. In  ulcerative  endocarditis  multiple  foci  of  suppuration  are  common. 
Localized  bone-disease  and  suppuration  in  the  liver  are  occasional  causes.    Cer- 


994  DISEASES  OF   THE  NERVOUS  SYSTEM. 

tain  inflammations  in  the  lungs,  particularly  bronchiectasis,  which  was  present 
in  17  of  38  cases  of  these  so-called  "pulmonal  cerebral  abscesses"  collected 
by  E.  T.  Williamson,  are  liable  to  be  followed  by  abscess.  It  is  an  occasional 
complication  of  empyema.  Abscess  of  the  brain  may  follow  the  specific  fevers. 
Bristowe  has  called  attention  to  its  occurrence  as  a  sequel  of  influenza.  The 
largest  number  of  cases  occur  between  the  twentieth  and  fortieth  years,  and 
the  condition  is  more  frequent  in  men  than  in  women.  Holt  has  collected  25 
cases  in  children  under  five  3'ears  of  age,  the  chief  causes  of  which  were  otitis 
media  and  trauma. 

Morbid  Anatomy. — The  abscess  may  be  solitary  or  multiple,  diffuse  or  cir- 
cumscribed. Practically  any  one  of  the  different  varieties  of  pyogenic  bac- 
teria may  be  concerned.  The  bacteriological  examination  often  shows  a  mix- 
ture of  different  varieties.  Occasionally  cultures  are  sterile,  owing  to  death 
of  the  bacteria.  In  the  acute,  rapidly  fatal  cases  following  injury  the  suppura- 
tion is  not  limited;  but  in  long-standing  cases  the  abscess  is  enclosed  in  a 
definite  capsule,  which  may  have  a  thickness  of  from  2  to  5  mm.  The  pus 
varies  much  in  appearance,  depending  upon  the  age  of  the  abscess.  In  early 
eases  it  may  be  mixed  with  reddish  debris  and  softened  brain  matter,  but  in 
the  solitary  encapsulated  abscess  the  pus  is  distinctive,  having  a  greenish  tint, 
an  acid  reaction,  and  a  peculiar  odor,  sometimes  like  that  of  sulphuretted 
hydrogen.  The  brain  substance  surrounding  the  abscess  is  usually  oedematous 
and  infiltrated.  The  size  varies  from  that  of  a  walnut  to  that  of  a  large  orange. 
There  are  cases  on  record  in  which  the  cavity  has  occupied  the  greater  portion 
of  a  hemisphere.  Multiple  abscesses  are  usually  small.  In  four-fifths  of  all 
eases  the  abscess  is  solitary.  Suppuration  occurs  most  frequently  in  the  cere- 
brum, and  the  temporal  lobe  is  more  often  involved  than  other  parts.  The 
cerebellum  is  the  next  most  common  seat,  particularly  in  connection  with  ear- 
disease. 

Symptoms. — Following  injury  or  operation  the  disease  may  run  an  acute 
course,  with  fever,  headache,  delirium,  vomiting,  and  rigors.  The  s}TQptoms 
are  those  of  an  acute  meningo-encephalitis,  and  it  may  be  very  difficult  to 
determine,  unless  there  are  localizing  s}Tnptoms,  whether  there  is  really  sup- 
puration in  the  brain  substance.  In  the  cases  following  ear-disease  the  symp- 
toms may  at  first  be  those  of  meningeal  irritation.  There  may  be  irritability, 
restlessness,  severe  headache,  and  aggravated  earache.  Other  striking  symp- 
toms, particularly  in  the  more  prolonged  cases,  are  drowsiness,  slow  cerebration, 
vomiting,  and  optic  neuritis.  In  the  chronic  form  of  brain  abscess  which  may 
follow  injury,  otorrhcea,  or  local  limg  trouble,  there  may  be  a  latent  period 
ranging  from  one  or  two  weeks  to  several  months,  or  even  a  year  or  more. 
In  the  "  silent "  regions,  when  the  abscess  becomes  encapsulated  there  ma}^  be 
no  s}Tnptoms  whatever  during  the  latent  period.  During  all  this  time  the 
patient  may  be  under  careful  observation  and  no  suspicion  be  aroused  of  the 
existence  of  suppuration.  Then  severe  headache,  vomiting,  and  fever  set  in, 
perhaps  with  a  chill.  So,  too,  after  a  blow  upon  the  head  or  a  fracture  the 
symptoms  of  the  lesion  may  be  transient,  and  months  afterward  cerebral  sjmip- 
toms  of  the  most  aggravated  character  may  develop. 

The  localization  of  the  lesion  is  often  difficult.  If  situated  in  or  near 
the  motor  region  there  may  be  convulsions  or  paralysis,  and  it  is  to  be  remem- 
bered that  an  abscess  in  the  temporal  lobe  may  compress  the  lower  part  of  the 


DIFFUSE  AND  FOCAL  DISEASES  OF  THE  BRAIN.  995 

pre-central  convolution  and  produce  paralysis  of  the  arm  and  face,  and  on  the 
left  side  cause  aphasia.  A  large  abscess  may  exist  in  the  frontal  lobe  without 
causing  paralysis,  but  in  these  cases  there  is  almost  always  some  mental  dul- 
ness.  In  the  temporal  lobe,  the  common  seat,  there  may  be  no  focalizing 
symptoms.  So  also  in  the  parieto-occipital  region;  though  here  early  exam- 
ination may  lead  to  the  detection  of  hemianopia.  In  abscess  of  the  cerebellum 
vomiting  is  common.  If  the  middle  lobe  is  affected  there  may  be  staggering 
— cerebellar  incoordination.  Localizing  symptoms  in  the  pons  and  other  parts 
are  still  more  uncertain. 

Diagnosis. — In  the  acute  cases  there  is  rarely  any  doubt.  A  consideration 
of  possible  etiological  factors  is  of  the  highest  importance.  The  history  of 
injury  followed  by  fever,  marked  cerebral  symptoms,  the  development  of 
rigors,  delirium,  and  perhaps  paralysis,  make  the  diagnosis  certain.  In  chronic 
ear-disease,  such  cerebral  symptoms  as  drowsiness  and  torpor,  with  irregular 
fever,  supervening  upon  the  cessation  of  a  discharge,  should  excite  the  suspicion 
of  abscess.  Cases  in  which  suppurative  processes  exist  in  the  orbit,  nose,  or 
naso-pharynx,  or  in  which  there  has  been  subcutaneous  phlegmon  of  the  head 
or  neck,  a  parotitis,  a  facial  erysipelas,  or  tuberculous  or  syphilitic  disease 
of  the  bones  of  the  skull,  should  be  carefully  watched,  and  immediately  in- 
vestigated should  cerebral  symptoms  appear.  It  is  particularly  in  the  chronic 
cases  that  difficulties  arise.  The  symptoms  resemble  those  of  tumor  of  the 
brain;  indeed,  they  are  those  of  tumor  plus  fever.  Choked  disk,  however,  so 
commonly  associated  with  tumor,  is  very  frequently  absent  in  abscess  of  the 
brain.  In  a  patient  with  a  history  of  trauma  or  with  localized  lung  or  pleural 
trouble,  who  for  weeks  or  months  has  had  slight  headache  or  dizziness,  the  onset 
of  a  rapid  fever,  especially  if  it  be  intermittent  and  associated  with  rigors, 
intense  headache,  and  vomiting,  points  strongly  to  abscess.  The  pulse-rate  in 
cases  of  cerebral  abscess  is  usually  accelerated,  but  cases  are  not  rare  in  which 
it  is  slowed.  Macewen  lays  stress  upon  the  value  of  percussion  of  the  skull 
as  an  aid  in  diagnosis.  The  note,  which  is  uniformly  dull,  becomes  much  more 
resonant  when  the  lateral  ventricles  are  distended  in  cerebellar  abscess  and 
in  conditions  in  which  the  venge  Galeni  are  compressed. 

It  is  not  always  easy  to  determine  whether  the  meninges  are  involved  with 
the  abscess.  Often  in  ear-disease  the  condition  is  that  of  meningo-encephalitis. 
Sometimes  in  association  with  acute  ear-disease  the  symptoms  may  simulate 
closely  cerebral  meningitis  or  even  abscess.  Indeed,  Cowers  states  that  not 
only  may  these  general  symptoms  be  produced  by  ear-disease,  but  even  distinct 
optic  neuritis. 

Treatment. — A  remarkable  advance  has  been  made  of  late  years  in  dealing 
with  these  cases,  owing  to  the  impunity  with  which  the  brain  can  be  explored. 
In  ear-disease  free  discharge  of  the  inflammatory  products  should  be  promoted 
and  careful  disinfection  practised.  The  treatment  of  injuries  and  fractures 
comes  within  the  scope  of  the  surgeon.  The  acute  symptoms,  such  as  fever, 
headache,  and  delirium,  must  be  treated  by  rest,  an  ice-cap,  and,  if  necessary, 
local  depletion.  In  all  cases,  when  a  reasonable  suspicion  exists  of  the  occur- 
rence of  abscess,  the  trephine  should  be  used  and  the  brain  explored.  The  cases 
following  ear-disease,  in  which  the  suppuration  is  in  the  temporal  lobe  or  in 
the  cerebellum,  offer  the  most  favorable  chances  of  recovery.  The  localization 
can  rarely  be  made  accurately  in  these  cases,  and  the  operator  must  be  guided 


996  DISEASES  OF  THE  NERVOUS  SYSTEM. 

more  by  general  anatomical  and  pathological  knowledge.  In  cases  of  injury 
the  trephine  should  be  applied  over  the  seat  of  the  blow  or  the  fracture.  In 
ear-disease  the  suppuration  is  most  frequent  in  the  temporal  lobe  or  in  the 
cerebellum,  and  the  operation  should  be  performed  at  the  points  most  accessible 
to  these  regions.  And,  lastly,  a  most  important,  one  might  almost  say  essen- 
tial, factor  in  the  successful  treatment  of  intracranial  suppuration  is  an 
intelligent  knowledge  on  the  part  of  the  surgeon  of  the  work  and  works  of 
Sir  William  Macewen. 

VI.     HYDROCEPHALUS. 

Definition. — A  condition,  congenital  or  acquired,  in  which  there  is  a  great 
accumulation  of  fluid  within  the  ventricles  of  the  brain. 

The  term  hydrocephalus  has  also  been  applied  to  the  collection  of  fluid 
between  the  cortex  of  the  brain  and  the  skull,  known  in  this  situation  as 
hydrocephalus  externus  or  hydroceplialus  ex  vacuo,  a  condition  common  in 
cases  of  atrophy  of  the  brain  substance,  met  with  in  old  age,  after  hsemorrhages, 
softenings,  or  scleroses,  in  lingering  and  cachectic  diseases,  as  cancer,  chronic 
nephritis,  chronic  alcoholism,  and  sometimes  in  rickets.  Occasionally  the  dis- 
ease is  caused  by  meningeal  cysts.  A  true  drops}^,  however,  of  the  araclinoid 
sac  probably  does  not  occur. 

The  cases  may  be  divided  into  three  groups — idiopathic  internal  hydro- 
cephalus (serous  meningitis),  congenital  or  infantile,  and  secondary  or  ac- 
quired. 

(1)  Serous  Meningitis  (Quincke)  (Idiopathic  Internal  Hydrocephalus; 
Angio-neurotic  Hydrocephalus) . — This  remarkable  form,  described  by  Quincke, 
is  very  important,  since  a  knowledge  of  the  condition  may  explain  very  anom- 
alous and  puzzling  cases.  It  is  an  ependymitis  causing  a  serous  effusion  into 
the  ventricles,  with  distention  and  pressure  effects.  It  may  be  compared  to  the 
serous  exudates  in  the  pleura  or  in  sjmovial  membranes.  It  is  not  certain 
that  the  process  is  inflammatory,  and  Quincke  likens  it  to  the  angio-neurotic 
cedema  of  the  skin.  In  very  acute  cases  the  ependyma  may  be  smooth  and 
natural  looking;  in  more  chronic  cases  it  may  be  thickened  and  sodden.  The 
exudate  does  not  differ  from  the  normal,  and  if  on  lumbar  puncture  a  fluid  is 
removed  of  a  specific  gravity  above  1.009,  with  albumin  above  two  tenths  per 
cent,  the  condition  is  more  likel}^  to  be  hydrocephalus  from  stasis,  secondary 
to  tumor,  etc. 

Both  children  and  adults  are  affected,  the  latter  more  frequently.  In  the 
acute  form  the  condition  is  mistaken  for  tuberculous  or  purulent  meningitis. 
There  are  headache,  retraction  of  the  neck,  and  signs  of  increased  intracranial 
pressure,  choked  disks,  slow  pulse,  etc.  Fever  is  usually  absent,  but  I  have 
seen  one  case  with  recurring  paroxysms  of  fever,  and  Morton  Prince  has 
described  a  similar  one.  In  both  the  exudate  was  clear  and  the  ependyma  not 
acutely  inflamed.  Quincke  has  reported  cases  of  recovery.  In  the  chronic 
form  the  symptoms  are  those  of  tumor — general,  such  as  headache,  slight  fever, 
somnolence,  and  delirium;  and  local,  as  exophthalmos,  optic  neuritis,  spasms, 
and  rigidity  of  muscles  and  paralysis  of  the  cerebral  nerves.  Eemarkable  ex- 
acerbations occur,  and  the  symptoms  vary  in  intensity  from  day  to  day. 
Eecovery  may  follow  after  an  illness  of  many  weeks,  and  some  of  the  re- 


DIFFUSE  AND  FOCAL  DISEASES  OF   THE  BRAIN.  997 

ported  cases  of  disappearance  of  all  symptoms  of  brain  tumor  belong  in  this 
category. 

(3)  Congenital  Hydrocephalus. — The  enlarged  head  may  obstruct  labor; 
more  frequently  the  condition  is  noticed  some  time  after  birth.  The  cause 
is  unknown.     It  has  occurred  in  several  members  of  the  same  family. 

The  anatomical  condition  in  these  cases  offers  no  clew  to  the  nature  of 
the  trouble.  The  lateral  ventricles  are  enormously  distended,  but  the  ependyma 
is  usually  clear,  sometimes  a  little  thickened  and  granular,  and  the  veins  large. 
The  choroid  plexuses  are  vascular,  sometimes  sclerotic,  but  often  natural  look- 
ing. The  third  ventricle  is  enlarged,  the  aqueduct  of  Sylvius  dilated,  and  the 
fourth  ventricle  may  be  distended.  The  quantity  of  fluid  may  reach  several 
litres.  It  is  limpid  and  contains  a  trace  of  albumin  and  salts.  The  changes 
in  consequence  of  this  enormous  ventricular  distention  are  remarkable.  The 
cerebral  cortex  is  greatly  stretched,  and  over  the  middle  region  the  thickness 
may  amount  to  no  more  than  a  few  millimetres  without  a  trace  of  the  sulci 
or  convolutions.  The  basal  ganglia  are  flattened.  The  skull  enlarges,  and  the 
circumference  of  the  head  of  a  child  of  three  or  four  years  may  reach  25  or 
even  30  inches.  The  sutures  widen.  Wormian  bones  develop  in  them,  and  the 
bones  of  the  cranium  become  exceedingly  thin.  The  veins  are  marked  beneath 
the  skin.  A  fluctuation  wave  may  sometimes  be  obtained,  and  Fisher's  brain 
murmur  may  be  heard.  The  orbital  plates  of  the  frontal  bone  are  depressed, 
causing  exophthalmos,  so  that  the  eyeballs  can  not  be  covered  by  the  eyelids. 
The  small  size  of  the  face,  widening  somewhat  above,  is  striking  in  comparison 
with  the  enormously  expanded  skull. 

Convulsions  may  occur.  The  reflexes  are  increased,  the  child  learns  to 
walk  late,  and  ultimately  in  severe  cases  the  legs  become  feeble  and  sometimes 
spastic.  Sensation  is  much  less  affected  than  motility.  Choked  disk  is  not 
uncommon.  The  mental  condition  is  variable;  the  child  may  be  bright,  but, 
as  a  rule,  there  is  some  grade  of  imbecility.  The  congenital  cases  usually  die 
within  the  first  four  or  five  years.  The  process  may  be  arrested  and  the  patient 
may  reach  adult  life.  Cases  of  this  sort  are  not  very  uncommon.  Even  when 
extreme,  the  mental  faculties  may  be  retained,  as  in  Bright's  celebrated  patient. 
Cardinal,  who  lived  to  the  age  of  twenty-nine,  and  whose  head  was  translucent 
when  the  sun.  was  shining  behind  him.  Care  must  be  taken  not  to  mistake 
the  rachitic  head  for  hydrocephalus. 

(3)  Acquired  Chronic  Hydrocephalus. — This  is  stated  to  be  occasionally 
primary  (idiopathic) — that  is  to  say,  it  comes  on  spontaneously  in  the  adult 
without  observable  lesion.  Dean  Swift  is  said  to  have  died  of  hydrocephalus, 
but  this  seems  very  unlikely.  It  is  based  upon  the  statement  that  "he  (Mr. 
White  way)  opened  the  skull  and  found  much  water  in  the  brain,"  a  condition 
no  doubt  of  hydrocephalus  ex  vacuo,  due  to  the  wasting  associated  with  his  pro- 
longed illness  and  paralysis.  In  nearly  all  cases  there  is  either  a  tumor  at  the 
base  of  the  brain  or  in  the  third  ventricle,  which  compresses  the  venae  Galeni. 
The  passage  from  the  third  to  the  fourth  ventricle  may  be  closed,  either  by  a 
tumor  or  by  parasites.  More  rarely  the  foramen  of  Magendie,  through  which 
the  ventricles  communicate  with  the  cerebro-spinal  meninges,  becomes  closed  by 
meningitis.  Chronic  inflammations  of  the  ependyma  may  in  similar  fashion 
block  the  foramina  of  exit  of  the  ventricular  fluid.  There  may  be  imilateral 
hydrocephalus  from  closure  of  one  of  the  foramina  of  Monro.    These  condi- 


998  DISEASES  OF  THE  NERVOUS  SYSTEM. 

tions^  occurring  in  adults,  may  produce  the  most  extreme  hydrocephalus  with- 
out any  enlargement  of  the  head.  Even  when  the  tumor  begins  early  in  life 
there  may  be  no  expansion  of  the  skull.  In  the  case  of  a  girl  aged  sixteen, 
blind  from  her  third  year,  the  head  was  not  unusually  large,  the  ventricles  were 
enormously  distended,  and  in  the  Eolandic  region  the  brain  substance  was  only 
5  mm.  in  thickness.  A  tumor  occupied  the  third  ventricle.  In  a  case  of 
cholesteatoma  of  the  floor  of  the  third  ventricle,  in  which  the  symptoms  per- 
sisted at  intervals  for  eight  or  nine  years,  the  ventricles  were  enormously 
distended  without  enlargement  of  the  skull.  In  other  instances  the  sutures 
separate  and  the  head  gradually  enlarges. 

The  symptoms  of  hydrocephalus  in  the  adult  are  curiously  variable.  In 
the  first  case  mentioned  there  were  early  headaches  and  gradual  blindness; 
then  a  prolonged  period  in  which  she  was  able  to  attend  to  her  studies.  Head- 
aches again  supervened,  the  gait  became  irregular  and  somewhat  ataxic.  Death 
occurred  suddenly.  In  the  other  case  there  were  prolonged  attacks  of  coma 
with  a  slow  pulse,  and  on  one  occasion  the  patient  remained  unconscious  for 
more  than  three  months.  Gradually  progressing  optic  neuritis  without  focal- 
izing symptoms,  headache,  and  attacks  of  somnolence  or  coma  are  suggestive 
symptoms.  These  cases  of  acquired  chronic  hydrocephalus  can  not  be  certainly 
diagnosed  during  life,  though  in  certain  instances  the  condition  may  be  sus- 
pected.    They  simulate  tumor  very  closely. 

Treatment. — Very  little  can  be  done  to  relieve  hydrocephalus.  Medicines 
are  powerless  to  cause  the  absorption  of  the  fluid.  More  rational  is  the  system 
of  gradual  compression,  with  or  without  the  withdrawal  of  small  quantities  of 
the  fluid.  The  compression  may  be  made  by  means  of  broad  plasters,  so  applied 
as  to  cross  each  other  on  the  vertex,  and  another  may  be  placed  round  the  cir- 
cumference.   In  the  meningitis  serosa  Quincke  advises  the  use  of  mercury. 

Of  late  years  puncture  of  the  ventricles,  an  operation  which  had  been 
abandoned,  has  been  revived;  it  has  been  resorted  to  in  the  meningitis  serosa. 
When  pressure  s^^mptoms  are  marked  Quincke's  procedure  may  be  used.  He 
recommends  puncture  of  the  subarachnoid  sac  between  the  third  and  the  fourth 
lumbar  vertebrge.  At  this  point  the  spinal  cord  can  not  be  touched.  The 
advantages  are  a  slower  removal  of  fluid  and  less  danger  of  collapse. 

Attempts  have  been  made  recently  to  find  some  method  of  establishing  per- 
manent drainage,  either  between  the  ventricles  and  the  intracranial  subdural 
space  or  between  the  lumbar  subaraclmoid  space  and  the  abdominal  cavity. 


F.    DISEASES   OF   THE   PERLPHEKAL   KERVES. 
I.    NEURITIS   (Inflammation  of  the  Bundles  of  Nerve  Fibres). 

Xeuritis  may  be  localized  in  a  single  nerve,  or  general,  involving  a  large 
number  of  nerves,  in  which  case  it  is  usually  known  as  7niiltiph  neuritis  or 
polynetiritis. 

Etiology. — Localized  neuritis  arises  from  (a)  cold,  which  is  a  very  fre- 
quent cause,  as,  for  example,  in  the  facial  nerve.  This  is  sometimes  known 
as  rheumatic  neuritis.  (&)  Traumatism — wounds,  blows,  direct  pressure  on 
the  nerves,  the  tearing  and  stretching  which  follow  a  dislocation  or  a  frac- 


DISEASES  OF  THE  PERIPHERAL  NERVES.  999 

tiire,  and  the  hypodermic  injection  of  ether.  Under  this  section  come  also 
the  professional  palsies,  due  to  pressure  in  the  exercise  of  certain  occupations, 
(c)  Extension  of  inflammation  from  neighboring  parts,  as  in  a  neuritis  of  the 
facial  nerve  due  to  caries  in  the  temporal  bone,  or  in  that  met  with  in  syphilitic 
disease  of  the  bones,  disease  of  the  joints,  and  occasionally  in  tumors. 

Multiple  neuritis  has  a  very  complex  etiology,  the  causes  of  which  may 
be  classified  as  follows:  (a)  The  poisons  of  infectious  diseases,  as  in  leprosy, 
diphtheria,  typhoid  fever,  small-pox,  scarlet  fever,  and  occasionally  in  other 
forms;  (h)  the  organic  poisons,  comprising  the  diffusible  stimulants,  such 
as  alcohol  and  ether,  bisulphide  of  carbon  and  naphtha,  and  the  metallic 
bodies,  such  as  lead,  arsenic,  and  mercury;  (c)  cachectic  conditions,  such  as 
occur  in  angemia,  cancer,  tuberculosis,  or  marasmus  from  any  cause;  (d)  the 
endemic  neuritis  or  beri-beri;  and  (e)  lastly,  there  are  cases  in  which  none 
of  these  factors  prevail,  but  the  disease  sets  in  suddenly  after  overexertion  or 
exposure  to  cold. 

Morbid  Anatomy. — In  neuritis  due  to  the  extension  of  inflammation  the 
nerve  is  usually  swollen,  infiltrated,  and  red  in  color.  The  inflammation  may 
be  chiefly  perineural  or  it  may  pass  into  the  deeper  portion — interstitial  neu- 
ritis— in  which  form  there  is  an  accumulation  of  lymphoid  elements  between 
the  nerve  bundles.  The  nerve  fibres  themselves  may  not  appear  involved,  but 
there  is  an  increase  in  the  nuclei  of  the  sheath  of  Schwann.  The  myelin  is 
fragmented,  the  nuclei  of  the  internodal  cells  are  swollen,  and  the  axis-cylin- 
ders present  varicosities  or  undergo  granular  degeneration.  Ultimately  the 
nerve  fibres  may  be  completely  destroyed  and  replaced  by  a  fibrous  connective 
tissue  in  which  much  fat  is  sometimes  deposited — the  lipomatous  neuritis  of 
Ley den. 

In  other  instances  the  condition  is  termed  parenchymatous  neuritis,  in 
which  the  changes  are  like  those  met  with  in  the  secondary  or  Wallerian 
degeneration,  which  follows  when  the  nerve  fibre  is  cut  off  from  the  cell  body 
of  the  neurone  to  which  it  belongs.  The  medullary  substance  and  the  axis- 
cylinders  are  chiefly  involved,  the  interstitial  tissue  being  but  little  altered  or 
only  affected  secondarily.  The  myelin  becomes  segmented  and  divides  into 
small  globules  and  granules,  and  the  axis-cylinders  become  granular,  broken, 
subdivided,  and  ultimately  disappear.  The  nuclei  of  the  sheath  of  Schwann 
proliferate  and  ultimately  the  fibres  are  reduced  to  a  state  of  atrophic  tubes 
without  a  trace  of  the  normal  structure.  The  muscles  connected  with  the 
degenerated  nerves  usually  show  marked  atrophic  changes,  and  in  some 
instances  the  change  in  the  nerve  sheath  appears  to  extend  directly  to  the 
interstitial  tissue  of  the  muscles — the  neuritis  fascians  of  Eichhorst. 

Symptoms. —  (a)  Localized  Neuritis. — As  a  rule  the  constitutional  dis- 
turbances are  slight.  The  most  important  symptom  is  pain  of  a  boring  or 
stabbing  character,  usually  felt  in  the  course  of  the  nerve  and  in  the  parts  to 
which  it  is  distributed.  The  nerve  itself  is  sensitive  to  pressure,  probably,  as 
Weir  Mitchell  suggests,  owing  to  the  irritation  of  its  nervi  nervorum.  The 
skin  may  be  slightly  reddened  or  even  oedematous  over  the  seat  of  the  inflam- 
mation. Mitchell  has  described  increase  in  the  temperature  and  sweating 
in  the  affected  region,  and  such  trophic  disturbances  as  effusion  into  the  Joints 
and  herpes.  The  function  of  the  muscle  to  which  the  nerve  fibres  are  distrib- 
uted is  impaired,  motion  is  painful,  and  there  may  be  twitchings  or  contrac- 


1000  DISEASES  OF   THE  NERVOUS  SYSTEM. 

tions.  The  tactile  sensation  of  the  part  may  be  somewhat  deadened,  even  when 
the  pain  is  greatly  increased.  In  the  more  chronic  cases  of  local  neuritis,  such, 
for  instance,  as  follow  the  dislocation  of  the  humerus,  the  localized  pain,  which 
at  first  may  be  severe,  gradually  disappears,  though  some  sensitiveness  of  the 
brachial  plexus  may  persist  for  a  long  time,  and  the  nerve  cords  may  be  felt 
to  be  swollen  and  firm.  The  pain  is  variable — sometimes  intense  and  distress- 
ing; at  others  not  causing  much  inconvenience.  Xumbness  and  formication 
may  be  present  and  the  tactile  sensation  may  be  greatly  impaired.  The  motor 
disturbances  are  marked.  Ultimately  there  is  extreme  atrophy  of  the  muscles. 
Contractures  may  occur  in  the  fingers.  The  skin  may  be  reddened  or  glossy, 
the  subcutaneous  tissue  cedematous,  and  the  nutrition  of  the  nails  may  be 
defective.    In  the  rheumatic  neuritis  subcutanous  fibroid  nodules  may  develop. 

A  neuritis  limited  at  first  to  a  peripheral  nerve  may  extend  upward — 
the  so-called  ascending  or  migratory  neuritis — and  involve  the-  larger  nerve 
trunks,  or  even  reach  the  spinal  cord,  causing  subacute  myelitis  (Gowers). 
The  condition  is  rarely  seen  in  the  neuritis  from  cold,  or  in  that  which  fol- 
lows fevers;  but  it  occurs  most  frequently  in  traumatic  neuritis. 

J.  K.  Mitchell,  in  his  monograph  on  injuries  of  nerves,  concludes  that  the 
larger  nerve  trunks  are  most  susceptible,  and  that  the  neuritis  may  spread  either 
up  or  down,  the  former  being  the  most  common.  The  paralysis  secondary  to 
visceral  disease,  as  of  the  bladder,  may  be  due  to  an  ascending  neuritis.  The 
inflammation  may  extend  to  the  nerves  of  the  other  side,  either  through  the 
spinal  cord  or  its  membranes,  or  Avithout  any  involvement  of  the  nerve-cen- 
tres, the  so-called  sympathetic  neuritis.  The  electrical  changes  in  localized 
neuritis  vary  a  great  deal,  depending  upon  the  extent  to  which  the  nerve  is 
injured.  The  lesion  may  be  so  slight  that  the  nerve  and  the  muscles  to  which  it 
is  distributed  may  react  normally  to  both  currents ;  or  it  may  be  so  severe  that 
the  t}^ical  reaction  of  degeneration  develops  within  a  few  days — i.  e.,  the  nerve 
does  not  respond  to  stimulation  by  either  current,  while  the  muscle  reacts  only 
to  the  galvanic  current  and  in  a  peculiar  maimer.  The  contraction  caused  is 
slow  and  lazy,  instead  of  sharp  and  quick  as  in  the  normal  muscle,  and  the 
AC  contraction  is  usually  stronger  than  the  KC  contraction.  Between  these 
two  extremes  there  are  many  different  grades,  and  a  careful  electrical  exam- 
ination is  most  important  as  an  aid  to  diagnosis  and  prognosis.* 

The  duration  varies  from  a  few  days  to  weeks  or  months.  A  slight  trau- 
matic neuritis  may  pass  off  in  a  day  or  two,  while  the  severer  cases,  such  as 
follow  unreduced  dislocation  of  the  humerus,  may  persist  for  months  or  never 
be  completely  relieved. 

(6)  Multiple  Neuritis. — This  presents  a  complex  sjTQptomatology.  The 
following  are  the  most  important  groups  of  cases : 

(1)  Acute  Fehrile  Polyneuritis. — The  attack  follows  exposure  to  cold  or 
overexertion,  or,  in  some  instances,  comes  on  spontaneously.  The  onset  resem- 
bles that  of  an  acute  infectious  disease.  There  may  be  a  definite  chill,  pains 
in  the  back  and  limbs  or  joints,  so  that  the  case  may  be  thought  to  be  acute 
rheumatism.  The  temperature  rises  rapidly  and  may  reach  103°  or  104°. 
There  are  headache,  loss  of  appetite,  and  the  general  symptoms  of  acute  in- 
fection.    The  limbs  and  back  ache.     Intense  pain  in  the  nerves,  however,  is 

*  See  under  Facial  Paralysis. 


DISEASES  OF  THE  PERIPHERAL  NERVES.  1001 

by  no  means  constant.  Tingling  and  formication  are  felt  in  the  fingers  and 
toes,  and  there  is  increased  sensitiveness  of  the  nerve  trunks  or  of  the  entire 
limb.  Loss  of  muscular  power,  first  marked,  perhaps,  in  the  legs,  gradually 
comes  on  and  extends  with  the  features  of  an  ascending  paralysis.  In  other 
cases  the  paralysis  begins  in  the  arms.  The  extensors  of  the  wrists  and  the 
flexors  of  the  ankles  are  early  affected,  so  that  there  is  foot  and  wrist  drop. 
In  severe  cases  there  is  general  loss  of  muscular  power,  producing  a  flabby 
paralysis,  which  may  extend  to  the  muscles  of  the  face  and  to  the  intercostals, 
and  respiration  may  be  carried  on  by  the  diaphragm  alone.  The  muscles  soften 
and  waste  rapidly.  There  may  be  only  hypersesthesia  with  soreness  and  stiff- 
ness of  the  limbs;  in  some  cases,  increased  sensitiveness  with  anaesthesia;  in 
other  instances  the  sensory  disturbances  are  slight.  The  clinical  picture  is 
not  to  be  distinguished,  in  many  cases,  from  Landry's  paralysis ;  in  others,  from 
the  subacute  myelitis  of  Duchenne. 

The  course  is  variable.  In  the  most  intense  forms  the  patient  may  die  in 
a  week  or  ten  days,  with  involvement  of  the  respiratory  muscles  or  from 
paralysis  of  the  heart.  As  a  rule  in  cases  of  moderate  severity,  after  persist- 
ing for  five  or  six  weeks,  the  condition  remains  stationary  and  then  slow 
improvement  begins.  The  paralysis  in  some  muscles  may  persist  for  many 
months  and  contractures  may  occur  from  shortening  of  the  muscles,  but  even 
when  this  occurs  the  outlook  is,  as  a  rule,  good, .  although  the  paralysis  may 
have  lasted  for  a  year  or  more. 

(3)  Recurring  Multiple  Neuritis. — Under  the  term  polyneuritis  recurrens 
Mary  Sherwood  has  described  from  Eichhorst's  clinic  2  cases  in  adults — in 
one  case  involving  the  nerves  of  the  right  arm,  in  the  other  both  legs.  In 
one  patient  there  were  three  attacks,  in  the  other  two,  the  distribution  in  the 
various  attacks  being  identical.  The  subject  has  been  fully  discussed  by  H.  M. 
Thomas  (Phila.  Med.  Jour.,  1898,  i). 

(3)  Alcoholic  Neuritis. — This,  perhaps  the  most  important  form  of  mul- 
tiple neuritis,  was  graphically  described  in  1832  by  James  Jackson,  Sr.,  of 
Boston.  Wilks  recognized  it  as  alcoholic  paraplegia,  but  the  starting-point 
of  the  recent  researches  on  the  disease  dates  from  the  observations  of  Dumenil, 
of  Eouen.  Of  late  years  our  knowledge  of  the  disease  has  extended  rapidly, 
owing  to  the  researches  of  Huss,  Leyden,  James  Boss,  Buzzard,  and  Henry 
Hun.  It  occurs  most  frequently  in  women,  particularly  in  steady,  quiet  tip- 
plers. Its  appearance  may  be  the  first  revelation  to  the  physician  or  to  the 
family  of  habits  of  secret  drinking.  The  onset  is  usually  gradual,  and  may 
be  preceded  for  weeks  or  months  by  neuralgic  pains  and  tingling  in  the  feet 
and  hands.  Convulsions  are  not  uncommon.  Fever  is  rare.  The  paralysis 
gradually  sets  in,  at  first  in  the  feet  and  legs,  and  then  in  the  hands  and  fore- 
arms. The  extensors  are  affected  more  than  the  flexors,  so  that  there  is  wrist- 
drop and  foot-drop.  The  paralysis  may  be  thus  limited  and  not  extend  higher 
in  the  limbs.  In  other  instances  there  is  paraplegia  alone,  while  in  the  most 
extreme  cases  all  the  extremities  are  involved.  In  rare  instances  the  facial 
muscles  and  the  sphincters  are  also  affected.  The  sensory  symptoms  are  very 
variable.  There  are  cases  in  which  there  are  numbness  and  tingling  only, 
without  great  pain.  In  other  cases  there  are  severe  burning  or  boring  pains, 
the  nerve  trunks  are  sensitive,  and  the  muscles  are  sore  when,  grasped.  The 
hands  and  feet  are  frequently  swollen  and  congested,  particularly  when  held 


1002  DISEASES  OF  THE  NERVOUS  SYSTEM. 

down  for  a  few  moments.     The  cutaneous  reflexes  as  a  rule  are  preserved. 
The  deep  reflexes  are  usually  lost. 

The  course  of  these  alcoholic  cases  is,  as  a  rule,  favorable,  and  after  per- 
sisting for  weeks  or  months  improvement  gradually  begins,  the  muscles  regain 
their  power,  and  even  in  the  most  desperate  cases  recovery  may  follow.  The 
extensors  of  the  feet  may  remain  paralyzed  for  some  time,  and  give  to  the 
patient  a  distinctive  walk,  the  so-called  steppage  gait,  characteristic  of  periph- 
eral neuritis.  It  is  sometimes  known  as  the  pseudo-tabetic  gait,  although  in 
reality  it  could  not  well  be  mistaken  for  the  gait  of  ataxia.  The  foot  is  thrown 
forcibly  forward,  the  toe  lifted  high  in  the  air  so  as  not  to  trip  upon  it.  The 
entire  foot  is  slapped  upon  the  ground  as  a  flail.  It  is  an  awkward,  clumsy 
gait,  and  gives  the  patient  the  appearance  of  constantly  stepping  over  obstacles. 
Among  the  most  striking  features  of  alcoholic  neuritis  are  the  mental  symp- 
toms. Delirium  is  common,  and  there  may  be  hallucinations  with  extravagant 
ideas,  resembling  somewhat  those  of  general  paralysis.  In  some  cases  the  pic- 
ture is  that  of  ordinary  delirium  tremens,  but  the  most  peculiar  and  almost 
characteristic  mental  disorder  is  that  so  well  described  by  Wilks,  in  which  the 
patient  loses  all  appreciation  of  time  and  place,  and  describes  with  circum- 
stantial details  long  journeys  which,  he  says,  he  has  recently  taken,  or  tells  of 
persons  whom  he  has  just  seen.    This  is  the  so-called  Korsakoff's  syndrome. 

(4)  Multiple  Neuritis  in  the  Infectious  Diseases. — This  has  been  already 
referred  to,  particularly  in  diphtheria,  in  which  it  is  most  common.  The 
peripheral  nature  of  the  lesion  in  these  instances  has  been  shown  by  post- 
mortem examination.  The  outlook  is  usually  favorable  and,  except  in  diph- 
theria, fatal  cases  are  uncommon.  Multiple  neuritis  in  tuberculosis,  diabetes, 
and  s}qDhilis  is  of  the  same  nature,  being  probably  due  to  toxic  materials 
absorbed  into  the  blood. 

(5)  The  Metallic  Poisons. — Neuritis  from  arsenic  may  follow:  (a)  The 
medicinal  use  particularly  of  Fowler's  solution.  I  have  reported  a  case  of 
Hodgkin's  disease  in  which  general  neuritis  was  caused  by  §  j  3  ij  of  the 
solution.  In  chorea  a  good  many  cases  have  been  reported.  Changes  in  the 
nails  are  not  uncommon,  chiefly  the  transverse  ridging.  In  one  case  in  my 
wards,  of  a  young  woman  who  had  taken  rough-on-rats,  there  were  remarkable 
white  lines — the  leuconychia — running  across  the  nails,  without  any  special 
ridging.  C.  J.  Aldrich  finds  that  this  is  not  uncommon  in  chronic  arsenical 
poisoning.  (&)  The  accidental  contamination  of  food  or  drink.  Chrome 
yellow  may  be  used  to  color  cakes,  as  in  the  cases  recorded  by  D.  D.  Stewart. 
A  remarkable  epidemic  of  neuritis  occurred  recently  in  the  Midland  Counties 
of  England,  which  was  traced  to  the  use  of  beer  containing  small  quantities 
of  arsenic,  a  contamination  from  the  sulphuric  acid  used  in  making  glucose. 
Some  hundreds  of  cases  occurred.  Ee}Tiolds,  who  studied  these  cases,  believes 
that  most  of  the  instances  of  neuritis  in  drinkers  are  arsenical,  but  admits  that 
the  slight  cases  may  be  due  to  the  alcohol  itself.  Pigmentation  of  the  skin  is 
an  important  distinguishing  sign.  The  general  features  have  been  referred  to 
under  arsenical  poisoning.  Lead  is  a  much  more  frequent  cause.  Neuritis 
has  followed  the  use  of  mercurial  inunctions.  Zinc  is  a  rare  cause.  I  saw  a 
case  with  Dr.  Urban  Smith  which  followed  the  use  of  two  grains  of  the 
sulpho-carbolate  taken  daily  for  three  years.  Tea  coffee,  and  tobacco  are 
mentioned  as  rare  causes. 


DISEASES  OF   THE  PERIPHERAL  NERVES.  1003 

(6)  Endemic  Neuritis,  Beri-heri,  has  been  considered  under  the  Infectious 
Diseases. 

Anesthesia  Paralysis. — Here  perhaps  may  most  appropriately  be  con- 
sidered the  forms  of  paralysis  following  the  use  of  anaesthetics,  or  of  too 
long-continued  compression  during  operations.  Much  has  been  written  in 
the  past  few  years  upon  this  subject.     There  are  two  groups  of  cases : 

1.  During  an  operation  the  nerves  may  be  compressed,  either  the  brachial 
plexus  by  the  humerus  or  the  musculo-spiral  by  the  table.  The  pressure  most 
frequently  occurs  when  the  arm  is  elevated  alongside  the  head,  as  in  laparot- 
omy done  in  the  Trendelenburg  position,  or  held  out  from  the  body,  as  in 
breast  amputations.  Instances  of  paralysis  of  the  crural  nerves  by  leg-holders 
are  also  reported.  The  too  firm  application  of  a  tourniquet  may  be  followed 
by  a  severe  paralysis. 

2.  Paralysis  from  cerebral  lesions  during  etherization.  In  one  of  Gar- 
rigues'  cases  paralysis  followed  the  operation,  and  at  the  autopsy,  seven  weeks 
later,  softening  of  the  brain  was  found.  Apoplexy  or  embolism  may  occur 
during  ansesthesia.  In  Montreal  a  cataract  operation  was  performed  on  an 
old  man.  He  did  not  recover  from  the  anaesthetic;  I  found  post  mortem  a 
cerebral  haemorrhage.  A  man  was  admitted  to  the  Philadelphia  Hospital,  com- 
pletely comatose,  who  on  the  previous  day  had  been  given  ether  for  a  minor 
operation.  He  never  recovered  consciousness,  but  remained  deeply  comatose, 
with  great  muscular  relaxation,  low  temperature,  97.5°,  and  noisy  respirations; 
he  died  two  days  later.  There  was,  unfortunately,  no  autopsy.  Epileptic 
convulsions  may  occur  during  the  ansesthesia,  and  may  even  prove  -fatal.  The 
possibility  has  to  be  considered  of  paralysis  from  loss  of  blood  in  prolonged 
operations,  though  I  have  no  personal  knowledge  of  any  such  cases. 

And,  lastly,  a  paralysis  might  result  from  the  toxic  effects  of  the  ether  in 
a  very  protracted  administration. 

Diagnosis. — The  electrical  condition  in  multiple  neuritis  is  thus  described 
by  Allen  Starr :  "  The  excitability  is  very  rapidly  and  markedly  changed ;  but 
the  conditions  which  have  been  observed  are  quite  various.  Sometimes  there 
is  a  simple  diminution  of  excitability,  and  then  a  very  strong  faradic  or 
galvanic  current  is  needed  to  produce  contractions.  Frequently  all  faradic 
excitability  is  lost  and  then  the  muscles  contract  to  a  galvanic  current  only. 
In  this  condition  it  may  require  a  very  strong  galvanic  current  to  produce 
contraction,  and  thus  far  it  is  quite  pathognomonic  of  neuritis.  For  in  an- 
terior polio-myelitis,  where  the  muscles  respond  to  galvanism  only,  it  does 
not  require  a  strong  current  to  cause  a  motion  until  some  months  after  the 
invasion. 

"  The  action  of  the  different  poles  is  not  uniform.  In  many  cases  the  con- 
traction of  the  muscle  when  stimulated  with  the  positive  pole  is  greater  than 
when  stimulated  with  the  negative  pole,  and  the  contractions  may  be  sluggish. 
Then  the  reaction  of  degeneration  is  present.  But  in  some  cases  the  normal 
condition  is  found  and  the  negative  pole  produces  stronger  contractions  than 
the  positive  pole.  A  loss  of  faradic  irritability  and  a  marked  decrease  in  the 
galvanic  irritability  of  the  muscle  and  nerve  are  therefore  important  symp- 
toms of  multiple  neuritis." 

There  is  rarely  any  diflficulty  in  distinguishing  the  alcohol  eases.  The 
combination  of  wrist  and  foot  drop  with  congestion  of  the  hands  and  feet. 


1004  DISEASES  OF   THE   NERVOUS  SYSTEM. 

and  the  peculiar  delirium  already  referred  to,  is  quite  characteristic.  The 
rapidly  advancing  cases  with  paralysis  of  all  extremities,  often  reaching  to 
the  face  and  involving  the  sphincters,  are  more  commonly  regarded  as  of 
spinal  origin,  but  the  general  opinion  seems  to  point  strongly  to  the  fact  that 
all  such  cases  are  peripheral.  The  less  acute  cases,  in  which  the  paralysis 
gradually  involves  the  legs  and  arms  with  rapid  wasting,  simulate  closely  and 
are  usually  confounded  with  the  subacute  atrophic  spinal  paralysis  of  Du- 
chenne.  The  diagnosis  from  locomotor  ataxia  is  rarely  difficult.  The  steppage 
gait  is  entirely  different  from  that  of  tabes.  There  is  rarely  positive  incoor- 
dination. The  patient  can  usually  stand  well  with  the  eyes  closed.  Foot-drop 
is  not  common  in  locomotor  ataxia.  The  lightning  pains  are  absent  and  there 
are  no  pupillary  s}Tnptoms.  The  etiology,  too,  is  of  moment.  The  patient 
is  recovering  from  a  paralysis  which  has  been  more  extensive,  or  from  arsen- 
ical poisoning,  or  he  has  diabetes. 

Treatment. — Eest  in  bed  is  essential.  In  the  acute  cases  with  fever,  the 
salicylates  and  antipyrin  are  recommended.  To  allay  the  intense  pain  morphia 
or  the  hot  applications  of  lead  water  and  laudanum  are  often  required.  Great 
care  must  be  exercised  in  treating  the  alcoholic  form,  and  the  physician  must 
not  allow  himself  to  be  deceived  by  the  statements  of  the  relatives.  It  is  some- 
times exceedingly  difficult  to  get  a  history  of  spirit-drinking.  In  the  alcoholic 
form  it  is  well  to  reduce  the  stimulants  gradually.  If  there  is  any  tendency 
to  bed-sores  an  air-bed  should  be  used  or  the  patient  placed  in  a  continuous 
bath.  Gentle  friction  of  the  muscles  may  be  applied  from  the  outset,  and  in 
the  later  stages,  when  the  atrophy  is  marked  and  the  pains  have  lessened, 
massage  is  probably  the  most  reliable  means  at  our  command.  Contrac- 
tures may  be  gradually  overcome  by  passive  movements  and  extension.  Often 
with  the  most  extreme  deformity  from  contracture,  recovery  is,  in  time, 
still  possible.  The  interrupted  current  is  useful  when  the  acute  stage  is 
passed. 

Of  internal  remedies,  strychnia  is  of  value  and  may  be  given  in  increasing 
doses.  Arsenic  also  may  be  employed,  and  if  there  is  a  history  of  syphilis 
the  iodide  of  potassium  and  mercury  may  be  given. 

II.     NEUROMATA. 

Tumors  situated  on  nerve  fibres  may  consist  of  nerve  substance  proper,  the 
true  neuromata,  or  of  fibrous  tissue,  the  false  neuromata.  The  true  neuroma 
usually  contains  nerve  fibres  only,  or  in  rare  instances  ganglion  cells.  Cases 
of  ganglionic  or  medullary  neuroma  are  extremely  rare;  some  of  them,  as 
Lancereaux  suggests,  are  undoubtedly  instances  of  malformation  of  the  brain 
substance.  In  other  instances,  as  in  the  case  which  I  reported,  the  tumor  is, 
in  all  probability,  a  glioma  with  cells  closely  resembling  those  of  the  central 
nervous  system.  The  growths  are  often  intermediate  in  their  anatomical  struc- 
ture between  the  true  and  the  false.  Thomson's  monograph,  On  Neuroma 
and  Neurofibromatosis  (Edin.,  1900),  should  be  consulted. 

(1)  Plexiform  Neuroma. — In  this  remarkable  condition  the  various  nerve 
cords  may  be  occupied  by  many  hundreds  of  tumors.  The  eases  are  often 
hereditary  and  usually  congenital.  The  tumors  may  occur  in  all  the  nerves 
of  the  body,  and  as  numbers  of  them  may  be  made  out  on  palpation,  the  diag- 


DISEASES  OF  THE  PERIPHERAL  NERVES.  1005 

nosis  is  usually  easy.  One  of  the  most  remarkable  cases  is  that  described  by 
Prudden,  the  specimens  of  which  are  in  the  medical  museum  of  Columbia 
College,  New  York.  There  were  over  1,182  distinct  tumors  distributed  on  the 
nerves  of  the  body.  These  tumors  rarely  are  painful,  but  may  cause  symptoms 
through  pressure  on  neighboring  structures. 

(2)  Generalized  Neurofibromatosis:  von  Recklinghausen's  Disease. — Spe- 
cial attention  was  first  directed  to  this  particular  form  of  multiple  neuroma 
by  von  Eecklinghausen  in  1882.  There  are  four  essential  features  of  the 
malady : 

(a)  Soft,  fibrous  nodules,  some  sessile,  others  pedunculated,  varying  greatly 
in  size  and  number,  are  scattered  over  the  surface  of  the  body.  These  sub- 
cutaneous growths  at  times  may  be  diffuse  and  reach  an  enormous  size,  pro- 
ducing a  condition  called  "  Elephantiasis  Neuromatosa." 

(&)  Tumors  resembling  those  of  plexiform  neuroma  may  be  present  on 
any  part  of  the  nerve  trunks  from  their  central  origin  to  the  periphery.  Their 
variable  situation  may  lead  to  a  variety  of  symptoms,  more  especially  as  they 
may  arise  from  the  nerve  roots  within  the  spinal  canal  or  cranium.  Superficial 
painful  nodules  may  also  be  present. 

(c)  Patches  of  brownish  pigmentation  of  the  skin,  either  as  small  spots  or 
large  areas,  are  always  present.  Congenital  nsevi  are  a  frequent  accompani- 
ment of  the  disease. 

(d)  There  are  many  variable  sensory  or  motor  phenomena  resulting  from 
the  presence  of  the  nerve  tumors,  but  peculiar  mental  changes,  with  loss  of 
intellectual  power  and  sometimes  difficulty  in  speaking,  are  especially  charac- 
teristic of  the  disease. 

The  prognosis  depends  on  the  possibility  of  successful  removal  of  such 
tumors  as  are  causing  greatest  inconvenience.  For  a  complete  recent  resume 
of  the  subject  see  Adrian's  review  in  the  Cent.  f.  d.  Grenzgebiete  d.  Med.  u. 
Chir.,  1903. 

(3)  "  TubercTila  Dolorosa." — Multiple  neuromata  may  especially  affect  the 
terminal  cutaneous  branches  of  the  sensory  nerves  and  lead  to  small  subcu- 
taneous painful  nodules,  often  found  on  the  face,  breast,  or  about  the  joints. 
They  may  be  associated  with  tumors  of  the  nerve  trunks. 

(4)  "  Amputation  Neuromata." — These  bulbous  swellings  may  form  on 
the  central  ends  of  nerves  which  have  been  divided  in  injuries  or  operations. 
They  are  especially  common  after  amputations.  They  are  due  to  the  tangled 
coil  of  axis-cylinder  processes  growing  down  from  the  central  stump  in  an 
effort  to  reach  their  former  end  structures.  They  are  very  painful,  and  usually 
require  surgical  removal,  but  often  recur. 

III.     DISEASES    OF    THE    CEREBRAL    NERVES. 

Olfactory  Nerves  and  Tracts. 

The  functions  of  the  olfactory  nerves  may  be  disturbed  at  their  origin, 
in  the  nasal  mucous  membrane,  at  the  bulb,  in  the  course  of  the  tract,  or 
at  the  centres  in  the  brain.  The  disturbances  may  be  manifested  in  sub- 
jective sensations  of  smell,  complete  loss  of  the  sense,  and  occasionally  in 
hypersesthesia. 


1006  DISEASES  OF   THE  NERVOUS  SYSTEM. 

(a)  Subjective  Sensations;  Parosmia. — Hallucinations  of  this  kind  are 
found  in  the  insane  and  in  epileps}'.  The  aura  may  be  represented  by  an 
unpleasant  odor,  described  as  resembling  chloride  of  lime,  burning  rags,  or 
feathers.  In  a  few  cases  with  these  subjective  sensations  tumors  have  been 
found  in  the  hippocampi.  In  rare  instances,  after  injury  of  the  head  the 
sense  is  perverted — odors  of  the  most  different  character  may  be  alike,  or  the 
odor  may  be  changed,  as  in  a  patient  noted  by  Morell  Mackenzie,  who  for 
some  time  could  not  touch  cooked  meat,  as  it  smelt  to  her  exactly  like  stink- 
ing fish. 

(&)  Increased  sensitiveness,  or  hyperosmia,  occurs  chiefly  in  nervous,  hys- 
terical women,  in  whom  it  may  sometimes  be  developed  so  greatly  that,  like 
a  dog,  they  can  recognize  the  difference  between  individuals  by  the  odor  alone. 

(c)  Anosmia;  Loss  of  the  Sense  of  Smell. — This  may  be  produced  by: 
(1)  Affections  of  the  origin  of  the  nerves  in  the  mucous  membrane,  which 
is  perhaps  the  most  frequent  cause.  It  is  by  no  means  uncommon  in  asso- 
ciation with  chronic  nasal  catarrh  and  pol}^i.  In  paralysis  of  the  fifth 
nerve,  the  sense  of  smell  may  be  lost  on  the  affected  side,  owing  to  interfer- 
ence with  the  secretion. 

It  is  doubtful  whether  the  cases  of  loss  of  smell  following  the  inhalations 
of  very  foul  or  strong  odors  should  come  under  this  or  under  the  central 
division. 

(2)  Lesions  of  the  bulbs  or  of  the  tracts.  In  falls  or  blows,  in  caries 
of  the  bones,  and  in  meningitis  or  tumor,  the  bulbs  or  the  olfactory  tracts 
may  be  involved.  After  an  injury  to  the  head  the  loss  of  smell  may  be  the 
only  symptom.  j\Iackenzie  notes  a  case  of  a  surgeon  who  was  thrown  from 
his  gig  and  lighted  on  his  head.  The  injury  was  slight,  but  the  anosmia 
which  followed  was  persistent.  In  locomotor  ataxia  the  sense  of  smell  may 
be  lost,  possibly  owing  to  atrophy  of  the  nerves. 

(3)  Lesions  of  the  olfactory  centres.  There  are  congenital  cases  in  which 
the  structures  have  not  been  developed.  Cases  have  been  reported  by  Beevor, 
Hughlings  Jackson,  and  others,  in  which  anosmia  has  been  associated  with 
disease  in  the  hemisphere.  The  centre  for  the  sense  of  smell  is  placed  by 
Ferrier  in  the  uncinate  gyrus.  Flechsig  describes  (1)  a  frontal  centre  in  the 
base  of  the  frontal  lobe  and  (2)  a  temporal  centre  in  the  uncus. 

To  test  the  sense  of  smell  the  pungent  bodies,  such  as  ammonia,  which 
act  upon  the  fifth  nerve,  should  not  be  used,  but  such  substances  as  cloves, 
peppermint,  and  musk.  This  sense  is  readily  tested  as  a  routine  matter  in 
brain  cases  by  having  two  or  three  bottles  containing  the  essential  oils.  In 
all  instances  a  rhinoscopical  examination  should  be  made,  as  the  condition 
may  be  due  to  local,  not  central  causes.  The  treutment  is  unsatisfactory 
even  in  the  cases  due  to  local  lesions  in  the  nostrils. 

Optic  Nerve  axd  Tract. 
(1)  Lesions  of  the  Retiyia. 

These  are  of  importance  to  the  physician,  and  information  of  the  great- 
est value  may  be  obtained  by  a  systematic  examination  of  the  eye-grounds. 
Only  a  brief  reference  can  here  be  made  to  the  more  important  of  the  appear- 
ances. 


DISEASES  OF  THE  PERIPHERAL  NERVES.  1007 

(a)  Retinitis. — This  occurs  in  certain  general  affections,  more  particu- 
larly in  Bright's  disease,  syphilis,  leukgemia,  and  aneemia.  The  common 
feature  in  all  these  states  is  the  occurrence  of  hgemorrhage  and  the  develop- 
ment of  opacities.  There  may  also  be  a  diffuse  cloudiness  due  to  effusion 
of  serum.  The  haemorrhages  are  in  the  layer  of  nerve  fibres.  They  vary 
greatly  in  size  and  form,  but  often  follow  the  course  of  vessels.  When  recent 
the  color  is  bright  red,  but  they  gradually  change  and  old  hgemorrhages  are 
almost  black.  The  white  spots  are  due  either  to  fibrinous  exudate  or  to  fatty 
degeneration  of  the  retinal  elements,  and  occasionally  to  accumulation  of  leu- 
cocytes or  to  a  localized  sclerosis  of  the  retinal  elements.  The  more  important 
of  the  forms  of  retinitis  to  be  recognized  are : 

Albuminuric  retinitis,  which  occurs  in  chronic  nephritis,  particularly  in 
the  interstitial  or  contracted  form.  The  percentage  of  cases  affected  is  from 
15  to  25.  There  are  instances  in  which  these  retinal  changes  are  associated 
with  the  granular  kidney  at  a  stage  when  the  amount  of  albumin  may  be 
slight  or  transient;  but  in  all  such  instances  it  will  be  found  that  there  is  a 
marked  arterio-sclerosis.  Gowers  recognizes  a  degenerative  form  (most  com- 
mon), in  which,  with  the  retinal  changes,  there  may  be  scarcely  any  alteration 
in  the  disk;  a  hsemorrhagic  form,  with  many  hsemorrhages  and  but  slight 
signs  of  inflammation;  and  an  inflammatory  form,  in  which  there  is  much 
swelling  of  the  retina  and  obscuration  of  the  disk.  It  is  noteworthy  that  in 
some  instances  the  inflammation  of  the  optic  nerve  predominates  over  the 
retinal  changes,  and  one  may  be  in  doubt  for  a  time  whether  the  condition  is 
really  associated  with  the  renal  changes  or  dependent  upon  intracranial 
disease. 

Syphilitic  Retinitis. — In  the  acquired  form  this  is  less  common  than  cho- 
roiditis.   In  inherited  syphilis  retinitis  pigmentosa  is  sometimes  met  with. 

Retinitis  in  Ancemia. — It  has  long  been  known  that  a  patient  may  become 
blind  after  a  large  haemorrhage,  either  suddenly  or  within  two  or  three  days, 
and  in  one  or  both  eyes.  Occasionally  the  loss  may  be  permanent  and  com- 
plete. In  some  of  these  instances  a  neuro-retinitis  has  been  found,  probably 
sufficient  to  account  for  the  symptoms.  In  the  more  chronic  anaemias,  par- 
ticularly in  the  pernicious  form,  retinitis  is  common,  as  determined  first  by 
Quincke. 

In  malaria  retinitis  or  neuro-retinitis  may  be  present,  as  noted  by  Stephen 
Mackenzie.  It  is  seen  only  in  the  chronic  cases  with  anaemia,  and  in  my 
experience  is  not  nearly  so  common  proportionately  as  in  pernicious  angemia. 

Leuhcemic  Retinitis. — In  this  affection  the  retinal  veins  are  large  and  dis- 
tended; there  is  also  a  peculiar  retinitis,  as  described  by  Liebreich.  It  is 
not  very  common.  It  existed  in  only  3  of  10  cases  of  which  I  have  notes  of 
examination  of  the  retina.  There  are  numerous  hsemorrhages  and  white  or 
yellow  areas,  which  may  be  large  and  prominent.  In  one  of  my  cases  the 
retina  post  mortem  was  dotted  with  many  small,  opaque,  white  spots,  looking 
like  little  tumors,  the  larger  of  which  had  a  diameter  of  nearly  2  mm.  In  Case 
13  of  my  series  the  leukaemia  was  diagnosed  from  the  condition  of  the  eye- 
grounds  alone,  by  JSTorris  and  De  Schweinitz,  at  whose  clinic  the  patient  had 
applied  on  account  of  failing  vision. 

Retinitis  is  also  found  occasionally  in  diabetes,  in  purpura,  in  chronic 
lead  poisoning,  and  sometimes  as  an  idiopathic  affection. 


1008  DISEASES  OF   THE  NERVOUS  SYSTEM. 

(h)  Functional  Disturbances  of  Vision. —  (1)  Toxic  Amaurosis. — This 
occvirs  in  uraemia  and  may  follow  convulsions  or  come  on  independentl3^ 
The  condition,  as  a  rule,  persists  only  for  a  day  or  two.  This  form  of  amau- 
rosis occurs  in  poisoning  by  lead,  alcohol,  and  occasionally  by  quinine.  It 
seems  more  probable  that  the  poisons  act  on  the  centres  and  not  on  the  retina. 

(2)  Tolacco  Amtlyopia. — The  loss  of  sight  is  usually  gradual,  equal  in 
both  eyes,  and  affects  particularly  the  centre  of  the  field  of  vision.  The  eye- 
grounds  may  be  normal,  but  occasionally  there  is  congestion  of  the  disks. 
On  testing  the  color  fields  a  central  scotoma  for  red  and  green  is  found  in  all 
cases.  Ultimately,  if  the  use  of  tobacco  is  continued,  organic  changes  may 
develop  with  atrophy  of  the  disk. 

(3)  Hysterical  Amaurosis. — More  frequently  this  is  loss  of  acuteness  of 
vision — amblyopia — but  the  loss  of  sight  in  one  or  both  eyes  may  apparently 
be  complete.     The  condition  will  be  mentioned  subsequently  under  hysteria. 

(4)  NigM-llindness — nyctalopia — ^the  condition  in  which  objects  are 
clearly  seen  during  the  day  or  by  strong  artificial  light,  but  become  invisible 
in  the  shade  or  in  twilight,  and  hemeralopia,  in  which  objects  can  not  be 
clearly  seen  without  distress  in  daylight  or  in  a  strong  artificial  light,  but 
are  readily  seen  in  a  deep  shade  or  in  twilight,  are  functional  anomalies  of 
vision  which  rarely  come  under  the  notice  of  the  physician.  It  may  occur 
in  epidemic  form, 

(5)  Retinal  hypercestliesia  is  sometimes  seen  in  hysterical  women,  but  is 
not  found  frequently  in  actual  retinitis.  I  have  seen  it  once,  however,  in 
albuminuric  retinitis,  and  once,  in  a  marked  degree,  in  a  patient  with  aortic 
insufficiency,  in  whose  retinaB  there  were  no  signs  other  than  the  throbbing 
arteries, 

(2)  Lesions  of  the  Optic  Nerve. 

(a)  Optic  Neuritis  (Papillitis;  Clio'ked  DisJc). — In  the  first  stage  there  is 
congestion  of  the  disk  and  the  edges  are  blurred  and  striated.  In  the  second 
stage  the  congestion  is  more  marked;  the  swelling  increases,  the  striation 
also  is  more  visible.  The  phj^siological  cupping  disappears  and  hsemorrhages 
are  not  uncommon.  The  arteries  present  little  change,  the  veins  are  dilated, 
and  the  disk  may  swell  greatly.  In  slight  grades  of  inflammation  the  swelling 
gradually  subsides  and  occasionally  the  nerve  recovers  completely.  In  in- 
stances in  which  the  swelling  and  exudate  are  very  great,  the  subsidence  is 
slow,  and  when  it  finally  disappears  there  is  complete  atrophy  of  the  nerve. 
The  retina  not  infrequently  participates  in  the  inflammation,  which  is  then 
a  neuro-retinitis. 

This  condition  is  of  the  greatest  importance  in  diagnosis.  It  may  exist 
in  its  early  stages  without  any  disturbance  of  vision,  and  even  with  exten- 
sive papillitis  the  sight  may  for  a  time  be  good. 

Optic  neuritis  is  seen  occasionally  in  angemia  and  lead  poisoning,  more 
commonly  in  Bright's  disease  as  neuro-retinitis.  It  occurs  occasionally  as 
a  primary  idiopathic  affection.  The  frequent  connection  with  intracranial 
disease,  particularly  tumor,  makes  its  presence  of  great  value  to  practition- 
ers. The  nature  of  the  growth  is  without  influence.  In  over  90  per  cent 
of  such  instances  the  papillitis  is  bilateral.  It  is  also  found  in  meningitis, 
either  the  tuberculous  or  the  simple  form.     In  meningitis  it  is  easy  to  see 


DISEASES  OF  THE  PERIPHERAL  NERVES.  1009 

how  the  inflammation  may  extend  down  the  nerve  sheath.  In  the  case  of 
tumor,  however,  it  is  probable  that  mechanical  conditions,  especially  the 
venous  stasis,  are  alone  responsible  for  the  oedematous  swelling.  It  often  sub- 
sides very  rapidly  after  a  palliative  craniectomy  has  been  performed. 

(h)  Optic  Atrophy. — This  may  be:  (1)  A  primary  affection.  There  is 
an  hereditary  form,  in  which  the  disease  has  developed  in  all  the  males  of  a 
family  shortly  after  puberty.  A  large  number  of  the  cases  of  primary  atrophy 
are  associated  with  spinal  disease,  particularly  locomotor  ataxia.  Other  causes 
which  have  been  assigned  for  the  primary  atrophy  are  cold,  sexual  excesses, 
diabetes,  the  specific  fevers,  alcohol,  and  lead. 

(2)  Secondary  atrophy  results  from  cerebral  diseases,  pressure  on  the 
chiasma  or  on  the  nerves,  or,  most  commonly  of  all,  as  a  sequence  of  papillitis. 

The  ophthalmoscopic  appearances  are  different  in  the  cases  of  primary 
and  secondary  atrophy.  In  the  former,  the  disk  has  a  gray  tint,  the  edges 
are  well  defined,  and  the  arteries  look  almost  normal;  whereas  in  the  con- 
secutive atrophy  the  disk  has  a  staring  opaque-white  aspect,  with  irregular 
outlines,  and  the  arteries  are  very  small. 

The  symptom  of  optic  atrophy  is  loss  of  sight,  proportionate  to  the  dam- 
age in  the  nerve.  The  change  is  in  three  directions :  "  ( 1 )  Diminished  acuity 
of  vision;  (2)  alteration  in  the  field  of  vision;  and  (3)  altered  perception  of 
color"  (Gowers).    The  outlook  in  primary  atrophy  is  bad. 

(3)  Affections  of  the  Chiasma  and  Tract. 

At  the  chiasma  the  optic  nerves  undergo  partial  decussation.  Each  optic 
tract,  as  it  leaves  the  chiasma,  contains  nerve  fibres  which  originate  in  the 
retinae  of  both  eyes.  Thus,  of  the  fibres  of  the  right  tract,  part  have  come 
through  the  chiasma  without  decussating  from  the  temporal  half  of  the  right 
retina,  the  other  and  larger  portion  of  the  fibres  of  the  tract  have  decussated 
in  the  chiasma,  coming  as  they  do  from  the  left  optic  nerve  and  the  nasal  half 
of  the"  retina  on  the  left  side.  The  fibres  which  cross  are  in  the  middle  por- 
tion of  the  chiasma,  while  the  direct  fibres  are  on  each  side.  The  following 
are  the  most  important  changes  which  ensue  in  lesions  of  the  tract  and  of  the 
chiasma : 

(a)  Unilateral  Affection  of  Tract. — If  on  the  right  side,  this  produces 
loss  of  function  in  the  temporal  half  of  the  retina  on  the  right  side,  and  in 
the  nasal  half  of  the  retina  on  the  left  side,  so  that  there  is  only  half  vision, 
and  the  patient  is  blind  to  objects  on  the  left  side.  This  is  termed  homony- 
mous hemianopia  or  lateral  hemianopia.  The  fibres  passing  to  the  right 
half  of  each  retina  being  involved,  the  patient  is  blind  to  objects  in  the 
left  half  of  each  visual  field.  The  hemianopia  may  be  partial  and  only  a 
portion  of  the  half  field  may  be  lost.  The  unaffected  visual  fields  may  have 
the  normal  extent,  but  in  some  instances  there  is  considerable  reduction. 
When  the  left  half  of  one  field  and  the  right  half  of  the  other,  or  vice  versa, 
are  blind,  the  condition  is  known  as  heteronymous  hemianopia. 

(&)  Disease  of  the  Chiasma. — (1)   A  lesion  involves,  as  a  rule,  chiefly 
the  central  portion,  in  which  the  decussating  fibres  pass  which  supply  the 
inner  or  nasal  halves  of  the  retinas,  producing  in  consequence  loss  of  vision 
in  the  outer  half  of  each  field,  or  what  is  known  as  temporal  hemianopia. 
65 


1010  DISEASES  OF  THE  NERVOUS  SYSTEM, 

(2)  If  the  lesion  is  more  eztensive  it  may  involve  not  only  the  central  por- 
tion, but  also  the  direct  fibres  on  one  side  of  the  commissure,  in  which  case 
there  would  be  total  blindness  in  one  eye  and  temporal  hemianopia  in  the 
other. 

(3)  Still  more  extensive  disease  is  not  infrequent  from  pressure  of  tumors 
in  this  region,  the  whole  chiasma  is  involved,  and  total  blindness  results.  The 
different  stages  in  the  process  may  often  be  traced  in  a  single  case  from  tem- 
poral hemianopia,  then  complete  blindness  in  one  eye  with  temporal  hemi- 
anopia in  the  other,  and  finally  complete  blindness. 

(4)  A  limited  lesion  of  the  outer  part  of  the  chiasma  involves  only  the 
direct  fibres  passing  to  the  temporal  halves  of  the  retinae  and  inducing  blind- 
ness in  the  nasal  field,  or,  as  it  is  called,  nasal  hemianopia.  This,  of  course,  is 
extremely  rare.  Double  nasal  hemianopia  may  occur  as  a  manifestation  of 
tabes  and  in  tumors  involving  the  outer  fibres  of  each  tract. 

(4)  Affections  of  the  Tract  and  Centres. 

The  optic  tract  crosses  the  crus  (cerebral  peduncle)  to  the  hinder  part 
of  the  optic  thalamus  and  divides  into  two  portions,  one  of  which  (the  lateral 
root)  goes  to  the  pulvinar  of  the  thalamus,  the  lateral  geniculate  body,  and 
to  the  anterior  quadrigeminal  body  (superior  colliculus).  From  these  parts, 
in  which  the  lateral  root  terminates,  fibres  pass  into  the  posterior  part  of  the 
internal  capsule  and  enter  the  occipital  lobe,  forming  the  fibres  of  the  optic 
radiation,  which  terminate  in  and  about  the  cuneus,  the  region  of  the  visual 
perceptive  centre.  The  fibres  of  the  medial  division  of  the  tract  pass  to  the 
medial  geniculate  body  and  to  the  posterior  quadrigeminal  body.  The  medial 
root  contains  the  fibres  of  the  commissura  inferior  of  v.  Gudden,  which  are 
believed  to  have  no  connection  with  the  retinae.  It  is  still  held  by  some  physi- 
ologists that  the  cortical  visual  centre  is  not  confined  to  the  occipital  lobe  alone, 
but  embraces  the  occipito-angular  region. 

A  lesion  of  the  fibres  of  the  optic  path  anywhere  between  the  cortical  cen- 
tre and  the  chiasma  will  produce  hemianopia.  The  lesion  may  be  situated: 
{a)  In  the  optic  tract  itself.  (&)  In  the  region  of  the  thalamus,  lateral 
geniculate  body,  and  the  corpora  quadrigemina,  into  which  the  larger  part  of 
each  tract  enters,  (c)  A  lesion  of  the  fibres  passing  from  the  centres  just 
mentioned  to  the  occipital  lobe.  This  may  be  either  in  the  hinder  part  of  the 
internal  capsule  or  the  white  fibres  of  the  optic  radiation,  {d)  Lesion  of  the 
cuneus.  Bilateral  disease  of  the  cuneus  may  result  in  total  blindness,  (e) 
There  is  clinical  evidence  to  show  that  lesion  of  the  angular  gyrus  may  be 
associated  with  visual  defect,  not  so  often  hemianopia  as  crossed  amblyopia, 
dimness  of  vision  in  the  opposite  eye,  and  great  contraction  in  the  field  of 
vision.  Lesions  in  this  region  are  associated  with  mind-blindness,  a  condition 
in  which  there  is  failure  to  recognize  the  nature  of  objects. 

The  effects  of  lesions  in  the  optic  nerve  in  different  situations  from  the  reti- 
nal expansion  to  the  brain  cortex  are  as  follows:  (1)  Of  the  optic  nerve — total 
blindness  of  the  corresponding  eye;  (2)  of  the  optic  chiasma,  either  temporal 
hemianopia,  if  the  central  part  alone  is  involved,  or  nasal  hemianopia,  if  the 
lateral  region  of  each  chiasma  is  involved;  (3)  lesion  of  the  optic  tract 
between    the    chiasma    and    the    lateral    geniculate    body    produces    lateral 


DISEASES  OF  THE  PERIPHERAL  NERVES. 


1011 


hemianopia ;  (4)  lesion  of  the  central  fibres  of  the  nerve  between  the  genicu- 
late bodies  and  the  cerebral  cortex  produces  lateral  hemianopia;  (5)  lesion  of 
the  cuneus  causes  lateral  hemianopia;  and  (6)  lesion  of  the  angular  gyrus 
may  be  associated  with  hemianopia,  sometimes  crossed  amblyopia,  and  the  con- 
dition known  as  mind-blindness.  (See  Fig.  10,  with  accompanying  expla- 
nation.) 


Fig.  10. — Diagram  of  visual  paths.  (Prom  Vialet,  modified.)  OP.  N.,  Optic  nerve.  OP.  C. 
Optic  chiasm.  OP,  T.,  Optic  tract.  OP.  R.,  Optic  radiations.  EXT.  GEN.,  External 
geniculate  body.  THO.,  Optic  thalamus.  C.  QU.,  Corpora  quadrigemina.  C.  C,  Corpus 
callosum.  V.  S.,  Visual  speech  centre.  A.  S.,  Auditory  speech  centre.  M.  S.,  Motor 
speech  centre.  A  lesion  at  1  causes  blindness  of  that  eye ;  at  2,  bi-temporal  hemianopia ; 
at  3,  nasal  hemianopia.  Symmetrical  lesions  at  3  and  3'  would  cause  bi-nasal  hemia- 
nopia ;  at  4,  hemianopia  of  both  eyes,  with  hemianopic  pupillary  inaction ;  at  5  or  6, 
hemianopia  of  both  eyes,  pupillary  reflexes  normal ;  at  7,  amblyopia,  especially  of  oppo- 
site eye ;  at  8,  on  left  side,  word-blindness. 

Diagnosis  of  the  Optic  Nerve  and  Tract. — The  student  or  practitioner  must 
have  a  clear  idea  of  the  physiology  of  the  nerve-centres  before  he  can  appre- 
ciate the  symptoms  or  undertake  the  diagnosis  of  lesions  of  the  optic  nerve. 


1012  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Having  determined  the  presence  of  iiemianopia,  the  question  arises  as  to  the 
situation  of  the  lesion,  whether  in  the  tract  between  the  chiasma  and  the  genic- 
ulate bodies  or  in  the  central  portion  of  the  fibres  between  these  bodies  and  the 
visual  centres.  This  can  be  determined  in  some  cases  by  the  test  known  as  Wer- 
nicke's hemiopic  pupillary  inaction.  The  pupil  reflex  depends  on  the  in- 
tegrity of  the  retina  or  receiving  membrane,  on  the  fibres  of  the  optic  nerve 
and  tract  which  transmit  the  impulse,  and  the  nerve-centre  at  the  termination 
of  the  optic  tract  which  receives  the  impression  and  transmits  it  to  the  third 
nerve  along  which  the  motor  impulses  pass  to  the  iris.  If  a  bright  light  is 
thrown  into  the  eye  and  the  pupil  reacts,  the  integrity  of  this  reflex  arc  is 
demonstrated.  It  is  possible  in  cases  of  lateral  hemianopia  so  to  throw  the 
light  into  the  eye  that  it  falls  upon  the  blind  half  of  the  retina.  If  when  this 
is  done  the  pupil  contracts,  the  indication  is  that  the  reflex  arc  above  referred 
to  is  perfect,  by  which  we  mean  that  the  optic  nerve  fibres  from  the  retinal 
expansion  to  the  centre,  the  centre  itself,  and  the  third  nerve  are  uninvolved. 
In  such  a  case  the  conclusion  would  be  justified  that  the  cause  of  the  hemi- 
anopia was  central ;  that  is,  situated  beyond  the  geniculate  body,  either  in  the 
fibres  of  the  optic  radiation  or  in  the  visual  cortical  centres.  If,  on  the  other . 
nand,  when  the  light  is  carefully  throvm  on  the  hemiopic  half  of  the  retina, 
the  pupil  remains  inactive,  the  conclusion  is  justifiable  that  there  is  interrup- 
tion in  the  path  between  the  retina  and  the  nucleus  of  the  third  nerve,  and  that 
the  hemianopia  is  not  central,  but  dependent  upon  a  lesion  situated  in  the 
optic  tract.  This  test  of  Wernicke's  is  sometimes  difficult  to  obtain.  It  is 
best  performed  as  follows :  "  The  patient  being  in  a  dark  or  nearly  dark  room 
with  the  lamp  or  gas-light  behind  his  head  in  the  usual  position,  I  bid  him 
look  over  to  the  other  side  of  the  room,  so  as  to  exclude  accommodative  iris 
movements  (which  are  not  necessarily  associated  with  the  reflex).  Then  I 
throw  a  faint  light  from  a  plane  mirror  or  from  a  large  concave  mirror,  held 
well  out  of  focus,  upon  the  eye  and  note  the  size  of  the  pupil.  With  my  other 
hand  I  now  throw  a  beam  of  light,  focussed  from  the  lamp  by  an  ophthalmo- 
scopic mirror,  directly  into  the  optical  centre  of  the  eye;  then  laterally  in 
various  positions,  and  also  from  above  and  below  the  equator  of  the  eye,  noting 
the  reaction  at  all  angles  of  incidence  of  the  ray  of  light "  (Seguin) . 

The  significance  of  hemianopia  varies.  There  is  a  functional  hemianopia 
associated  with  migraine  and  hysteria.  In  a  considerable  proportion  of  all 
cases  there  are  signs  of  organic  brain-disease.  In  a  certain  number  of  in- 
stances of  slight  lesions  of  the  occipital  lobe  hemichromatopsia  has  been 
observed.  The  homomnnous  halves  of  the  retina  as  far  as  the  fix:ation  point 
are  dulled,  or  blind  for  colors.  Hemiplegia  is  common,  in  which  event  the 
loss  of  power  and  blindness  are  on  the  same  side.  Thus,  a  lesion  in  the  left 
hemisphere  involving  the  motor  tract  produces  right  hemiplegia,  and  when 
the  fibres  of  the  optic  radiation  are  involved  in  the  internal  capsule,  there  is 
also  lateral  hemianopia,  so  that  objects  in  the  field  of  vision  to  the  right  are 
not  perceived.  Hemiangesthesia  is  not  uncommon  in  such  cases,  owing  to  the 
close  association  of  the  sensory  and  visual  tracts  at  the  posterior  part  of  the 
internal  capsule.    Certain  forms  of  aphasia  also  occur  in  many  of  the  cases. 

The  optic  aphasia  of  Freund  may  be  mentioned  here.  The  patient  after 
an  apoplectic  attack,  though  able  to  recognize  ordinary  objects  shown  to  him 
is  unable  to  name  them  correctly.     If  he  be  permitted  to  touch  the  object  he 


DISEASES  OF  THE  PERIPHERAL  NERVES.  1013 

may  be  able  to  name  it  quickly  and  correctly.  Freund's  optic  aphasia  differs 
from  mind-blindness,  since  in  the  latter  afEection  the  objects  seen  are  not 
recognized.  Optic  aphasia,  like  word-blindness,  never  occurs  alone,  but  is 
always  associated  with  hemianopia,  or  mind-blindness,  and  often  also  with 
word-deafness.  In  the  cases  which  have  thus  far  come  to  autopsy  there  has 
always  been  a  lesion  in  the  white  matter  of  the  occipital  lobe  on  the  left  side. 

Motor  Nerves  of  Tut  Eyeball. 

Third  Nerve  (Nervus  oculomotorius) . — The  nucleus  of  origin  of  this  nerve 
is  situated  in  the  floor  of  the  aqueduct  of  Sylvius;  the  nerve  passes  through 
the  crus  at  the  side  of  which  it  emerges.  Passing  along  the  wall  of  the  cav- 
ernous sinus,  it  enters  the  orbit  through  the  sphenoidal  fissure  and  supplies, 
by  its  superior  branch,  the  levator  palpebrae  superioris  and  the  superior  rectus, 
and  by  its  inferior  branch  the  internal  and  inferior  recti  muscles  and  the  infe- 
rior oblique.  Branches  pass  to  the  ciliary  muscle  and  the  constrictor  of  the 
iris.  Lesions  may  affect  the  nucleus  or  the  nerve  in  its  course  and  cause  either 
paralysis  or  spasm. 

Paralysis. — A  nuclear  lesion  is  usually  associated  with  the  disease  of  the 
centres  for  the  other  eye  muscles,  producing  a  condition  of  general  ophthal- 
moplegia. More  commonly  the  nerve  itself  is  involved  in  its  course,  either  by 
meningitis,  gummata,  or  aneurism,  or  is  attacked  by  a  neuritis,  as  in  diph- 
theria and  locomotor  ataxia.  Complete  paralysis  of  the  third  nerve  is  accom- 
panied by  the  following  symptoms : 

Paralysis  of  all  the  muscles,  except  the  superior  oblique  and  external  rec- 
tus, by  which  the  eye  can  be  moved  outward  and  a  little  downward  and  inward. 
There  is  divergent  strabismus.  There  is  ptosis  or  drooping  of  the  upper  eye- 
lid, owing  to  paralysis  of  the  levator  palpebrge.  The  pupil  is  usually  dilated. 
It  does  not  contract  to  light,  and  the  power  of  accommodation  is  lost.  The 
most  striking  features  of  this  paralysis  are  the  external  strabismus,  with 
diplopia  or  double  vision,  and  the  ptosis.  In  very  many  cases  the  affection 
of  the  third  nerve  is  partial.  Thus  the  levator  palpebrae  and  the  superior 
rectus  may  be  involved  together,  or  the  ciliary  muscles  and  the  iris  may  be 
affected  and  the  external  muscles  may  escape. 

There  is  a  remarkable  form  of  recurring  oculo-motor  paralysis  affecting 
chiefly  women,  and  involving  all  the  branches  of  the  nerve.  In  some  cases 
the  attacks  have  come  on  at  intervals  of  a  month;  in  others  a  much  longer 
period  has  elapsed.  The  attacks  may  persist  throughout  life.  They  are  some- 
times associated  with  pain  in  the  head  and  sometimes  with  migraine.  Mary 
Sherwood  has  collected  from  the  literature  23  cases. 

Ptosis  is  a  common  and  important  symptom  in  nervous  affections.  We 
may  here  briefly  refer  to  the  conditions  under  which  it  may  occur :  (a)  A  con- 
genital, incurable  form,  which  is  frequently  seen;  (&)  the  form  associated 
with  definite  lesion  of  the  third  nerve,  either  in  its  course  or  at  its  nucleus. 
This  may  come  on  with  paralysis  of  the  superior  rectus  alone  or  with  paralysis 
of  the  internal  and  inferior  recti  as  well,  (c)  There  are  instances  of  com- 
plete or  partial  ptosis  associated  with  cerebral  lesions  without  any  other  branch 
of  the  third  nerve  being  paralyzed.  The  exact  position  of  the  cortical  centre 
or  centres  is  as  yet  unknown,     (d)   Hysterical  ptosis,  which  is  double  and 


1014  DISEASES  OF  THE  NERVOUS  SYSTEM. 

occurs  with  other  hysterical  s}Tnptoins.  (e)  Pseudo-ptosis,  due  to  affection 
of  the  s}Tapathetic  nerve,  is  associated  with  symptoms  of  vaso-motor  palsy, 
such  as  elevation  of  the  temperature  on  the  affected  side  with  redness  and 
oedema  of  the  skin.  Contraction  of  the  pupil  exists  on  the  same  side  and  the 
eyeball  appears  rather  to  have  shrunk  into  the  orbit,  (f)  In  idiopathic  mus- 
cular atrophy,  when  the  face  muscles  are  involved,  there  may  be  marked 
bilateral  ptosis.  And,  lastly,  in  weak,  delicate  women  there  is  often  to  be 
seen  a  transient  ptosis,  particularly  in  the  morning. 

Among  the  most  important  of  the  symptoms  of  the  third-nerve  paralysis 
are  those  which  relate  to  the  ciliary  muscle  and  iris. 

Ctcloplegia,  paralysis  of  the  ciliary  muscle,  causes  loss  of  the  power  of 
accommodation.  Distant  vision  is  clear,  but  near  objects  can  not  be  prop- 
erly seen.  In  consequence  the  vision  is  indistinct,  but  can  be  restored  by  the 
use  of  convex  glasses.  This  may  occur  in  one  or  in  both  eyes;  in  the  latter 
case  it  is  usually  associated  with  disease  in  the  nuclei  of  the  nerve.  Cyclo- 
plegia  is  an  early  and  frequent  symptom  in  diphtheritic  paralysis  and  occurs 
also  in  tabes. 

Iridoplegia,  or  paralysis  of  the  iris,  occurs  in  three  forms  (Gowers). 

(a)  Accommodation  iridoplegia,  in  which  the  pupil  does  not  diminish  in 
size  during  the  act  of  accommodation.  To  test  for  this  the  patient  should 
look  first  at  a  distant  and  then  at  a  near  object  in  the  same  line  of  vision. 

(h)  Reflex  Iridoplegia. — The  path  for  the  iris  reflex  is  along  the  optic 
nerve  and  tract  to  its  termination,  then  to  the  nucleus  of  the  third  nerve, 
and  along  the  trunk  of  this  nerve  to  the  ciliary  ganglion,  and  so  through 
the  ciliary  nerves  to  the  eyes.  Each  eye  should  be  tested  separately,  the  other 
one  being  covered.  The  patient  should  look  at  a  distant  object  in  a  dark  part 
of  the  room;  then  a  light  is  brought  suddenly  in  front  of  the  eye  at  a  dis- 
tance of  three  or  four  feet,  so  as  to  avoid  the  effect  of  accommodation.  Loss 
of  this  iris  reflex  with  retention  of  the  accommodation  contraction  is  known 
as  the  Arg}dl  Eobertson  pupil. 

(c)  Loss  of  the  Shin  Reflex. — If  the  skin  of  the  neck  is  pinched  or  pricked 
the  pupil  dilates  reflexly,  the  aft'erent  impulses  being  conveyed  along  the  cer- 
vical sympathetic.  Erb  pointed  out  that  this  skin  reflex  is  lost  usually  in 
association  with  the  reflex  contraction,  but  the  two  are  not  necessarily  con- 
joined. In  iridoplegia  the  pupils  are  often  small,  particularly  in  spinal  dis- 
ease, as  in  the  characteristic  small  pupils  of  tabes — spinal  myosis.  Irido- 
plegia may  coexist  with  a  pupil  of  medium  size. 

Inequality  of  the  pupils — anisocoria — is  not  infrequent  in  progressive  pare- 
sis and  in  tabes.     It  may  also  occur  in  perfectly  healthy  individuals. 

Spasm. — Occasionally  in  meningitis  and  in  hysteria  there  is  spasm  of  the 
muscles  supplied  by  the  third  nerve,  particularly  the  internal  rectus  and  the 
levator  palpebrse.  The  clonic  rhythmical  spasm  of  the  eye  muscles  is  known 
as  nystagmus,  in  which  there  is  usually  a  bilateral,  rhythmical,  involuntary 
movement  of  the  eyeballs.  The  condition  is  met  with  in  many  congenital 
and  acquired  brain  lesions,  in  albinism,  and  sometimes  in  coal-miners. 

Fourth.  Nerve  {Nervus  trochlearis) . — This  supplies  the  superior  oblique 
muscle.  In  its  course  around  the  outer  surface  of  the  crus  and  in  its  pas- 
sage into  the  orbit  it  is  liable  to  be  compressed  by  tumors,  by  aneurism,  or  in 
the  exudation  of  basilar  meningitis.     Its  nucleus  in  the  upper  part  of  the 


DISEASES  OF  THE  PERIPHERAL  NERVES.  1015 

fourth  ventricle  may  be  involved  by  tumors  or  undergo  degeneration  with  the 
other  ocular  nuclei.  The  superior  oblique  muscle  acts  in  such  a  way  as  to  direct 
the  eyeball  downward  and  rotate  it  slightly.  The  paralysis  causes  defective 
downward  and  inward  movement,  often  too  slight  to  be  noticed.  The  head  is 
inclined  somewhat  forward  and  toward  the  sound  side,  and  there  is  double 
vision  when  the  patient  looks  down. 

Sixth  Nerve  (Nervus  abducens) . — ^This  nerve  emerges  at  the  junction  of 
the  pons  and  medulla,  then,  passing  forward,  it  enters  the  orbit  and  supplies 
the  external  rectus  muscle.  Owing  to  its  long  course  and  exposed  position  it 
is  more  commonly  injured  than  any  other  cranial  nerve.  It  is  affected  by 
meningitis  at  the  base,  by  gummata  or  other  tumors,  and  sometimes  by  cold. 
There  is  internal  strabismus,  and  the  eye  can  not  be  turned  outward.  Diplopia 
occurs  on  looking  toward  the  paralyzed  side. 

"  When  the  nucleus  is  affected  there  is,  in  addition  to  paralysis  of  the 
external  rectus,  inability  of  the  internal  rectus  of  the  opposite  eye  to  turn  that 
eye  inward.  As  a  consequence  of  this  the  axes  of  the  eyes  are  kept  parallel, 
and  both  are  conjugately  deviated  to  the  opposite  side,  away  from  the  side 
of  lesion.  The  reason  of  this  is  that  the  nucleus  of  the  sixth  nerve  sends 
fibres  up  in  the  pons  to  that  part  of  the  nucleus  of  the  opposite  third  nerve 
which  supplies  the  internal  rectus.  We  thus  have  paralysis  of  the  internal 
rectus  without  the  nucleus  of  the  third  nerve  being  involved,  owing  to  its 
receiving  its  nervous  impulses  for  parallel  movement  from  the  sixth  nucleus 
of  the  opposite  side.  As  the  sixth  nucleus  is  in  such  proximity  to  the  facial 
nerve  in  the  substance  of  the  pons,  it  is  frequently  found  that  the  whole  of 
the  face  on  the  same  side  is  paralyzed,  and  gives  the  electrical  reaction  of 
degeneration,  so  that  with  a  lesion  of  the  left  sixth  nucleus  there  is  conjugate 
deviation  of  both  eyes  to  the  right — i.  e.,  paralysis  of  the  left  external  and  the 
right  internal  rectus,  and  sometimes  complete  paralysis  of  the  left  side  of  the 
face"  (Beevor). 

General  Features  of  Paralysis  of  the  Motor  Nerves  of  the-  Eye. — Gowers 
divides  them  into  five  groups : 

(a)  Limitation  of  Movement. — Thus,  in  paralysis  of  the  external  rectus, 
the  eyeball  can  not  be  moved  outward.  When  the  paralysis  is  incomplete 
the  movement  is  deficient  in  proportion  to  the  degree  of  the  palsy, 

(&)  Strabismus. — The  axes  of  the  eyes  do  not  correspond.  Thus,  paral- 
ysis of  the  internal  rectus  causes  a  divergent  squint;  of  the  external  rectus, 
a  convergent  squint.  At  first  this  is  evident  only  when  the  eyes  are  moved 
in  the  direction  of  the  action  of  the  weak  muscle,  but  may  become  con- 
stant by  the  contraction  of  the  opposing  muscle.  The  deviation  of  the  axis 
of  the  affected  eye  from  parallelism  with  the  other  is  called  the  primary 
deviation. 

(c)  Secondary  Deviation. — If,  while  the  patient  is  looking  at  an  object, 
the  sound  eye  is  covered,  so  that  he  fixes  the  object  looked  at  with  the  affected 
eye  only,  the  sound  eye  is  moved  still  further  in  the  same  direction — e.  g., 
outward,  when  there  is  paralysis  of  the  opposite  internal  rectus.  This  is  known 
as  secondary  deviation.  It  depends  upon  the  fact  that,  if  two  muscles  are 
acting  together,  when  one  is  weak  and  an  effort  is  made  to  contract  it,  the 
increased  effort — innervation — acts  powerfully  upon  the  other  muscle,  causing 
an  increased  contraction. 


1016  DISEASES  OF   THE  NERVOUS  SYSTEM. 

(d)  Erroneous  Projection. — "We  judge  of  the  relation  of  external  ob- 
jects to  each  other  by  the  relation  of  their  images  on  the  retina;  but  we  judge 
of  their  relation  to  our  own  body  by  the  position  of  the  e5^eball  as  indicated 
to  us  by  the  innervation  we  give  to  the  ocular  muscles"  (Gowers).  With 
the  eyes  at  rest  in  the  mid-position,  an  object  at  which  we  are  looking  is 
directly  opposite  our  face.  Turning  the  eyes  to  one  side,  we  recognize  that 
object  in  the  middle  of  the  field  or  to  the  side  of  this  former  position.  We 
estimate  the  degree  by  the  amount  of  movement  of  the  eyes,  and  when  the 
object  moves  and  we  follow  it  we  judge  of  its  position  by  the  amount  of  move- 
ment of  the  eyeballs.  When  one  ocular  muscle  is  weak,  the  increased  inner- 
vation gives  the  impression  of  a  greater  movement  of  the  eye  than  has  really 
taken  place.  The  mind,  at  the  same  time,  receives  the  idea  that  the  object  is 
further  on  one  side  than  it  really  is,  and  in  an  attempt  to  touch  it  the  finger 
may  go  beyond  it.  As  the  equilibrium  of  the  body  is  in  a  large  part  main- 
tained by  a  knowledge  of  the  relation  of  external  objects  to  it  obtained  by  the 
action  of  the  eye  muscles,  this  erroneous  projection  resulting  from  paralysis 
disturbs  the  harmony  of  these  visual  impressions  and  may  lead  to  giddiness — 
ocular  vertigo. 

(e)  Double  Vision. — This  is  one  of  the  most  disturbing  features  of  paral- 
ysis of  the  eye  muscles.  The  visual  axes  do  not  correspond,  so  that  there  is 
a  double  image — diplopia.  That  seen  by  the  sound  eye  is  termed  the  true 
image;  that  by  the  paralyzed  eye,  the  false.  In  simple  or  homonjinous 
diplopia  the  false  image  is  "  on  the  same  side  of  the  other  as  the  eye  by  which 
it  is  seen."  In  crossed  diplopia  it  is  on  the  other  side.  In  convergent  squint 
the  diplopia  is  simple:  in  divergent  it  is  crossed. 

Ophthalmoplegia. — Under  this  term  is  described  a  chronic  progressive 
paralysis  of  the  ocular  muscles.  Two  forms  are  recognized — ophthalmoplegia 
externa  and  ophthalmoplegia  interna.  The  conditions  may  occur  separately 
or  together  and  are  described  by  Gowers  under  nuclear  ocular  palsy. 

Ophthalmoplegia  externa. — The  condition  is  one  of  more  or  less  com- 
plete palsy  of  the  external  muscles  of  the  eyeball,  due  usually  to  a  slow  degen- 
eration in  the  nuclei  of  the  nerves,  but  sometimes  to  pressure  of  tumors  or  to- 
basilar  meningitis.  It  is  often,  but  not  necessarily,  associated  with  ophthal- 
moplegia interna.  Siemerling,  in  a  monograph  on  the  subject,  states  that  6^ 
cases  are  on  record.  In  only  11  of  these  could  s^^jhilis  be  positively  deter- 
mined. The  levator  muscles  of  the  eyelids  and  the  superior  recti  are  first 
involved,  and  gradually  the  other  muscles,  so  that  the  eyeballs  are  fixed  and 
the  eyelids  droop.  There  is  sometimes  slight  protrusion  of  the  e3^eballs.  The 
disease  is  essentially  chronic  and  may  last  for  many  years.  It  is  found  par- 
ticularly in  association  with  general  paralysis,  locomotor  ataxia,  and  in  pro- 
gressive muscular  atrophy.  Mental  disorders  were  present  in  11  of  the  62 
cases.  With  it  may  be  associated  atrophy  of  the  optic  nerve  and  affections  of 
other  cerebral  nerves.  Occasionally,  as  noted  by  Bristowe,  it  may  be  func- 
tional. 

Ophthalmoplegia  ixteexa. — Jonathan  Hutchinson  applied  this  term  to 
a  progressive  paralysis  of  the  internal  ocular  muscles,  causing  loss  of  pupil- 
lary action  and  the  power  of  accommodation.  When  the  internal  and  ex- 
ternal muscles  are  involved  the  affection  is  known  as  total  ophthalmoplegia, 
and  in  a  majority  of  the  cases  the  two  conditions  are  associated.     In  some 


DISEASES  OF  THE  PERIPHERAL  NERVES.  1017 

instances  the  internal  form  may  depend  upon  disease  of  the  ciliary  gan- 
glion. 

While,  as  a  rule,  opthalmoplegia  is  a  chronic  process,  there  is  an  acute 
form  associated  with  hsemorrhagic  softening  of  the  nuclei  of  the  ocular  mus- 
cles. There  is  usually  marked  cerebral  disturbance.  It  was  to  this  form  that 
Wernicke  gave  the  name  poliencephalitis  superior. 

Treatment  of  Ocular  Palsies. — It  is  important  to  ascertain,  if  possible, 
the  cause.  The  forms  associated  with  locomotor  ataxia  are  obstinate,  and 
resist  treatment.  Occasionally,  however,  a  palsy,  complete  or  partial,  may 
pass  away  spontaneously.  The  group  of  cases  associated  with  chronic  degen- 
erative changes,  as  in  progressive  paresis  and  bulbar  paralysis,  is  little  affected 
by  treatment.  On  the  other  hand,  in  syphilitic  cases,  mercury  and  iodide  of 
potassium  are  indicated  and  are  often  beneficial.  Arsenic  and  strychnia,  the 
latter  hypodermically,  may  be  employed.  In  any  case  in  which  the  onset  is 
acute,  with  pain,  hot  fomentations  and  counter-irritation  or  leeches  applied 
to  the  temple  give  relief.  The  direct  treatment  by  electricity  has  been  exten- 
sively employed,  but  probably  without  any  special  effect.  The  diplopia  may 
be  relieved  by  the  use  of  prisms,  or  it  may  be  necessary  to  cover  the  affected  eye 
with  an  opaque  glass. 

Fifth  J^erve  (Nervus  trigeminus). 

Paralysis  may  result  from:  (a)  Disease  of  the  pons,  particularly  hemor- 
rhage or  patches  of  sclerosis,  (h)  Injury  or  disease  at  the  base  of  the  brain. 
Fracture  rarely  involves  the  nerve;  on  the  other  hand,  meningitis,  acute  or 
chronic,  and  caries  of  the  bone  are  not  uncommon  causes,  (c)  The  branches 
may  be  affected  as  they  pass  out — the  first  division  by  tumors  pressing  on  the 
cavernous  sinus  or  by  aneurism;  the  second  and  third  divisions  by  growths 
which  invade  the  spheno-maxillary  fossa.  (d)  Primary  neuritis,  which 
is  rare. 

Symptoms. —  (a)  Sensory  Portion. — Disease  of  the  fifth  nerve  may  cause 
loss  of  sensation  in  the  parts  supplied,  including  the  half  of  the  face,  the  cor- 
responding side  of  the  head,  the  conjunctiva,  the  mucosa  of  the  lips,  tongue, 
hard  and  soft  palate,  and  of  the  nose  of  the  same  side.  The  anaesthesia  may 
be  preceded  by  tingling  or  pain.  The  muscles  of  the  face  are  also  insensible 
and  the  movements  may  be  slower.  The  sense  of  smell  is  interfered  with, 
owing  to  dryness  of  the  mucous  membrane.  There  may  be  disturbance  of 
the  sense  of  taste.  The  salivary,  lachrymal,  and  buccal  secretions  may  be 
lessened,  and  the  teeth  may  become  loose.  Unless  properly  guarded  from 
injury  an  ulcerative  inflammation  of  the  eye  may  follow.  This  was  formerly 
supposed  to  be  due  to  nutritional  changes  from  paralysis  of  so-called  trophic 
nerve  fibres.  This  idea  has  of  late  years  been  overthrown  by  the  large  number 
of  cases  in  which  the  Gasserian  ganglion  has  been  removed  for  obstinate 
neuralgia  without  consequent  inflammation  of  the  eye.  Herpes  may  develop 
in  the  region  supplied  by  the  nerve,  usually  the  upper  branch,  and  is  asso- 
ciated with  much  pain,  which  may  be  peculiarly  enduring,  lasting  for 
months  or  years  (Gowers).  In  herpes  zoster  with  the  neuritis  there  may  be 
slight  enlargement  of  the  cervical  glands,  (See  under  JSTeuralgia  for  Tic 
Douloureux.) 


1018  DISEASES  OF  THE  NERVOUS  SYSTEM. 

(i)  Motor  Poetiox. — The  inability  to  use  the  muscles  of  mastication  on 
the  affected  side  is  the  distinguishing  feature  of  paralysis  of  this  portion  of 
the  nerve.  It  is  recognized  by  placing  the  finger  on  the  masseter  and  tem- 
poral muscles,  and,  when  the  patient  closes  the  jaw,  the  feebleness  of  their 
contraction  is  noted.  If  paralyzed,  the  external  pterygoid  can  not  move  the 
jaw  toward  the  unaffected  side;  and  when  depressed,  the  jaw  deviates  to  the 
paralyzed  side.  The  motor  paralysis  of  the  fifth  nerve  is  almost  invariably  a 
result  of  involvement  of  the  nerve  after  it  has  left  the  nucleus.  Cases,  however, 
have  been  associated  with  cortical  lesions.  The  cortical  motor  centre  for  the 
trigeminus,  or  for  movements  effecting  closure  of  the  jaw,  lies  below  that  for 
movements  of  the  face  at  the  lower  part  of  the  anterior  central  convolution. 

Spasm  of  the  Muscles  of  Mastication. — Trismus,  the  masticatory  spasm 
of  Eomberg,  may  be  tonic  or  clonic,  and  is  either  an  associated  phenomenon 
in  general  convulsions  or,  more  rarely,  an  independent  affection.  In  the  tonic 
form  the  jaws  are  kept  close  together — ^lock-jaw — or  can  be  separated  only  for 
a  short  space.  The  muscles  of  mastication  can  be  seen  in  contraction  and 
felt  to  be  hard;  the  spasm  is  often  painful.  This  tonic  contraction  is  an 
early  s}Tnptom  in  tetanus,  and  is  sometimes  seen  in  tetany.  A  form  of  this 
tonic  spasm  occurs  in  hysteria.  Occasionally  trismus  follows  exposure  to  cold, 
and  is  said  to  be  due  to  reflex  irritation  from  the  teeth,  the  mouth,  or  caries 
of  the  jaw.  It  may  also  be  a  symptom  of  organic  disease  due  to  irritation 
near  the  motor  nucleus  of  the  fifth  nerve. 

Clonic  spasm  of  the  muscles  supplied  by  the  fiith  occurs  in  the  form  of 
rapidly  repeated  contractions,  as  in  '"'  chattering  teeth."'  This  is  rare  apart 
from  general  conditions,  though  cases  are  on  record,  usually  in  women  late 
in  life,  in  whom  this  isolated  clonic  spasm  of  the  muscles  of  the  jaw  has  been 
found.  In  another  form  of  clonic  spasm  sometimes  seen  in  chorea,  there  are 
forcible  single  contractions.  Gowers  mentions  an  instance  of  its  occurrence  as 
an  isolated  affection. 

(c)  GusTATOET. — Complete  or  partial  loss  of  the  sense  of  taste  over  the 
anterior  two-thirds  of  the  tongue  has  been  supposed  by  some  to  follow  paralysis 
of  the  fifth  nerve.  There  are  two  views  concerning  the  course  of  the  fibres  that 
carry  gustatory  impulse  from  this  part  of  the  tongue.  According  to  some 
they  take  a  devious  path,  passing  with  the  chorda  tjmpani  to  the  geniculate 
ganglion,  thence  by  the  great  superficial  petrosal  nerve  to  Meckel's  ganglion, 
and  this  they  leave  to  reach  the  maxillary  nerve,  which  they  follow  through  the 
trigeminal  nerve  to  the  brain.  A  study  of  clinical  cases  of  disease  of  the  fifth 
nerve  has  led  to  this  view.  It  seems  more  probable,  however,  from  the  fact 
that  a  large  number  of  the  trigeminal  neurectomies  are  not  followed  by  loss  of 
taste,  that  the  fibres  pass  to  the  brain  directly  from  the  geniculate  ganglion 
by  the  nervus  intermedins  of  Wrisberg.  Possibly  there  may  be  more  than  one 
course  for  these  fibres. 

The  diagnosis  of  disease  of  the  trifacial  nerve  is  rarely  difficult.  It  must 
be  remembered  that  the  preliminary  pain  and  h}'per£esthesia  are  sometimes 
mistaken  for  ordinary  neuralgia.  The  loss  of  sensation  and  the  palsy  of  the 
muscles  of  mastication  are  readily  determined. 

Treatment. — When  the  pain  is  severe  morphia  may  be  required  and  local 
applications  are  useful.  If  there  is  a  suspicion  of  sj^hilis,  appropriate  treat- 
ment should  be  siven.     Faradization  is  sometimes  beneficial. 


DISEASES  OF  THE  PERIPHERAL  NERVES.  1019 

Facial  Nerve, 

Paralysis  {Bell's  Palsy). — The  facial  or  seventh  may  be  paralyzed  by  (1) 
lesions  of  the  cortex — supranuclear  palsy;  (2)  lesions  of  the  nucleus  itself; 
or  (3)  involvement  of  the  nerve  trunk  in  its  tortuous  course  within  the  pona 
and  through  the  wall  of  the  skull. 

1.  Supranuclear  paralysis,  due  to  lesion  of  the  cortex  or  of  the  facial  fibres 
in  the  corona  radiata  or  internal  capsule,  is,  as  a  rule,  associated  with  hemi- 
plegia. It  may  be  caused  by  tumors,  abscess,  chronic  inflammation,  or  soften- 
ing in  the  cortex  or  in  the  region  of  the  internal  capsule.  It  is  distinguished 
from  the  peripheral  form  by  well-marked  characters — the  persistence  of  the 
normal  electrical  excitability  of  both  nerves  and  muscles  and  the  frequent 
absence  of  involvement  of  the  upper  branches  of  the  nerve,  so  that  the  orbicu- 
laris palpebrarum,  frontalis,  and  corrugator  muscles  are  spared.  In  rare 
instances  these  muscles  are  paralyzed.  In  this  form  the  voluntary  movements 
are  more  impaired  than  the  emotional.  Isolated  paralysis — monoplegia 
facialis — due  to  involvement  of  the  cortex  or  of  the  fibres  in  their  path  to 
the  nucleus,  is  uncommon.  In  the  great  majority  of  cases  supranuclear  facial 
paralysis  is  part  of  a  hemiplegia.  Paralysis  is  on  the  same  side  as  that  of  the 
arm  and  leg  because  the  facial  muscles  bear  precisely  the  same  relation  to  the 
cortex  as  the  spinal  muscles.  The  nuclei  of  origin  on  either  side  of  the  middle 
line  in  the  medulla  are  united  by  decussating  fibres  with  the  cortical  centre 
on  the  opposite  side  (see  Fig.  9).  A  few  fibres  reach  the  nucleus  from  the 
cerebral  cortex  of  the  same  side  (Melius,  Hoche),  and  this  uncrossed  path 
may  innervate  the  upper  facial  muscles  (Bruce). 

2.  The  nuclear  paralysis  caused  by  lesions  of  the  nerve-centres  in  the 
medulla  is  not  common  alone ;  but  is  seen  occasionally  in  tumors,  chronic  soft- 
ening, and  haemorrhage.  We  have  had  one  instance  of  its  involvement  in 
anterior  polio-myelitis.  In  diphtheria  this  centre  may  also  be  involved.  The 
symptoms  are  practically  similar  to  those  of  an  affection  of  the  nerve  fibre 
itself — infranuclear  paralysis. 

3.  Involvement  of  the  Nerve  Trunk. — Paralysis  may  result  from : 

{a)  Involvement  of  the  nerve  as  it  passes  through  the  pons — that  is,  be- 
tween its  nucleus  in  the  floor  of  the  fourth  ventricle  and  the  point  of  emer- 
gence in  the  postero-lateral  aspect  of  the  pons.  The  specially  interesting 
feature  in  connection  with  involvement  of  this  part  is  the  production  of  what 
is  called  alternating  or  crossed  paralysis,  the  face  being  involved  on  the  same 
side  as  the  lesion,  and  the  arm  and  leg  on  the  opposite  side,  since  the  motor 
path  is  involved  above  the  point  of  decussation  in  the  medulla  ( Fig.  9 ) .  This 
occurs  only  when  the  lesion  is  in  the  lower  section  of  the  pons.  A  lesion  in 
the  upper  half  of  the  pons  involves  the  fibres  not  of  the  outgoing  nerve  on  the 
same  side,  but  of  the  fibres  from  the  hemispheres  before  they  have  crossed  to 
the  nucleus  of  the  opposite  side.  In  this  case  there  would  of  course  be,  as 
in  hemiplegia,  paralysis  of  the  face  and  limbs  on  the  side  opposite  to  the 
lesion.  The  palsy,  too,  would  resemble  the  cerebral  form,  involving  only  the 
lower  fibres  of  the  facial  nerve. 

(&)  The  nerve  may  be  involved  at  its  point  of  emergence  by  tumors,  par- 
ticularly by  the  cerebello-pontine  growths,  by  gummata,  meningitis,  or  occa- 
sionally it  may  be  injured  in  fracture  of  the  base. 


1020  DISEASES  OF   THE  NERVOUS  SYSTEM. 

(c)  In  passing  through  the  Fallopian  canal  the  nerve  may  be  involved 
in  disease  of  the  ear.  particularly  by  caries  of  the  bone  in  otitis  media.  This 
is  a  common  cause  in  children.  I  have  seen  two  instances  follow  otitis  in 
puerperal  fever. 

(d)  As  the  nerve  emerges  from  the  styloid  foramen  it  is  exposed  to  in- 
juries and  blows  which  not  infrequently  cause  paralysis.  The  fibres  may  be 
cut  in  the  removal  of  tumors  in  this  region,  or  the  parah'sis  may  be  caused  by 
pressure  of  the  forceps  in  an  instrumental  delivery. 

(e)  Exposure  to  cold  is  the  most  common  cause  of  facial  paralysis  (Bell's 
palsy),  inducing  a  neuritis  of  the  nerve  within  the  Fallopian  canal. 

(f)  Syphilis  is  not  an  infrequent  cause,  and  the  paralysis  may  appear 
early  with  the  secondary  s^maptoms. 

(g)  It  may  occur  in  association  with  herpes. 

Facial  diplegia  is  a  rare  condition  occasionally  found  in  affections  at  the 
base  of  the  brain,  lesions  in  the  pons,  simultaneous  involvement  of  the  nerves 
in  ear-disease,  and  in  diphtheritic  paralysis.  Disease  of  the  nuclei  or  sym- 
metrical involvement  of  the  cortex  might  also  produce  it.  It  may  occur  as 
a  congenital  affection.    H.  M.  Thomas  has  described  two  cases  in  one  family. 

Symptoms. — In  the  peripheral  facial  paralysis  all  the  branches  of  the 
nerve  are  involved.  The  face  on  the  affected  side  is  immobile  and  can  neither 
be  moved  at  vrill  nor  participate  in  any  emotional  movements.  The  skin  is 
smooth  and  the  wrinkles  are  effaced,  a  point  particularly  noticeable  on  the 
forehead  of  elderly  persons.  The  eye  can  not  be  closed,  the  lower  lid  droops, 
and  the  eye  waters.  On  the  affected  side  the  angle  of  the  mouth  is  lowered, 
and  in  drinking  the  lips  are  not  kept  in  close  apposition  to  the  glass,  so  that 
the  liqnid  is  apt  to  run  out.  In  smiling  or  laughing  the  contrast  is  most 
striking,  as  the  affected  side  does  not  move,  which  gives  a  curious  unequal 
appearance  to  the  two  sides  of  the  face.  The  eye  can  not  be  closed  nor  can 
the  forehead  be  T\Tinkled.  In  long-standing  cases,  when  the  reaction  of 
degeneration  is  present,  if  the  patient  tries  to  close  the  eyes  while  looking 
fixedly  at  an  object  the  lids  on  the  sound  side  close  firmly,  but  on  the  paralyzed 
side  there  is  only  a  slight  inhibitory  droop  of  the  upper  lid,  and  the  eye  is 
turned  upward  and  outward  by  the  inferior  oblique.  On  asking  the  patient 
to  show  his  upper  teeth,  the  angle  of  the  mouth  is  not  raised.  In  all  these 
movements  the  face  is  drawn  to  the  sound  side  by  the  action  of  the  muscles. 
Speaking  may  be  slightly  interfered  vtdth,  owing  to  the  imperfection  in  the 
formation  of  the  labial  sounds.  Whistling  can  not  be  performed.  In  chew- 
ing the  food,  owing  to  the  paralysis  of  the  buccinator,  particles  collect  on  the 
affected  side.  The  paralysis  of  the  nasal  muscles  is  seen  on  asking  the  patient 
to  sniff.  Owing  to  the  fact  that  the  lips  are  drawn  to  the  sound  side,  the 
tongue,  when  protruded,  looks  as  if  it  were  pushed  to  the  paralyzed  side ;  but 
on  taking  its  position  from  the  incisor  teeth,  it  will  be  found  to  be  in  the  mid- 
dle line.  The  reflex  movements  are  lost  in  this  peripheral  form.  It  is  usually 
stated  that  the  palate  is  partially  paralyzed  on  the  same  side  and  that  the 
u^^lla  deviates.  Both  Gowers  and  Hughlings  Jackson  deny  the  existence  of 
this  involvement  in  the  great  majority  of  cases,  and  Horsley  and  Beevor  have 
shown  that  these  parts  are  innervated  by  the  accessory  nerve  to  the  vagus. 

When  the  nerve  is  involved  within  the  canal  between  the  genu  and  the; 
origin  of  the  chorda  t^Tiipani,  the  sense  of  taste  is  lost  in  the  anterior  part  of 


DISEASES  OF  THE  PERIPHERAL  NERVES.  1021 

the  tongue  on  the  affected  side.  When  the  nerve  is  damaged  outside  the  skull 
the  sense  of  taste  is  unaffected.  Hearing  is  often  impaired  in  facial  paralysis, 
most  commonly  by  preceding  ear-disease.  The  paralysis  of  the  stapedius 
muscle  may  lead  to  increased  sensitiveness  to  musical  notes.  Herpes  is  some- 
times associated  with  facial  paralysis.  Pain  is  not  common,  but  there  may 
be  neuralgia  about  the  ear.     The  face  on  the  affected  side  may  be  swollen. 

The  electrical  reactions,  which  are  those  of  a  peripheral  palsy,  have  con- 
siderable importance  from  a  prognostic  standpoint.  Erb's  rules  are  as  fol- 
lows :  If  there  is  no  change,  either  f aradic  or  galvanic,  the  prognosis  is  good 
and  recovery  takes  place  in  from  fourteen  to  twenty  days.  If  the  faradic 
and  galvanic  excitability  of  the  nerve  is  only  lessened  and  that  of  the  muscle 
increased  to  the  galvanic  current  and  the  contraction  formula  altered  (the 
contraction  sluggish  AC>KC),  the  outlook  is  relatively  good  and  recovery 
will  probably  take  place  in  from  four  to  six  weeks ;  occasionally  in  from  eight 
to  ten.  When  the  reaction  of  degeneration  is  present — that  is,  if  the  faradic 
and  galvanic  excitability  of  the  nerves  and  the  faradic  excitability  of  the  mus- 
cles are  lost  and  the  galvanic  excitability  of  the  muscle  is  quantitatively  in- 
creased and  qualitatively  changed,  and  if  the  mechanical  excitability  is  altered 
— the  prognosis  is  relatively  unfavorable  and  the  recovery  may  not  occur  for 
two,  six,  eight,  or  even  fifteen  months. 

CouESE. — The  course  of  facial  paralysis  is  usually  favorable.  The  onset 
in  the  form  following  cold  is  very  rapid,  developing  perhaps  within  twenty- 
four  hours,  but  rarely  is  the  paralysis  permanent.  Eecurring  attacks  have 
been  described;  Sinkler  mentions  five.  On  the  other  hand,  in  the  paralysis 
from  injury,  as  by  a  blow  on  the  mastoid  process,  the  condition  may  remain. 
When  permanent,  the  muscles  are  entirely  toneless.  In  some  instances  con- 
tracture develops  as  the  voluntary  power  returns,  and  the  natural  folds  and  the 
wrinkles  on  the  affected  side  may  be  deepened,  so  that  on  looking  at  the  face 
one  at  first  may  have  the  impression  that  the  affected  side  is  the  sound  one. 
This  is  corrected  at  once  on  asking  the  patient  to  smile,  when  it  is  seen  which 
side  of  the  face  has  the  most  active  movement.  Aretseus  noted  the  difficulty 
sometimes  experienced  in  determining  which  side  was  affected  until  the  patient 
spoke  or  laughed. 

The  diagnosis  of  facial  paralysis  is  usually  easy.  The  distinction  between 
the  peripheral  and  central  form  is  based  on  facts  already  mentioned. 

Teeatment. — In  the  cases  which  result  from  cold  and  are  probably  due 
to  neuritis  within  the  bony  canal,  hot  applications  first  should  be  made;  sub- 
sequently the  thermo-cautery  may  be  used  lightly  at  intervals  of  a  day  or  two 
over  the  mastoid  process,  or  small  blisters  applied.  If  the  ear  is  diseased, 
free  discharge  for  the  secretion  should  be  obtained.  The  galvanic  current  may 
be  employed  to  keep  up  the  nutrition  of  the  muscles.  The  positive  pole  should 
be  placed  behind  the  ear,  the  negative  one  along  the  zygomatic  and  other  mus- 
cles. The  application  can  be  made  daily  for  a  quarter  of  an  hour  and  the 
patient  can  readily  be  taught  to  make  it  himself  before  the  looking-glass. 
Massage  of  the  muscles  of  the  face  is  also  useful.  A  course  of  iodide  of  potas- 
sium may  be  given  even  when  there  is  no  indication  of  syphilis. 

In  those  cases  in  which  the  nerve  has  been  destroyed  by  an  injury,  during 
an  operation  or  from  disease,  and  when  there  has  been  no  evidence  of  return- 
ing function  after  keeping  up  the  electric  treatment  for  a  few  months,  a  nerve 


1022  DISEASES  OF  THE  NERVOUS  SYSTEM. 

anastomosis  should  be  performed.  For  this  purpose  either  the  spinal  acces- 
sory or  the  hypoglossal  nerve  may  be  used.  Though  the  normal  conditions 
may  never  be  completely  regained  after  such  an  operation,  the  motor  power 
will  be  largely  restored  to  the  paralyzed  muscles  and  the  obtrusive  deformity 
greatly  lessened.  This  procedure,  based  on  the  results  of  physiological  experi- 
mentation, makes  one  of  the  most  striking  of  modern  operations. 

Spasm. — The  spasm  may  be  limited  to  a  few  or  involve  all  the  muscles 
innervated  by  the  facial  nerve,  and  may  be  unilateral  or  bilateral. 

It  is  known  also  by  the  name  of  mimic  spasm  or  of  convulsive  tic.  Sev- 
eral different  affections  are  usually  considered  under  the  name  of  facial  or 
mimic  spasm,  but  we  shall  here  speak  only  of  the  simple  spasm  of  the  facial 
muscles,  either  primary  or  following  paralysis,  and  shall  not  include  the  cases 
of  habit  spasm  in  children,  or  the  tic  convulsif  of  the  French. 

Gowers  recognizes  two  classes — one  in  which  there  is  an  organic  lesion, 
and  an  idiopathic  form.  It  is  thought  to  be  due  also  to  reflex  causes,  such 
as  the  irritation  from  carious  teeth  or  the  presence  of  intestinal  worms.  The 
disease  usually  occurs  in  adults,  whereas  the  habit  spasm  and  the  tic  convulsif 
of  the  French,  often  confounded  with  it,  are  most  common  in  children.  True 
mimic  spasm  occasionally  comes  on  in  childhood  and  persists.  In  the  case  of 
a  school-mate,  the  affection  was  marked  as  early  as  the  eleventh  or  twelfth  year 
and  still  continues.  When  the  result  of  organic  disease,  there  has  usually  been 
a  lesion  of  the  centre  in  the  cortex,  as  in  the  case  reported  by  Berkley,  or 
pressure  on  the  nerve  at  the  base  of  the  brain  by  aneurism  or  tumor. 

Symptoms. — The  spasm  may  involve  only  the  muscles  around  the  eye — 
blepharospasm — in  which  case  there  is  constant,  rapid,  quick  action  of  the 
orbicularis  palpebrarum,  which,  in  association  with  photophobia,  may  be  tonic 
in  character.  More  commonly  the  spasm  affects  the  lateral  facial  muscles  with 
those  of  the  eye,  and  there  is  constant  twitching  of  the  side  of  the  face  with 
partial  closure  of  the  eye.  The  frontalis  is  rarely  involved.  In  aggravated 
cases  the  depressors  of  the  angle  of  the  mouth,  the  levator  menti,  and  the 
platysma  myoides  are  affected.  This  spasm  is  confined  to  one  side  of  the  face 
in  a  majority  of  cases,  though  it  may  extend  and  become  bilateral.  It  is 
increased  by  emotional  causes  and  by  voluntary  movements  of  the  face.  As 
a  rule,  it  is  painless,  but  there  may  be  tender  points  over  the  course  of  the  fifth 
nerve,  particularly  the  supraorbital  branch.  Tonic  spasm  of  the  facial  mus- 
cle may  follow  paralysis,  and  is  said  to  result  occasionally  from  cold. 

The  outlook  in  facial  spasm  is  always  dubious.  A  majority  of  the  cases 
persist  for  years  and  are  incurable. 

Treatment. — Sources  of  irritation  should  be  looked  for  and  removed. 
When  a  painful  spot  is  present  over  the  fifth  nerve,  blistering  or  the  appli- 
cation of  the  thermo-cautery  may  relieve  it.  Hypodermic  injections  of  strych- 
nia may  be  tried,  but  are  of  doubtful  benefit.  Weir  Mitchell  recommends  the 
freezing  of  the  cheek  for  a  few  minutes  daily  or  every  second  day  with  the 
spray,  and  this,  in  some  instances,  is  beneficial.  Often  the  relief  is  transient ; 
the  cases  return,  and  at  every  clinic  may  be  seen  half  a  dozen  or  more  of  such 
patients  who  have  run  the  gamut  of  all  measures  without  material  improve- 
ment. Severe  cases  may  require  surgical  interference.  The  nerve  may  be 
divided  near  the  stylomastoid  foramen  and  an  anastomosis  made  between  it 
and  the  spinal  accessory. 


DISEASES  OF  THE  PERIPHERAL  NERVES.  1023 


Auditory  Nerve. 

The  eighth,  known  also  as  portio  mollis  of  the  seventh  pair,  passes  from 
the  ear  through  the  internal  auditory  meatus,  and  in  reality  consists  of  two 
separate  nerves — the  cochlear  and  vestibular  roots.  These  two  roots  have  en- 
tirely different  functions,  and  may  therefore  be  best  considered  separately. 
The  cochlear  nerve  is  the  one  connected  with  the  organ  of  Corti,  and  is  con- 
cerned in  hearing.  The  vestibular  nerve  is  connected  with  the  vestibule  and 
semicircular  canals,  and  has  to  do  with  the  maintenance  of  equilibrium. 

The  Cochlear  Nerve. 

The  cortical  centre  for  hearing  is  in  the  temporo-sphenoidal  lobe.  Primary 
disease  of  the  auditory  nerve  in  its  centre  or  intracranial  course  is  uncommon. 
More  frequently  the  terminal  branches  are  affected  within  the  labyrinth. 

(a)  Affection  of  the  Cortical  Centre. — In  the  monkey,  experiments  indi- 
cate that  the  superior  temporal  gyrus  represents  the  centre  for  hearing.  In 
man  the  cases  of  disease  indicate  that  it  has  the  same  situation,  as  destruction 
of  this  gyrus  on  the  left  side  results  in  word-deafness,  which  may  be  defined 
as  an  inability  to  understand  the  meaning  of  words,  though  they  may  still 
be  heard  as  sounds.  The  central  auditory  path  extending  to  the  cortical  centre 
from  the  terminal  nuclei  of  the  cochlear  nerve  may  be  involved  and  produce 
deafness.  This  may  result  from  involvement  of  the  lateral  lemniscus,  from 
the  presence  of  a  tumor  in  the  corpora  quadrigemina,  especially  if  it  involve 
the  posterior  quadrigeminal  bodies,  from  a  lesion  of  the  internal  geniculate 
body,  or  it  may  be  associated  with  a  lesion  of  the  internal  capsule. 

(&)  Lesions  of  the  nerve  at  the  base  of  the  brain  may  result  from  the 
pressure  of  tumors,  meningitis  (particularly  the  cerebro-spinal  form),  haem- 
orrhage, or  traumatism.  A  primary  degeneration  of  the  nerve  may  occur  in 
locomotor  ataxia.  Primary  disease  of  the  terminal  nuclei  of  the  cochlear  nerve 
(nucleus  nervi  cochlearis  dorsalis  and  nucleus  nervi  cochlearis  ventralis)  is 
rare.  By  far  the  most  interesting  form  results  from  epidemic  cerebro-spinal 
meningitis,  in  which  the  nerve  is  frequently  involved,  causing  permanent 
deafness.     In  young  children  the  condition  results  in  deaf-mutism. 

(c)  In  a  majority  of  the  cases  associated  with  auditory-nerve  symptoms 
the  lesion  is  in  the  internal  ear,  either  primary  or  the  result  of  extension  of 
disease  of  the  middle  ear.  Two  groups  of  symptoms  may  be  produced — hyper- 
sesthesia  and  irritation,  and  diminished  function  or  nervous  deafness. 

(1)  Hypercesthesia  and  Irritation. — This  may  be  due  to  altered  function 
of  the  centre  as  well  as  of  the  nerve  ending.  True  hypersesthesia — hyperacusis 
— is  a  condition  in  which  sounds,  sometimes  even  those  inaudible  to  other 
persons,  are  heard  with  great  intensity.  It  occurs  in  hysteria  and  occasionally 
in  cerebral  disease.  As  already  mentioned,  in  paralysis  of  the  stapedius  low 
notes  may  be  heard  with  intensity.  In  dysgesthesia,  or  dysacusis,  ordinary 
sounds  cause  an  unpleasant  sensation,  as  commonly  happens  in  connection 
with  headache,  when  ordinary  noises  are  badly  borne. 

Tinnitus  aurium  is  a  term  employed  to  designate  certain  subjective  sensa- 
tions of  ringing,  roaring,  tickling,  and  whirring  noises  in  the  ear.  It  is  a 
very  common  and  often  a  distressing  symptom.     It  is  associated  with  many 


1024  DISEASES  OF  THE  NERVOUS  SYSTEM. 

forms  of  ear-disease  and  may  result  from  pressure  of  wax  on  the  drum.  It  is 
rare  in  organic  disease  of  the  central  connections  of  the  nerve.  Sudden  in- 
tense stimulation  of  the  nerve  may  cause  it.  A  form  not  uncommonly  met 
with  in  medical  practice  is  that  in  which  the  patient  hears  a  continual  bruit 
in  the  ear,  and  the  noise  has  a  systolic  intensification,  usually  on  one  side.  I 
have  twice  been  consulted  by  physicians  for  this  condition  under  the  belief 
that  they  had  an  internal  aneurism,  A  systolic  murmur  may  be  heard  occa- 
sionally on  auscultation.  It  occurs  in  conditions  of  anemia  and  neurasthenia. 
Subjective  noises  in  the  ear  may  precede  an  epileptic  seizure  and  are  sometimes 
present  in  migraine.  In  whatever  form  tinnitus  exists,  though  slight  and 
often  regarded  as  trivial,  it  occasions  great  annoyance  and  often  mental  dis- 
tress, and  has  even  driven  patients  to  suicide. 

The  diagnosis  is  readily  made;  but  it  is  often  extremely  difficult  to  deter- 
mine upon  what  condition  the  tinnitus  depends.  The  relief  of  constitutional 
states,  such  as  anaemia,  neurasthenia,  or  gout,  may  result  in  cure.  A  careful 
local  examination  of  the  ear  should  always  be  made.  One  of  the  most  worry- 
ing forms  is  the  constant  clicking,  sometimes  audible  many  feet  away  from 
the  patient,  and  due  probably  to  clonic  spasm  of  the  muscles  connected  with 
the  Eustachian  tube  or  of  the  levator  palati.  The  condition  may  persist  for 
years  unchanged,  and  then  disappear  suddenly.  The  pulsating  forms  of  tinni- 
tus, in  which  the  sound  is  like  that  of  a  systolic  hruit,  are  almost  invariably 
subjective,  and  it  is  very  rare  to  hear  anything  with  the  stethoscope.  It  is 
to  be  remembered  that  in  children  there  is  a  systolic  brain  murmur,  best 
heard  over  the  ear,  and  in  some  instances  appreciable  in  the  adult. 

(2)  Diminished  Function  or  Nervous  Deafness. — In  testing  for  nervous 
deafness,  if  the  tuning-fork  can  not  be  heard  when  placed  near  the  meatus, 
but  the  vibrations  are  audible  by  placing  the  foot  of  the  tuning-fork  against 
the  temporal  bone,  the  conclusion  may  be  drawn  that  the  deafness  is  not  due 
to  involvement  of  the  nerve.  The  vibrations  are  conveyed  through  the  tem- 
poral bone  to  the  cochlea  and  vestibule.  The  watch  may  be  used  for  the  same 
purpose,  and  if  the  meatus  is  closed  and  the  watch  is  heard  better  in  contact 
with  the  mastoid  process  than  when  opposite  the  open  meatus,  the  deafness 
is  probably  not  nervous.  Disturbance  of  the  function  of  the  auditory  nerve 
is  not  a  very  frequent  s}miptom  in  brain-disease,  but  in  all  cases  the  function 
of  the  nerve  should  be  carefully  tested. 

The  Vestibular  Nerve. 

The  most  frequent  s}T2iptoms  met  with  in  association  with  disease  of  the 
vestibular  nerve  and  its  central  connections  are  vertigo,  nystagmus,  and  loss 
of  coordination  of  the  muscles  of  the  head,  neck,  and  eyes. 

Auditory  Vertigo — Meniere's  Disease, — In  1861  Meniere,  a  French  phy- 
sician, described  an  affection  characterized  by  noises  in  the  ear,  vertigo  (which 
might  be  associated  with  loss  of  consciousness),  vomiting,  and,  in  many  cases, 
progressive  loss  of  hearing.  The  following  grouping  of  the  cases  has  been 
made  by  Parkes  Weber:  (1)  The  apoplectic  form,  due  to  hgemorrhage  into  the 
labyrinth,  as  in  leukaemia,  followed,  as  a  rule,  by  complete  deafness  in  one 
or  both  ears.  (2)  The  cases  associated  with  progressive  inflammatory  disease 
of  the  labyrinth.     (3)  Associated  with  organic  changes  in  the  auditory  nerves, 


DISEASES  OF  THE  PERIPHERAL  NERVES.  1025 

as  in  tumors,  sometimes  in  tabes,  and  in  cases  of  aural  vertigo  associated  with 
facial  paralysis  on  one  side.  (4)  Cases  in  which  a  paroxysm  of  epilepsy  is 
preceded  by  an  auditory  aura.  (5)  The  moderate  attacks  which  are  associated 
with  the  various  middle-ear  affections,  with  wax  in  the  meatus,  with  violent 
syringing  of  the  ears,  etc.,  all  of  which  are  probably  due  to  increase  in  the 
intra-labyrinthine  pressure.  Meniere's  symptoms  may  occasionally  be  due  to 
temporary  excessive  increase  in  the  perilymph,  possibly  of  angioneurotic 
character. 

Symptoms. — The  attack  usually  sets  in  suddenly  with  a  buzzing  noise  in 
the  ears  and  the  patient  feels  as  if  he  was  reeling  or  staggering.  He  may  feel 
himself  to  be  reeling,  or  the  objects  about  him  may  seem  to  be  turning,  or  the 
phenomena  may  be  combined.  The  attack  is  often  so  abrupt  that  the  patient 
falls,  though,  as  a  rule,  he  has  time  to  steady  himself  by  grasping  some  neigh- 
boring object.  There  may  be  slight  but  transient  loss  of  consciousness.  In  a 
few  minutes,  or  even  less,  the  vertigo  passes  off  and  the  patient  becomes  pale 
and  nauseated,  a  clammy  sweat  breaks  out  on  the  face,  and  vomiting  may 
follow. 

The  tinnitus  is  described  as  either  a  roaring  or  a  throbbing  sound.  Ocular 
symptoms  may  be  present;  thus,  jerking  of  the  eyeballs  or  nystagmus  may 
develop  during  the  attack,  or  diplopia. 

Labyrinthine  vertigo  is  paroxysmal,  coming  on  at  irregular  intervals,  some- 
times of  weeks  or  months;  or  several  attacks  may  occur  in  a  day. 

The  disturbances  of  equilibrium,  including  the  vertigo,  are  dependent  upon 
a  disturbance  of  the  functions  of  the  vestibular  nerve  or  of  the  organs  with 
which  this  nerve  is  connected,  either  in  its  peripheral  distribution  or  by  means 
of  its  central  connection.  The  auditory  symptoms  often  accompanying  it  are 
doubtless  always  due  to  involvement  of  the  cochlear  nerve  or  its  peripheral 
or  central  connections. 

Diagnosis. — The  combination  of  tinnitus  with  giddiness,  with  or  without 
gastric  disturbance,  is  sufficient  to  establish  a  diagnosis.  There  are  other 
forms  of  vertigo  from  which  it  must  be  distinguished.  The  form  known  as 
gastric  vertigo,  which  is  associated  with  dyspepsia  and  occurs  most  commonly 
in  persons  of  middle  age,  is,  as  a  rule,  readily  distinguished  by  the  absence 
of  tinnitus  or  evidences  of  disturbance  in  the  function  of  the  auditory  nerve. 
This  variety  of  vertigo  is  much  less  common  than  Trousseau's  description 
would  lead  us  to  believe.  It  is  important  to  note  the  close  connection  of  vertigo 
with  ocular  defects. 

The  cardio-vascular  vertigo,  one  of  the  most  common  forms,  occurs  in 
cases  of  valvular  disease,  particularly  aortic  insufficiency,  and  as  frequently 
in  arterio-sclerosis. 

Endemic  Paralytic  Vertigo. — In  parts  of  Switzerland  and  France  there  is 
a  remarkable  form  of  vertigo  described  by  Gerlier,  which  is  characterized  by 
attacks  of  paretic  weakness  of  the  extremities,  falling  of  the  eyelids,  remarkable 
depression,  but  with  retention  of  consciousness.  It  occurs  also  in  northern 
Japan,  where  Miura  says  it  develops  paroxysmally  among  the  farm  laborers 
of  both  sexes  and  all  ages.    It  is  known  there  as  Jcuhisagari. 

Aural  vertigo  must  be  carefully  distinguished  from  attacks  of  petit  mal, 
or,  indeed,  of  definite  epilepsy.  It  is  rare  in  petit  mal  to  have  noises  in  the 
ear  or  actual  giddiness,  but  in  the  aura  preceding  an  epileptic  attack  the 


1026  DISEASES  OF  THE  NERVOUS  SYSTEM. 

patient  may  feel  giddy.  Giddiness  and  transient  loss  of  consciousness  may 
be  associated  with  organic  disease  of  the  brain,  more  particularly  with  tumor. 
Vomiting  also  may  be  present.  A  careful  investigation  of  the  symptoms  will 
usually  lead  to  a  correct  diagnosis. 

The  outlook  in  Meniere^s  disease  is  uncertain.  While  many  cases  recover 
completely,  in  others  deafness  results  and  the  attacks  recur  at  shorter  inter- 
vals. In  aggravated  cases  the  patient  constantly  suffers  from  vertigo,  and 
may  even  be  confined  to  his  bed. 

Teeatment. — Bromide  of  potassium,  in  30-grain  doses  three  times  a  day, 
is  sometimes  beneficial.  If  there  is  a  history  of  syphilis,  the  iodide  should  be 
administered.  The  salicylates  are  recommended,  and  Charcot  advises  quinine 
to  einchonism.  In  cases  in  which  there  is  increase  in  the  aisrterial  tension, 
nitroglycerin  may  be  given,  at  first  in  very  small  doses,  but  increasing  gradu- 
ally. It  is  not  specially  valuable  in  Meniere's  disease,  but  in  the  cases  of 
giddiness  in  middle-aged  men  and  women  associated  with  arterio-sclerosis  it 
sometimes  acts  very  satisfactorily.  Correction  of  errors  of  refraction  is  some- 
times followed  by  prompt  relief  of  the  vertigo. 

Glosso-phaeyngeal  Neeve   (Nervus  glossopliaryngeus). 

The  ninth  nerve  contains  both  motor  and  sensory  fibres  and  is  also  a  nerve 
of  the  special  sense  of  taste  to  the  tongue.  It  supplies,  by  its  motor  branches, 
the  stylo-pharyngeus  and  the  middle  constrictor  of  the  pharynx.  The  sensory 
fibres  are  distributed  to  the  upper  part  of  the  pharynx. 

Symptoms. — Of  nuclear  disturbance  we  know  very  little.  The  pharyngeal 
symptoms  of  bulbar  paralysis  are  probably  associated  with  involvement  of  the 
nuclei  of  this  nerve.  Lesion  of  the  nerve  trunk  itself  is  rare,  but  it  may  be 
compressed  by  tumors  or  involved  in  meningitis.  Disturbance  of  the  sense  of 
taste  may  result  from  loss  of  function  of  this  nerve,  in  which  case  it  is  chiefly 
in  the  posterior  part  of  the  tongue  and  soft  palate. 

The  general  disturbances  of  the  sense  of  taste  may  here  be  briefly  referred 
to.  Loss  of  the  sense  of  taste — ageusia — may  be  caused  by  disturbance  of  the 
peripheral  end  organs,  as  in  affections  of  the  mucosa  of  the  tongue.  This  is 
very  common  in  the  dry  tongue  of  fever  or  the  furred  tongue  of  dyspepsia, 
under  which  circumstances,  as  the  saying  is,  everything  tastes  alike.  Strong 
irritants,  too,  such  as  pepper,  tobacco,  or  vinegar,  may  dull  or  diminish  the 
sense  of  taste.  Complete  loss  may  be  due  to  involvement  of  the  nerves  either 
in  their  course  or  in  the  centres.  Perversion  of  the  sense  of  taste — parageusis 
— is  rarely  found,  except  as  an  hysterical  manifestation  and  in  the  insane. 
Increased  sensitiveness  is  still  more  rare.  There  are  occasional  subjective 
sensations  of  taste,  occurring  as  an  aura  in  epilepsy  or  as  part  of  the  hallu- 
cinations in  the  insane. 

To  test  the  sense  of  taste  the  patient's  eyes  should  be  closed  and  small 
quantities  of  various  substances  applied  to  the  protruded  tongue.  The  sensa- 
tion should  be  perceived  before  the  tongue  is  withdrawn.  The  following  are 
the  most  suitable  tests :  For  bitterness,  quinine ;  for  sweetness,  a  strong  solution 
of  sugar  or  saccharin;  for  acidity,  vinegar;  and  for  the  saline  test,  common 
salt.  One  of  the  most  important  tests  is  the  feeble  galvanic  current,  which 
gives  the  well-known  metallic  taste. 


DISEASES  OF  THE  PERIPHERAL  NERVES.  1027 

Pneumogasteic  Nerve   {Nervus  vagus). 

The  tenth  nerve  has  an  important  and  extensive  distribution,  supplying 
the  pharynx,  larynx,  lungs,  heart,  oesophagus,  and  stomach.  The  nerve  may 
be  involved  at  its  nucleus  along  with  the  spinal  accessory  and  the  hypoglossal, 
forming  what  is  known  as  bulbar  paralysis.  It  may  be  compressed  by  tumors 
or  aneurism,  or  in  the  exudation  of  meningitis,  simple  or  syphilitic.  In  its 
course  in  the  neck  the  trunk  may  be  involved  by  tumors  or  in  wounds.  It  has 
been  tied  in  ligature  of  the  carotid,  and  has  been  cut  in  the  removal  of  deep- 
seated  tumors.     The  trunk  may  be  attacked  by  neuritis. 

The  affections  of  the  vagus  are  best  considered  in  connection  with  the 
distribution  of  the  separate  nerves. 

(a)  Pharyngeal  Branches. — In  combination  with  the  glosso-pharyngeal  the 
branches  from  the  vagus  form  the  pharyngeal  plexus,  from  which  the  muscles 
and  mucosa  of  the  pharynx  are  supplied.  In  paralysis  due  to  involvement  of 
this  either  in  the  nuclei,  as  in  bulbar  paralysis,  or  in  the  course  of  the  nerve, 
as  in  diphtheritic  neuritis,  there  is  difficulty  in  swallowing  and  the  food  is  not 
passed  on  into  the  oesophagus.  If  the  nerve  on  one  side  only  is  involved,  the 
deglutition  is  not  much  impaired.  In  these  cases  the  particles  of  food  fre- 
quently pass  into  the  larynx,  and,  when  the  soft  palate  is  involved,  into  the 
posterior  nares. 

Spasm  of  the  pharynx  is  always  a  functional  disorder,  usually  occurring 
in  hysterical  and  nervous  people.  Growers  mentions  a  case  of  a  gentleman 
who  could  not  eat  unless  alone,  on  account  of  the  inability  to  swallow  in  the 
presence  of  others  from  spasm  of  the  pharynx.  This  spasm  is  a  well-marked 
feature  in  hydrophobia,  and  I  have  seen  it  in  a  case  of  pseudo-hydrophobia. 

(&)  Laryngeal  Branches. — The  superior  laryngeal  nerve  supplies  the  mu- 
cous membrane  of  the  larynx  above  the  cords  and  the  crico-thyroid  muscle. 
The  inferior  or  recurrent  laryngeal  curves  around  the  arch  of  the  aorta  on 
the  left  side  and  the  subclavian  artery  on  the  right,  passes  along  the  trachea 
and  supplies  the  mucosa  below  the  cords  and  all  the  muscles  of  the  larynx 
except  the  crico-thyroid  and  the  epiglottidean.  Experiments  have  shown  that 
these  motor  nerves  of  the  pneumogastric  are  all  derived  from  the  spinal 
accessory.  The  remarkable  course  of  the  recurrent  laryngeal  nerves  renders 
them  liable  to  pressure  by  tumors  within  the  thorax,  particularly  by  aneurism. 
The  following  are  the  most  important  forms  of  paralysis : 

(1)  Bilateral  Paralysis  of  the  Abductors. — In  this  condition,  the 
posterior  crico-arytenoids  are  involved  and  the  glottis  is  not  opened  during 
inspiration.  The  cords  may  be  close  together  in  the  position  of  phonation, 
and  during  inspiration  may  be  brought  even  nearer  together  by  the  pressure 
of  air,  so  that  there  is  only  a  narrow  chink  through  which  the  air  whistles 
with  a  noisy  stridor.  This  dangerous  form  of  laryngeal  paralysis  occurs  occa- 
sionally as  a  result  of  cold,  or  may  follow  a  laryngeal  catarrh.  The  posterior- 
muscles  have  been  found  degenerated  when  the  others  were  healthy.  The  con- 
dition may  be  produced  by  pressure  upon  both  vagi,  or  upon  both  recurrent 
nerves.  As  a  central  affection  it  occurs  in  tabes  and  bulbar  paralysis,  but  may 
be  seen  also  in  hysteria.  The  characteristic  symptoms  are  inspiratory  stridor 
with  unimpaired  phonation.  Possibly,  as  Gowers  suggests,  many  cases  of 
so-called  hysterical  spasm  of  the  glottis  are  in  reality  abductor  paralysis. 


1028 


DISEASES  OF   THE  NERVOUS  SYSTEM. 


(2)  Unilateral  Abductor  Paralysis. — This  frequently  results  from  the 
pressure  of  tumors  or  involvement  of  one  recurrent  nerve.  Aneurism  is  by 
far  the  most  common  cause,  though  on  the  right  side  the  nerve  may  be  involved 
in  thickening  of  the  pleura.  The  symptoms  are  hoarseness  or  roughness  of 
the  voice,  such  as  is  so  common  in  aneurism.  Dyspnoea  is  not  often  present. 
The  cord  on  the  affected  side  does  not  move  in  inspiration.  Subsequently  the 
adductors  may  also  become  involved,  in  which  case  the  phonation  is  still  more 
impaired. 

(3)  Adductor  Paralysis. — This  results  from  involvement  of  the  lateral 
crico-arytenoid  and  the  arytenoid  muscle  itself.  It  is  common  in  hysteria, 
particularly  of  women,  and  causes  the  hysterical  aphonia,  which  may  come  on 
suddenly.  It  may  result  from  catarrh  of  the  larynx  or  from  overuse  of  the 
voice.  In  laryngoscopic  examination  it  is  seen,  on  attempting  phonation,  that 
there  is  no  power  to  bring  the  cords  together.  In  this  connection  the  following 
table  from  Gowers'  work  will  be  found  valuable  to  the  student: 


Symptoms. 

No  voice;  no  cough; 
stridor  only  on  deep  in- 
spiration. 

Voice  low  pitched 
and  hoarse;  no  cough; 
stridor  absent  or  slight 
on  deep  breathing. 

Voice  little  changed; 
cough  normal ;  inspira- 
tion difficult  and  long, 
with  loud  stridor. 

Symptoms  inconclu- 
sive; little  affection  of 
voice  or  cough. 

No  voice ;  perfect 
cough;  no  stridor  or 
dyspnoea. 


Signs. 

Both  cords  moder- 
ately abducted  and  mo- 
tionless. 

One  cord  moderately 
abducted  and  motionless, 
the  other  moving  freely, 
and  even  beyond  the  mid- 
dle line  in  phonation. 

Both  cords  near  to- 
gether, and  during  in- 
spiration not  separated, 
but  even  drawn  nearer 
together. 

One  cord  near  the 
middle  line  not  moving 
during  inspiration,  the 
other  normal. 

Cords  normal  in  po- 
sition and  moving  nor- 
mally in  respiration, 
but  not  brought  together 
on  an  attempt  at  phona- 
tion. 


Lesion. 
Total  bilateral  palsy. 

Total  unilateral  palsy. 
Total  abductor  palsy. 


Unilateral      abductor 
palsy. 

Adductor  palsy. 


Spasm  of  the  Muscles  of  the  Larynx. — ^In  this  the  adductor  muscles 
are  involved.  It  is  not  an  uncommon  affection  in  children,  and  has  already 
been  referred  to  as  lar3Tigismus  stridulus.  Paroxysmal  attacks  of  laryngeal 
spasm  are  rare  in  the  adult,  but  cases  are  described  in  which  the  patient, 
usually  a  young  girl,  wakes  at  night  in  an  attack  of  intense  dyspnoea,  which 
may  persist  long  enough  to  produce  cyanosis.  Liveing  states  that  they  may 
replace  attacks  of  migraine.     They  occur  in  a  characteristic  form  in  loco- 


DISEASES  OF   THE  PERIPHERAL  NERVES.  1029 

motor  ataxia,  forming  tlic  so-called  laryngeal  crises.  There  is  a  condition 
known  as  spastic  aphonia,  in  which,  when  the  patient  attempts  to  speak,  pho- 
nation  is  completely  prevented  by  a  spasm. 

Disturbance  of  the  sensory  nerves  of  the  larynx  is  rare. 

Anesthesia  may  occur  in  bulbar  paralysis  and  in  diphtheritic  neuritis — 
a  serious  condition,  as  portions  of  food  may  enter  the  windpipe.  It  is  usu- 
ally associated  with  dysphagia  and  is  sometimes  present  in  hysteria.  Hyper- 
sesthesia  of  the  larynx  is  rare. 

(c)  Cardiac  Branches. — The  cardiac  plexus  is  formed  by  the  union  of 
branches  of  the  vagi  and  of  the  sympathetic  nerves.  The  vagus  fibres  sub- 
serve motor,  sensory,  and  probably  trophic  functions. 

(1)  MoTOE. — The  fibres  which  inhibit,  control,  and  regulate  the  cardiac 
action  pass  in  the  vagi.  Irritation  may  produce  slowing  of  the  action.  Czer- 
mak  could  slow  or  even  arrest  the  heart's  action  for  a  few  beats  by  pressing 
a  small  tumor  in  his  neck  against  one  pneumogastric  nerve,  and  it  is  said 
that  the  same  can  be  produced  by  forcible  bilateral  pressure  on  the  carotid 
canal.  There  are  instances  in  which  persons  appear  to  have  had  voluntary 
control  over  the  action  of  the  heart.  Cheyne  mentions  the  case  of  Colonel 
Townshend,  "  who  could  die  or  expire  when  he  pleased,  and  yet  by  an  efEort 
or  somehow  come  to  life  again,  which  it  seems  he  had  sometimes  tried  before 
he  had  sent  for  us."  Retardation  of  the  heart's  action  has  also  followed  acci- 
dental ligature  of  one  vagus.  Irritation  of  the  nuclei  may  also  be  accom- 
panied with  a  neurosis  of  this  nerve.  On  the  other  hand,  when  there  is  com- 
plete paralysis  of  the  vagi,  the  inhibitory  action  may  be  abolished  and  the 
acceleratory  influences  have  full  sway.  The  heart's  action  is  then  greatly 
increased.  This  is  seen  in  some  instances  of  diphtheritic  neuritis  and  in 
involvement  of  the  nerve  by  tumors,  or  its  accidental  removal  or  ligature. 
Complete  loss  of  function  of  one  vagus,  however,  may  not  be  followed  by  any 
symptoms. 

(3)  Sensoey  symptoms  on  the  part  of  the  cardiac  branches  are  very  varied. 
Normally,  the  heart's  action  proceeds  regularly  without  the  participation  of 
consciousness,  but  the  unpleasant  feelings  and  sensations  of  j)alpitation  and 
pain  are  conveyed  to  the  brain  through  this  nerve.  How  far  the  fibres  of  the 
pneumogastric  are  involved  in  angina  it  is  impossible  to  say.  The  various 
disturbances  of  sensation  are  described  under  the  cardiac  neuroses. 

{d)  Pulmonary  Branches. — We  know  very  little  of  the  pulmonary  branches 
of  the  vagi.  The  motor  fibres  are  stated  to  control  the  action  of  the  bronchial 
muscles,  and  it  has  long  been  held  that  asthma  may  be  a  neurosis  of  these 
fibres.  The  various  alterations  in  the  respiratory  rhythm  are  probably  due 
more  to  changes  in  the  centre  than  in  the  nerves  themselves. 

(e)  Gastric  and  (Esophageal  Branches. — The  muscular  movements  of  these 
parts  are  presided  over  by  the  vagi  and  vomiting  is  induced  through  them, 
usually  reflexly,  but  also  by  direct  irritation,  as  in  meningitis.  Spasm  of  the 
oesophagus  generally  occurs  with  other  nervous  phenomena.  Gastralgia  may 
sometimes  be  due  to  cramp  of  the  stomach,  but  is  more  commonly  a  sensory 
disturbance  of  this  nerve,  due  to  direct  irritation  of  the  peripheral  ends,  or 
is  a  neuralgia  of  the  terminal  fibres.  Hunger  is  said  to  be  a  sensation  aroused 
by  the  pneumogastric,  and  some  forms  of  nervous  dyspepsia  probably  depend 
upon  disturbed  function  of  this  nerve.     The  severe  gastric  crises  which  occur 


1030  DISEASES  OF   THE  NERVOUS  SYSTEM. 

in  locomotor  ataxia  are  due  to  central  irritation  of  the  nuclei.     Some  describe 
exophthalmic  goitre  under  lesions  of  the  vagi. 

Spiistal  Accessoey  Neeve  (Nervus  accessorius) . 

Paralysis. — The  smaller  or  internal  part  of  this  nerve  joins  the  vagus  and 
is  distributed  through  it  to  the  lar}'ngeal  muscles.  The  larger  external  part 
is  distributed  to  the  sterno-mastoid  and  trapezius  muscles. 

The  nuclei  of  the  nerve,  particularly  of  the  accessory  part,  may  be  in- 
volved in  bulbar  paralysis.  The  nuclei  of  the  external  portion,  situated  as 
they  are  in  the  cervical  cord,  may  be  attacked  in  progressive  degeneration  of 
the  motor  nuclei  of  the  cord.  The  nerve  may  be  involved  in  the  exudation  of 
meningitis,  or  be  compressed  by  tumors,  or  in  caries.  The  symptoms  of  paraly- 
sis of  the  accessory  portion  which  joins  the  vagus  have  already  been  given  in 
the  account  of  the  palsy  of  the  larj-ngeal  branches  of  the  pneumogastric.  Dis- 
ease or  compression  of  the  external  portion  is  followed  b}^  paralysis  of  the 
sterno-mastoid  and  of  the  trapezius  on  the  same  side.  In  paralysis  of  one 
sterno-mastoid,  the  patient  rotates  the  head  with  difficulty  to  the  opposite 
side,  but  there  is  no  torticollis,  though  in  some  cases  the  head  is  held  obliquely. 
As  the  trapezius  is  supplied  in  part  from  the  cervical  nerves,  it  is  not  com- 
pletely paralyzed,  but  the  portion  which  passes  from  the  occipital  bone  to  the 
acromion  is  functionless.  The  paralysis  of  the  muscle  is  well  seen  when  the 
patient  draws  a  deep  breath  or  shrugs  the  shoulders.  The  middle  portion  of 
the  trapezius  is  also  weakened,  the  shoulder  droops  a  little,  and  the  angle 
of  the  scapula  is  rotated  inward  by  the  action  of  the  rhomboids  and  the  levator 
anguli  scapulse.  Elevation  of  the  arm  is  impaired,  for  the  trapezius  does  not 
fix  the  scapula  as  a  point  from  which  the  deltoid  can  work. 

In  progressive  muscular  atroph}'  we  sometimes  see  bilateral  paralysis  of 
these  muscles.  Thus,  if  the  sterno-mastoids  are  affected,  the  head  tends  to 
fall  back;  when  the  trapezii  are  involved,  it  falls  forward,  a  characteristic 
attitude  of  the  head  in  many  cases  of  progressive  muscular  atrophy.  Gowers 
suo-CTests  that  lesions  of  the  accessorv  in  difficult  labor  mav  account  for  those 
cases  in  which  during  the  first  year  of  life  the  child  has  great  difficulty  in 
holding  up  the  head.  In  children  this  drooping  of  the  head  is  an  important 
symptom  in  cervical  meningitis,  the  result  of  caries. 

The  treatment  of  the  condition  depends  much  upon  the  cause.  In  the 
central  nuclear  atrophy  but  little  can  be  done.  In  paralysis  from  pressure 
the  symptoms  may  gradually  be  relieved.  The  paralyzed  muscles  should  be 
stimulated  by  electricity  and  massage. 

Accessory  Spasm. — (Toeticollis;  Wryn^eck.) — The  forms  of  spasm 
affecting  the  cervical  muscles  are  best  considered  here,  as  the  muscles  supplied 
by  the  accessory  are  chiefly,  though  not  solely,  responsible  for  the  condition. 
The  following  forms  may  be  described  in  this  section : 

(a)  Congenital  Toeticollis. — This  condition,  also  known  as  fixed  torti- 
collis, depends  upon  the  shortening  and  atrophy  of  the  sterno-mastoid  on 
one  side.  It  occurs  in  children  and  may  not  be  noticed  for  several  years  on 
account  of  the  shortness  of  the  neck,  the  parents  often  alleging  that  it  has 
only  recently  come  on.  It  affects  the  right  side  almost  exclusively.  A  re- 
markable circumstance  in  connection  with  it  is  the  existence  of  facial  asym- 


DISEASES  OF   THE  PERIPHERAL  NERVES,  1031 

metry  noted  by  Wilks,  which  appears  to  be  an  essential  part  of  this  congenital 
form.  It  occurred  in  6  cases  reported  by  Golding-Bird.  In  congenital  wry- 
neck the  sterno-mastoid  is  shortened,  hard  and  firm,  and  in  a  condition  of 
more  or  less  advanced  atrophy.  This  must  be  distinguished  from  the  local 
thickening  in  the  sterno-mastoid  due  to  rupture,  which  may  occur  at  the  time 
of  birth  and  produce  an  induration  or  muscle  callus.  Although  the  sterno- 
mastoid  is  almost  always  affected,  there  are  rare  cases  in  which  the  fibrous 
atrophy  affects  the  trapezius.  This  form  of  wryneck  in  itself  is  unimportant, 
since  it  is  readily  relieved  by  tenotomy,  but  Golding-Bird  states  that  the  facial 
asymmetry  persists,  or  indeed  may,  as  shown  by  photographs  in  my  case,  be- 
come more  evident.  With  reference  to  the  pathology  of  the  affection,  Golding- 
Bird  concludes  that  the  facial  asymmetry  and  the  torticollis  are  integral  parts 
of  one  affection  which  has  a  central  origin,  and  is  the  counterpart  in  the  head 
and  neck  of  infantile  paralysis  with  talipes  in  the  foot. 

(b)  Spasmodic  Weyneck. — Two  varieties  of  this  spasm  occur,  the  tonic 
and  the  clonic,  which  may  alternate  in  the  same  case ;  or,  as  is  most  common, 
they  are  separate  and  remain  so  from  the  outset.  The  disease  is  most  frequent 
in  adults  and,  according  to  Gowers,  more  common  in  females.  In  America 
it  is  certainly  more  frequent  in  males.  Of  the  8  or  10  cases  which  came 
under  my  observation  in  Montreal  and  Philadelphia,  all  were  males.  In 
females  it  may  be  an  hysterical  manifestation.  There  may  be  a  marked  neu- 
rotic family  history,  but  it  is  usually  impossible  to  fix  upon  any  definite  etio- 
logical factor.  Some  cases  have  followed  cold;  others  a  blow.  Brissaud  has 
described  what  he  calls  mental  torticollis.  It  is  usually  met  with  in  neuras- 
thenic patients  and  in  elderly  persons,  and  consists  of  a  clonic  spasm  of  the 
rotators  of  the  head. 

The  symptoms  are  well  defined.  In  the  tonic  form  the  contracted  sterno- 
mastoid  draws  the  occiput  toward  the  shoulder  of  the  affected  side;  the  chin 
is  raised,  and  the  face  rotated  to  the  other  shoulder.  The  sterno-mastoid  may 
be  affected  alone  or  in  association  with  the  trapezius.  When  the  latter  is 
implicated  the  head  is  depressed  still  more  toward  the  same  side.  In  long- 
standing cases  these  muscles  are  prominent  and  very  rigid.  There  may  be 
some  curvature  of  the  spine,  the  convexity  of  which  is  toward  the  sound  side. 
The  cases  in  which  the  spasm  is  clonic  are  much  more  distressing  and  serious. 
The  spasm  is  rarely  limited  to  a  single  muscle.  The  sterno-mastoid  is  almost 
always  involved  and  rotates  the  head  so  as  to  approximate  the  mastoid  proc- 
ess to  the  inner  end  of  the  clavicle,  turning  the  face  to  the  opposite  side  and 
raising  the  chin.  When  with  this  the  trapezius  is  affected,  the  depression  of 
the  head  toward  the  same  side  is  more  marked.  The  head  is  drawn  somewhat 
backward ;  the  shoulder,  too,  is  raised  by  its  action.  According  to  Gowers,  the 
splenius  is  associated  with  the  sterno-mastoid  about  half  as  frequently  as  the 
trapezius.  Its  action  is  to  incline  the  head  and  rotate  it  slightly  toward 
the  same  side.  Other  muscles  may  be  involved,  such  as  the  scalenus  and 
platysma  myoides ;  and  in  rare  cases  the  head  may  be  rotated  by  the  deep  cervi- 
cal muscles,  the  rectus  and  obliquus.  There  are  cases  in  which  the  spasm  is 
bilateral,  causing  a  backward  movement — the  retro-collic  spasm.  This  may 
be  either  tonic  or  clonic,  and  in  extreme  cases  the  face  is  horizontal  and  looks 
upward. 

These  clonic  contractions  may  come  on  without  warning,  or  be  preceded 


1032  DISEASES  OF  THE  NERVOUS  SYSTEM. 

for  a  time  by  irregular  pains  or  stiffness  of  the  neck.  The  jerking  movements 
recur  every  few  moments,  and  it  is  impossible  to  keep  the  head  still  for  more 
than  a  minute  or  two.  In  time  the  muscles  undergo  hj^Dertrophy  and  may  be 
distinctly  larger  on  one  side  than  the  other.  In  some  cases  the  pain  is  consid- 
erable ;  in  others  there  is  simply  a  feeling  of  fatigue.  The  spasms  cease  dur- 
ing sleep.  Emotion,  excitement,  and  fatigue  increase  them.  The  spasm  may 
extend  from  the  muscles  of  the  neck  and  involve  those  of  the  face  or  of  the 
arms. 

The  disease  varies  much  in  its  course.  Cases  occasionally  get  well,  but 
the  great  majority  of  them  persist,  and,  even  if  temporarily  relieved,  the 
disease  frequently  recurs.  The  affection  is  usually  regarded  as  a  functional 
neurosis,  but  it  is  possibly  due  to  disturbance  of  the  cortical  centres  presiding 
over  the  muscles. 

Treatment. — Temporary  relief  is  sometimes  obtained;  a  permanent  cure 
is  exceptional.  Various  drugs  have  been  used,  but  rarely  with  benefit.  Occa- 
sionally, large  doses  of  bromide  will  lessen  the  intensity  of  the  spasm.  Mor- 
phia, subcutaneousl}',  has  been  successful  in  some  reported  cases,  but  there 
is  the  great  danger  of  establishing  the  morphia  habit.  Galvanism  may  be 
tried.  Counter-irritation  is  probably  useless.  Fixation  of  the  head  mechan- 
ically can  rarely  be  borne  by  the  patient.  These  obstinate  cases  fall  ultimately 
into  the  hands  of  the  surgeon,  and  the  operations  of  stretching,  division,  and 
excision  of  the  accessory  nerve  and  division  of  the  muscles  have  been  tried. 
Temporary  relief  may  follow,  but,  as  a  rule,  the  condition  returns.  Risien 
Eussell  thinks  that  resection  of  the  posterior  branches  of  the  upper  cervical 
nerves  is  most  likely  to  give  relief,  and  this  has  been  done  by  Keen  and 
others. 

(c)  The  XODDIXG  SPASM  of  children  may  here  be  mentioned  as  involving 
chiefly  the  muscles  innervated  by  the  accessory  nerve.  It  may  be  a  simple  trick, 
a  form  of  habit  spasm,  or  a  phenomenon  of  epilepsy  (E.  nutans),  in  which 
case  it  is -associated  with  transient  loss  of  consciousness.  A  similar  nodding 
spasm  may  occur  in  older  children.  In  women  it  sometimes  occurs  as  an  hys- 
terical manifestation,  commonly  as  part  of  the  so-called  salaam  convulsion. 

Hypoglossal  Nerve. 

This  is  the  motor  nerve  of  the  tongue  and  for  most  of  the  muscles  attached 
to  the  hyoid  bone.  Its  cortical  centre  is  probably  the  lower  part  of  the  ante- 
rior central  gyrus. 

Paralysis. —  (1)  Cortical  Lesion. — The  tongue  is  often  involved  in  hemi- 
plegia, and  the  paralysis  may  result  from  a  lesion  of  the  cortex  itself,  or  of 
the  fibres  as  they  pass  to  the  medulla.  It  does  not  occur  alone  and  is  consid- 
ered with  hemiplegia.  There  is  this  difference,  however,  between  the  cortical 
and  other  forms,  that  the  muscles  on  both  sides  of  the  tongue  may  be  more  or 
less  affected  but  do  not  waste,  nor  are  their  electrical  reactions  disturbed. 

(3)  ISTucLEAR  and  infra-xuclear  lesions  of  the  h3^poglossal  result  from 
slow  progressive  degeneration,  as  in  bulbar  paralysis  or  in  locomotor  ataxia; 
occasionally  there  is  acute  softening  from  obstruction  of  the  vessels.  The 
nuclei  of  both  nerves  are  usually  affected  together,  but  may  be  attacked  sepa- 
rately.    Trauma  and  lead  poisoning  have  also  been  assigned  as  causes.     The 


DISEASES  OF  THE  PERIPHERAL  NERVES.  1033 

fibres  may  be  damaged  by  a  tumor,  and  at  the  base  by  meningitis ;  or  the  nerve 
is  sometimes  involved  in  the  condylar  foramen  by  disease  of  the  skull.  It  may 
be  involved  in  its  course  in  a  scar,  as  in  Birkett's  case,  or  compressed  by  a 
tumor  in  the  parotid  region.  As  a  result,  there  is  loss  of  function  in  the 
nerve  fibres  and  the  tongue  undergoes  atrophy  on  the  affected  side.  It  is 
protruded  toward  the  paralyzed  side  and  may  show  fibrillary  twitching. 

The  symptoms  of  involvement  of  one  hypoglossal,  either  at  its  centre  or  in 
its  course,  are  those  of  unilateral  paralysis  and  atrophy  of  the  tongue.  When 
protruded,  it  is  pushed  toward  the  affected  side,  and  there  are  fibrillary  twitch- 
ings.  The  atrophy  is  usually  marked  and  the  mucous  membrane  on  the  affected 
side  is  thrown  into  folds.  Articulation  is  not  much  impaired  in  the  unilateral 
affection.  There  is  a  remarkable  triad  of  symptoms,  to  which  Hughlings 
Jackson  first  called  attention — unilateral  hemi-atrophy  of  the  tongue,  loss  of 
power  in  the  palate  muscle,  with  paralysis  of  the  larynx  on  the  same  side. 
When  the  disease  is  bilateral,  the  tongue  lies  almost  motionless  in  the  floor 
of  the  mouth;  it  is  atrophied,  and  can  not  be  protruded.  Speech  and  masti- 
cation are  extremely  difficult  and  deglutition  may  be  impaired.  If  the  seat  of 
the  disease  is  above  the  nuclei,  there  may  be  little  or  no  wasting.  The  condi- 
tion is  seen  in  progressive  bulbar  paralysis  and  occasionally  in  progressive  mus- 
cular atrophy. 

The  diagnosis  is  readily  made  and  the  situation  of  the  lesion  can  usually 
be  determined,  since  when  supra-nuclear  there  is  associated  hemiplegia  and 
no  wasting  of  the  muscles  of  the  tongue.  Nuclear  disease  is  only  occasionally 
unilateral ;  most  commonly  bilateral  and  part  of  a  bulbar  paralysis.  It  should 
be  borne  in  mind  that  the  fibres  of  the  hypoglossal  may  be  involved  within  the 
medulla  after  leaving  their  nuclei.  In  such  a  case  there  may  be  paralysis  of 
the  tongue  on  one  side  and  paralysis  of  the  limbs  on  the  opposite  side,  and  the 
tongue,  when  protruded,  is  pushed  toward  the  sound  side. 

Spasm. — This  rare  affection  may  be  unilateral  or  bilateral.  It  is  most  fre- 
quently a  part  of  some  other  convulsive  disorder,  such  as  epileps}'^,  chorea,  or 
spasm  of  the  facial  muscles.  In  some  cases  of  stuttering,  spasm  of  the  tongue 
precedes  the  explosive  utterance  of  the  words.  It  may  occur  in  hysteria,  and 
is  said  to  follow  reflex  irritation  in  the  fifth  nerve.  The  most  remarkable  cases 
are  those  of  paroxysmal  clonic  spasm,  in  which  the  tongue  is  rapidly  thrust  in 
and  out,  as  many  as  forty  or  fifty  times  a  minute.  In  the  case  reported  by 
Gowers  the  attacks  occurred  during  sleep  and  continued  for  a  year  and  a  half. 
The  spasm  is  usually  bilateral.  Wendt  has  reported  a  case  in  which  it  was 
unilateral.     The  prognosis  is  usually  good. 

IV.     DISEASES    OF    THE    SPINAL    NERVES. 

Cervical  Plexus. 

(1)  Occipito-cervical  Neuralgia. — This  involves  the  nerve  territory  sup- 
plied by  the  occipitalis  major  and  minor,  and  the  auricularis  magnus  nerves. 
The  pains  are  chiefly  in  the  back  of  the  head  and  neck  and  in  the  ear.  The 
condition  may  follow  cold  and  is  sometimes  associated  with  stiffness  of  the 
neck  or  torticollis.  Unless  connected  with  it  there  exists  disease  of  the  bones 
or  unless  it  is  due  to  pressure  of  tumors,  the  outlook  is  usually  good.  There 
67 


1034  DISEASES  OF  THE  NERVOUS  SYSTEM. 

are  tender  points  mid"vray  between  the  mastoid  process  and  the  spine  and  just 
above  the  parietal  eminence,  and  between  the  stemo-niastoid  and  the  trapezius. 
The  affection  may  be  due  to  direct  pressure  in  carr}'ing  heavy  weights. 

(2)  Pressure  of  Cervical  Ribs. — It  is  remarkable  how  common  is  this 
anomaly,  and  the  X-rays  have  shown  that  a  series  of  cases  of  (a)  wasting 
of  one  arm.  particularly  of  the  small  muscles  of  the  hands,  occurring  some- 
times in  families,  [h)  neuralgic  and  pargesthetic  conditions,  and  (c)  local 
spasms  of  the  muscles  of  the  hand,  are  due  to  the  pressure  of  a  cervical  rib  on 
the  nerves.  The  diagnosis  is  readily  made  and  prompt  relief  follows  removal 
of  the  rib. 

(3)  Affections  of  tlie  Phrenic  Nerve. — Paralysis  may  follow  a  lesion  in 
the  anterior  horns  at  the  level  of  the  third  and  fourth  cervical  nerves,  or  may 
be  due  to  compression  of  the  nerve  by  tumors  or  aneurism.  More  rarely 
paralysis  results  from  neuritis,  dijihtheritic  or  saturnine. 

Wlien  the  diaplrragm  is  paralyzed  respiration  is  carried  on  by  the  intercos- 
tal and  accessory  muscles.  "Wlien  the  patient  is  quiet  and  at  rest  little  may  be 
noticed,  but  the  abdomen  retracts  in  inspiration  and  is  forced  out  in  expiration. 
On  exertion  or  even  on  attempting  to  move  there  may  be  dyspnoea.  If  the 
paralysis  sets  in  suddenl}-  there  may  be  dj'spnoea  and  lividity,  which  is  usually 
temporary  (W.  Pasteur).  Intercurrent  attacks  of  bronchitis  seriously  aggra- 
vate the  condition.  Difficulty  in  coughing,  owing  to  the  impossibility  of 
drawing  a  full  breath,  adds  greatly  to  the  danger  of  this  complication. 

When  the  phrenic  nerve  is  paralyzed  on  one  side  the  paralysis  may  be 
scarcely  noticeable,  but  careful  inspection  shows  that  the  descent  of  the  dia- 
plrragm is  much  less  on  the  affected  side. 

The  diagnosis  of  paralysis  is  not  always  easy,  particularly  in  women,  who 
habitually  use  this  muscle  less  than  men,  and  in  whom  the  diaphragmatic 
breathing  is  less  conspicuous.  Immobility  of  the  diaphragm  is  not  uncommon, 
particularly  in  diaphragmatic  pleurisy,  in  large  effusions,  and  in  extensive 
emphysema.     The  muscle  itself  may  be  degenerated  and  its  power  impaired. 

Owing  to  the  lessened  action  of  the  diaphragm,  there  is  a  tendency  to 
accumulation  of  blood  at  the  bases  of  the  lungs,  and  there  may  be  impaired 
resonance  and  signs  of  oedema.  As  a  rule,  however,  the  paralysis  is  not  con- 
fined to  this  muscle,  but  is  part  of  a  general  neuritis  or  an  anterior  polio- 
myelitis, and  there  are  other  s}Tn23toms  of  value  in  determining  its  presence. 
The  outlook  is  usually  serious.  Pasteur  states  that  of  15  cases  following  diph- 
theria, only  8  recovered.    The  treatment  is  that  of  the  neuritis  or  polio-mj^elitis. 

Hiccoug"li. — Here  may,  perhaps,  best  be  considered  this  remarkable  s}Tnp- 
tom,  caused  by  intermittent,  sudden  contraction  of  the  diaphragm.  The  mech- 
anism, however,  is  complex,  and  while  the  afferent  impressions  to  the  respira- 
tory centre  may  be  peripheral  or  central,  the  efferent  are  distributed  through  the 
phrenic  nerve  to  the  diaphragm,  causing  the  intermittent  spasm,  and  through 
the  laryngeal  branches  of  the  vagus  to  the  glottis,  causing  sudden  closure  as 
the  air  is  rapidly  inspired.     W.  Langf  ord  S}'mes  groups  the  cases  into : 

(a)  IxFLAMMATOEY,  Seen  particularly  in  affections  of  the  abdominal  vis- 
cera, gastritis,  peritonitis,  hernia,  internal  strangulation,  appendicitis,  suppu- 
rative pancreatitis,  and  in  the  severe  forms  of  t}'phoid  fever. 

(&)  Iekitative,  as  in  the  direct  stimulation  of  the  diaphragm  when  very 
hot  substances  are  swallowed,  in  disease  of  the  cesophagus  near  the  diaphragm, 


DISEASES  OF  THE  PERIPHERAL  NERVES.  1035 

and  in  many  conditions  of  gastric  and  intestinal  disorder,  more  particularly 
those  associated  with  flatus. 

(c)  Specific^  or,  perhaps  more  properly,  idiopathic,  in  which  no  evi- 
dent causes  are  present.  In  these  cases  there  is  usually  some  constitutional 
taint,  as  gout,  diabetes,  or  chronic  Bright's  disease.  I  have  seen  several 
instances  of  obstinate  hiccough  in  the  later  stages  of  chronic  interstitial 
nephritis. 

{d)  Neurotic,  cases  in  which  the  primary  cause  is  in  the  nervous  system; 
hysteria,  epilepsy,  shock,  or  cerebral  tumors.  Of  these  cases  the  hysterical 
are,  perhaps,  the  most  obstinate. 

The  treatment  is  often  very  unsatisfactory.  Sometimes  in  the  milder 
forms  a  sudden  reflex  irritation  will  check  it  at  once.  Readers  of  Plato's 
Symposium  will  remember  that  the  physician  Eryximachus  recommended  to 
Aristophanes,  who  had  hiccough  from  eating  too  much,  either  to  hold  his 
breath  (which  for  trivial  forms  of  hiccough  is  very  satisfactory)  or  to  gargle 
with  a  little  water ;  but  if  it  still  continued,  "  tickle  your  nose  with  something 
and  sneeze;  and  if  you  sneeze  once  or  twice  even  the  most  violent  hiccough 
is  sure  to  go."  The  attack  must  have  been  of  some  severity,  as  it  is  stated 
subsequently  that  the  hiccough  did  not  disappear  until  Aristophanes  had 
resorted  to  the  sneezing. 

Ice,  a  teaspoonful  of  salt  and  lemon-juice,  or  salt  and  vinegar,  or  a  tea- 
spoonful  of  raw  spirits  may  be  tried.  When  the  hiccough  is  due  to  gastric 
irritation,  lavage  is  sometimes  promptly  curative.  I  saw  a  case  of  a  week's 
duration  cured  by  a  hypodermic  injection  of  gr.  ^  of  apomorphia.  In  obsti- 
nate cases  the  various  antispasmodics  have  been  used  in  succession.  Pilo- 
carpine has  been  recommended.  The  ether  spray  on  the  epigastrium  may  be 
promptly  curative.  Hypodermics  of  morphia,  inhalations  of  chloroform,  the 
use  of  nitrite  of  amyl  and  of  nitroglycerin,  have  been  beneficial  in  some  cases. 
Galvanism  over  the  phrenic  nerve,  or  pressure  on  the  nerves,  applied  between 
the  heads  of  the  sterno-cleido-mastoid  muscles'  may  be  used.  Strong  traction 
upon  the  tongue  may  give  immediate  relief. 

Brachial  Plexus. 

(1)  Combined  Paralysis. — The  plexus  may  be  involved  in  the  supracla- 
vicular region  by  compression  of  the  nerve  trunks  as  they  leave  the  spine,  or  by 
tumors  and  other  morbid  processes  in  the  neck.  Below  the  clavicle  lesions  are 
more  common  and  result  from  injuries  following  dislocation  or  fracture,  some- 
times from  neuritis.  A  cervical  rib  may  lead  to  a  pressure  paralysis  of 
the  lower  cord  of  the  plexus.  A  not  infrequent  form  of  injury  in  this  re- 
gion follows  falls  or  blows  on  the  neck,  which  by  lateral  flexion  of  the 
head  and  depression  of  the  shoulder  seriously  stretch  the  plexus.  The  en- 
tire plexus  may  be  ruptured  and  the  arm  be  totally  paralyzed.  The  rupture 
may  occur  anywhere  between  the  vertebrge  and  the  clavicle,  and  involve 
all  the  cords  of  the  plexus,  or  only  the  upper  ones.  The  so-called  "  obstet- 
rical palsy,"  due  to  drawing  apart  of  the  head  and  the  shoulder  during 
delivery,  is  an  instance  of  this  sort  of  injury.  In  these  cases,  however,  the 
rupture  of  the  plexus  is  usually  only  a  partial  one,  involving  its  upper  cord 
alone,  so  that  the  deltoid,  biceps,  supra-  and  infra-spinati,  brachialis  anticus, 


1036  DISEASES  OF   THE  NERVOUS  SYSTEM. 

and  supinator  longus  muscles  may  alone  be  affected.  When  the  entire  plexus 
has  been  ruptured  a  complete  motor  and  sensor}-  parah'sis  of  the  arm  is  pro- 
duced. The  roots  may  even  be  torn  away  from  the  spinal  cord.  The  pupil  will 
then  be  contracted  on  the  side  of  the  injury,  and  the  arm  hang  from  the  body 
like  a  flail.  Another  common  cause  of  lesion  of  the  brachial  plexus  is  luxation 
of  the  head  of  the  humerus,  particularly  the  subcoracoid  form. 

A  primary  neuritis  of  the  brachial  plexus  is  rare.  More  commonly  the 
process  is  an  ascending  neuritis  from  a  lesion  of  a  peripheral  branch,  involving 
first  the  radial  or  ulnar  nerves,  and  spreading  upward  to  the  plexus,  producing 
graduall}"  complete  loss  of  power  in  the  arm. 

(2)  Lesions  of  Individual  Nerves  of  the  Plexus.— (a)  Loxg  Tiioeacic 
i^EEVE. — Serratus  paralysis  follows  injury  to  this  nerve  in  the  neck,  usu- 
allv  bv  direct  pressure  yd.  carrying  loads,  and  is  very  common  in  soldiers. 
It  may  be  due  to  a  neuritis  following  an  acute  infection  or  exposure.  Isolated 
serratus  paralysis  is  rare.  It  usually  occurs  in  connection  with  paralysis  of 
other  muscles  of  the  shoulder  girdle,  as  in  the  myopathies  and  in  progressive' 
muscular  atrophy.  Concomitant  trapezius  paralysis  is  the  most  frequent.  In 
the  isolated  paralysis  there  is  little  or  no  deformity  with  the  hands  hanging 
by  the  sides.  There  is  slight  abnormal  obliquity  of  the  posterior  border  of  the 
scapula  and  prominence  of  the  inferior  angle,  but  when,  as  so  commonly  hap- 
pens, the  middle  part  of  the  trapezius  is  also  paralyzed,  the  deformity  is 
marked.  The  shoulder  is  at  a  lower  level,  the  inferior  angle  of  the  scapula 
is  displaced  inward  and  upward,  and  the  superior  angle  projects  upward. 
When  the  arms  are  held  out  in  front  at  right  angles  to  the  body  the  scapula 
becomes  winged  and  stands  out  prominently.  The  arm  can  not,  as  a  rule, 
be  raised  above  the  horizontal.  The  outlook  of  the  cases  due  to  injury  or  to 
neuritis  is  good. 

(&)  Circumflex  Nekve. — This  supplies  the  deltoid  and  the  teres  minor. 
The  nerve  is  apt  to  be  involved  in  injuries,  in  dislocations,  bruising  by  a 
crutch,  or  sometimes  by  extension  of  inflammation  from  the  joint.  Occasion- 
ally the  paralysis  arises  from  a  pressure  neuritis  during  an  illness.  As  a  con- 
sequence of  loss  of  power  in  the  deltoid,  the  arm  can  not  be  raised.  The  wast- 
ing is  usually  marked  and  changes  the  shape  of  the  shoulder.  Sensation  may 
also  be  impaired  in  the  skin  over  the  muscle.  The  joint  may  be  relaxed  and 
there  may  be  a  distinct  space  between  the  head  of  the  humerus  and  the 
acromion. 

(c)  MuscuLO-spiRAL  Paealtsis  ;  Eadial  Paralysis. — This  is 'one  of  the 
most  common  of  peripheral  palsies,  and  results  from  the  exposed  position  of 
the  musculo-spiral  nerve.  It  is  often  bruised  in  the  use  of  the  crutch,  by 
injuries  of  the  arm,  blows,  or  fractures.  It  is  frequently  injured  when  a 
person  falls  asleep  with  the  arm  over  the  back  of  a  chair,  or  by  pressure  of 
the  body  upon  the  arm  when  a  person  is  sleeping  on  a  bench  or  on  the  ground. 
It  may  be  paralyzed  by  sudden  violent  contraction  of  the  triceps.  It  is  some- 
times involved  in  a  neuritis  from  cold,  but  this  is  uncommon  in  comparison 
with  other  causes.  The  paralysis  of  lead  poisoning  is  the  result  of  involve- 
ment of  certain  branches  of  this  nerve. 

A  lesion  when  high  up  involves  the  triceps,  the  brachialis  anticus,  and  the 
supinator  longus,  as  "VA'ell  as  the  extensors  of  the  wrist  and  fingers.  Naturally, 
in  lesions  just  above  the  elbow  the  arm  muscles  and  the  sui^inator  longus  are 


DISEASES  OF  THE  PERIPHERAL  NERVES.  1037 

spared.  The  most  characteristic  feature  of  the  paralysis  is  the  wrist-drop  and 
the  inability  to  extend  the  first  phalanges  of  the  fingers  and  thumb.  In  the 
pressure  palsies  the  supinators  are  usually  involved  and  the  movements  of 
supination  can  not  be  accomplished.  The  sensations  may  be  impaired,  or  there 
may  be  marked  tingling,  but  the  loss  of  sensation  is  rarely  so  pronounced  as 
that  of  motion. 

The  affection  is  readily  recognized,  but  it  is  sometimes  difficult  to  say  upon 
what  it  depends.  The  sleep  and  pressure  palsies  are,  as  a  rule,  unilateral  and 
involve  the  supinator  longus.  The  paralysis  from  lead  is  bilateral  and  the 
supinators  are  unaffected.  Bilateral  wrist-drop  is  a  very  common  symptom 
in  many  forms  of  multiple  neuritis,  particularly  the  alcoholic;  but  the  mode 
of  onset  and  the  involvement  of  the  legs  and  arms  are  features  which  make  the 
diagnosis  easy.  The  duration  and  course  of  the  musculo-spiral  paralyses  are 
very  variable.  The  pressure  palsies  may  disappear  in  a  few  days.  Kecovery 
is  the  rule,  even  when  the  affection  lasts  for  many  weeks.  The  electrical  exam- 
ination is  of  importance  in  the  prognosis,  and  the  rules  laid  down  under 
paralysis  of  the  facial  nerve  hold  good  here. 

The  treatment  is  that  of  neuritis. 

(d)  Ulnar  Nerve. — The  motor  branches  supply  the  ulnar  half  of  the  deep 
flexor  of  the  fingers,  the  muscles  of  the  little  finger,  the  interossei,  the  adduc- 
tor and  the  inner  head  of  the  short  fiexor  of  the  thumb,  and  the  ulnar  flexor 
of  the  wrist.  The  sensory  branches  supply  the  ulnar  side  of  the  hand — two 
and  a  half  fingers  on  the  back,  and  one  and  a  half  fingers  on  the  front.  Paral- 
ysis may  result  from  pressure,  usually  at  the  elbow-joint,  although  the  nerve 
is  here  protected.  Possibly  the  neuritis  in  the  ulnar  nerve  in  some  cases  of 
acute  illness  may  be  due  to  this  cause.  G-owers  mentions  the  case  of  a  lady 
who  twice  had  ulnar  neuritis  after  confinement.  Owing  to  paralysis  of  the 
ulnar  flexor  of  the  wrist,  the  hand  moves  toward  the  radial  side;  adduction 
of  the  thumb  is  impossible;  the  first  phalanges  can  not  be  fiexed,  and  the 
others  can  not  be  extended.  In  long-standing  cases  the  first  phalanges  are 
overextended  and  the  others  strongly  flexed,  producing  the  claw-hand ;  but  this 
is  not  so  marked  as  in  the  progressive  muscular  atrophy.  The  loss  of  sensa- 
tion corresponds  to  the  sensory  distribution  just  mentioned. 

(e)  Median  ISTerve. — This  supplies  the  flexors  of  the  fingers  except  the 
ulnar  half  of  the  deep  flexors,  the  abductor  and  the  flexors  of  the  thumb,  the 
two  radial  lumbricales,  the  pronators,  and  the  radial  flexor  of  the  wrist.  The 
sensory  fibres  supply  the  radial  side  of  the  palm  and  the  front  of  the  thumb, 
the  first  two  fingers  and  half  the  third  finger,  and  the  dorsal  surfaces  of  the 
same  three  fingers. 

This  nerve  is  seldom  involved  alone.  Paralysis  results  from  injury  and 
occasionally  from  neuritis.  The  signs  are  inability  to  pronate  the  forearm 
beyond  the  mid-position.  The  wrist  can  be  flexed  only  toward  the  ulnar  side ; 
the  thumb  can  not  be  opposed  to  the  tips  of  flngers.  The  second  phalanges 
can  not  be  flexed  on  the  first;  the  distal  phalanges  of  the  first  and  second 
fingers  can  not  be  fiexed;  but  in  the  third  and  fourth  fingers  this  action  can 
be  performed  by  the  ulnar  half  of  the  flexor  profundus.  The  loss  of  sensation 
is  in  the  region  corresponding  to  the  sensory  distribution  already  mentioned. 
The  wasting  of  the  thumb  muscles,  which  is  usually  marked  in  this  paralysis, 
gives  to  it  a  characteristic  appearance. 


1038  DISEASES  OF  THE  NERVOUS  SYSTEM, 

LuMBAE  A]sT)  Sacral  Plexuses. 

The  lumbar  plexus  is  sometimes  involved  in  growths  of  the  lymph-glands, 
in  psoas  abscess,  and  in  disease  of  the  bones  of  the  vertebrae.  Of  its  branches 
the  obturator  nerve  is  occasionally  injured  during  parturition.  When  para- 
lyzed the  power  is  lost  over  the  adductors  of  the  thigh  and  one  leg  can  not 
be  crossed  over  the  other.  Outward  rotation  is  also  disturbed.  The  anterior 
crural  nerve  is  sometimes  involved  in  wounds  or  in  dislocation  of  the  hip-joint, 
less  commonly  during  parturition,  and  sometimes  hj  disease  of  the  bones  and 
in  psoas  abscess.  The  special  symptoms  of  affection  of  this  nerve  are  paralysis 
of  the  extensors  of  the  knee  with  wasting  of  the  muscles,  anesthesia  of  the 
antero-lateral  parts  of  the  thigh  and  of  the  inner  side  of  the  leg  to  the  big 
toe.  This  nerve  is  sometimes  involved  early  in  growths  about  the  spine,  and 
there  may  be  pain  in  its  area  of  distribution.  Loss  of  the  power  of  abducting 
the  thigh  results  from  paralysis  of  the  gluteal  nerve,  which  is  distributed  to 
the  gluteus  medius  and  minimus  muscles. 

External  Cutaneous  Nerve. — A  peculiar  form  of  sensory  disturbance,  con- 
fined to  the  territory  of  this  nerve,  was  first  described  by  Bernhardt  in  1895, 
and  a  few  months  later  by  Eoth,  who  gave  it  the  name  of  meralgia  parcesthet- 
ica.  The  disease  is  probably  due  to  a  neuritis  which  seems  to  originate  in  that 
part  of  the  nerve  where  it  passes  under  Poupart's  ligament,  just  internal  to 
the  anterior  superior  iliac  spine.  The  nerve  is  usually  tender  on  pressure  at 
this  point.  The  disease  is  more  common  in  men.  Musser  and  Sailer  in  1900 
collected  99  cases,  of  which  To  were  in  men.  A  large  number  of  the  cases  are 
attributable  to  direct  traumatism  or  to  simj)le  pressure  on  the  nerve  by  the 
aponeurotic  canal  through  which  it  passes.  Pregnancy  is  among  the  more 
common  causes  in  women.  The  sensory  disturbances  consist  of  various  forms 
of  parsesthesia  located  over  the  outer  side  of  the  thigh,  oftentimes  with  some 
actual  diminution  in  the  acuity  of  sense  perception.  The  symptoms  in  varying 
intensit}"  may  persist  for  years,  and  the  discomfort  in  some  cases  be  so  great, 
and  so  much  exaggerated  even  by  the  mere  touch  of  the  clothing,  that  patients 
may  be  greatly  incapacitated  thereby.  Excision  of  the  nerve  as  it  passes  ujider 
Poupart's  ligament  has  given  good  results. 

The  sacral  plexus  is  frequently  involved  in  tumors  and  inflammations 
within  the  pelvis  and  may  be  injured  during  parturition.  Neuritis  is  com- 
mon, usually  an  extension  from  the  sciatic  nerve. 

Of  the  branches,  the  sciatic  nerve,  when  injured  at  or  near  the  notch,  causes 
paralysis  of  the  flexors  of  the  legs  and  the  muscles  below  the  knee,  but  injury 
below  the  middle  of  the  thigh  involves  only  the  latter  muscles.  There  is  also 
anaesthesia  of  the  outer  half  of  the  leg,  the  sole,  and  the  greater  portion  of 
the  dorsum  of  the  foot.  Wasting  of  the  muscles  frequently  follows,  and  there 
may  be  trophic  disturbances.  In  paralysis  of  one  sciatic  the  leg  is  fixed  at 
the  knee  by  the  action  of  the  quadriceps  extensor  and  the  patient  is  able  to 
walk. 

Paralysis  of  the  small  sciatic  nerve  is  rarely  seen.  The  gluteus  maximus 
is  involved  and  there  may  be  difficulty  in  rising  from  a  seat.  There  is  a  strip 
of  anesthesia  along  the  back  of  the  middle  third  of  the  thigh. 

External  Popliteal  Nerve. — -Paralysis  involves  the  peronsei,  the  long  ex- 
tensor of  the  toes,  tibialis  anticus,  and  the  extensor  brevis  digitorum.     The 


1 


DISEASES  OF   THE  PERIPHERAL  NERVES.  1039 

ankle  can  not  be  flexed,  resulting  in  a  condition  kno^m  as  foot-drop,  and  as 
the  toes  can  not  be  raised  the  whole  leg  must  be  lifted,  producing  the  charac- 
teristic steppage  gait  seen  in  so  many  forms  of  peripheral  neuritis.  In  long- 
standing cases  the  foot  is  permanently  extended  and  there  is  wasting  of  the 
anterior  tibial  and  peroneal  muscles.  The  loss  of  sensation  is  in  the  outer 
half  of  the  front  of  the  leg  and  on  the  dorsum  of  the  foot. 

Internal  Popliteal  Nerve. — When  paralyzed,  plantar  flexion  of  the  foot  and 
flexion  of  the  toes  are  impossible.  The  foot  can  not  be  adducted,  nor  can  the 
patient  rise  on  tiptoe.  In  long-standing  cases  talipes  calcaneus  follows  and 
the  toes  assume  a  claw-like  position  from  secondary  contracture,  due  to  over- 
extension of  the  proximal  and  flexion  of  the  second  and  third  phalanges. 

Sciatica. 

This  is,  as  a  rule,  a  neuritis  either  of  the  sciatic  nerve  or  of  its  cords  of 
origin.     It  may  in  some  instances  be  a  functional  neurosis  or  neuralgia. 

It  occurs  most  commonly  in  adult  males.  A  history  of  rheumatism  or  of 
gout  is  present  in  many  cases.  Exposure  to  cold,  particularly  after  heavy 
muscular  exertion,  or  a  severe  wetting  are  not  uncommon  causes.  Within  the 
pelvis  the  nerves  may  be  compressed  by  large  ovarian  or  uterine  tumors,  by 
lymphadenomata,  by  the  foetal  head  during  labor;  occasionally  lesions  of  the 
hip- joint  induce  a  secondary  sciatica.  More  commonly,  however,  the  condition 
is  due  to  chronic  arthritis  of  the  spinal  column.  The  condition  of  the  nerve 
has  been  examined  in  a  few  cases,  and  it  has  often  been  seen  in  the  operation 
of  stretching.  It  is,  as  a  rule,  swollen,  reddened,  and  in  a  condition  of  inter- 
stitial neuritis.  The  affection  may  be  most  intense  at  the  sciatic  notch  or  in 
the  nerve  about  the  middle  of  the  thigh. 

Of  the  symptoms,  pain  is  the  most  constant  and  troublesome.  The  onset 
may  be  severe,  with  slight  pyrexia,  but,  as  a  rule,  it  is  gradual,  and  for  a  time 
there  is  only  slight  pain  in  the  back  of  the  thigh,  particularly  in  certain  posi- 
tions or  after  exertion.  Soon  the  pain  becomes  more  intense,  and  instead  of 
being  limited  to  the  upper  portion  of  the  nerve,  extends  down  the  thigh,  reach- 
ing the  foot  and  radiating  over  the  entire  distribution  of  the  nerve.  The 
patient  can  often  point  out  the  most  sensitive  spots,  usually  at  the  notch  or 
in  the  middle  of  the  thigh ;  and  on  pressure  these  are  exquisitely  painful.  The 
pain  is  described  as  gnawing  or  burning,  and  is  usually  constant,  but  in  some 
instances  is  paroxysmal,  and  often  worse  at  night.  On  walking  it  may  be  very 
great ;  the  knee  is  bent  and  the  patient  treads  on  the  toes,  so  as  to  relieve  the 
tension  on  the  nerve.  In  protracted  cases  there  may  be  much  wasting  of 
the  muscles,  but  the  reaction  of  degeneration  can  seldom  be  obtained.  In  these 
chronic  cases  cramp  may  occur  and  fibrillar  contractions.  Herpes  may  develop, 
but  this  is  unusual.  In  rare  instances  the  neuritis  ascends  and  involves  the 
spinal  cord. 

The  duration  and  course  are  extremely  variable.  As  a  rule  it  is  an  ob- 
stinate affection,  lasting  for  months,  or  even,  with  slight  remissions,  for  years. 
Kelapses  are  not  uncommon,  and  the  disease  may  be  relieved  in  one  nerve  only 
to  appear  in  the  other.  In  the  severer  forms  the  patient  is  bedridden,  and 
such  cases  prove  among  the  most  distressing  and  trying  which  the  physician 
is  called  upon  to  treat. 


1040  DISEASES  OF   THE  NERVOUS  SYSTEM. 

In  the  diagnosis  it  is  important,  in  the  first  place,  to  determine  whether 
the  disease  is  primary,  or  secondary  to  some  affection  of  the  pelvis  or  of  the 
spinal  cord.  A  careful  rectal  examination  should  be  made,  and,  in  women, 
pelvic  tumor  should  he  excluded.  Lumbago  may  be  confounded  with  it.  Af- 
fections of  the  hip-joint  are  easih'  distinguished  by  the  absence  of  tenderness 
in  the  course  of  the  nerve  and  the  sense  of  pain  on  movement  of  the  hip-joint 
or  on  pressure  in  the  region  of  the  trochanter.  There  are  instances  of  sacro- 
iliac disease  in  which  the  patient  complains  of  pain  in  the  upper  part  of  the 
thigh,  which  may  sometimes  radiate;  but  careful  examination  will  readily 
distinguish  between  the  affections.  Pressure  on  the  nerve  trunks  of  the  cauda 
equina,  as  a  rule,  causes  bilateral  pain  and  disturbances  of  sensation,  and,  as 
double  sciatica  is  rare,  these  circumstances  always  suggest  lesion  of  the  nerve 
roots.  Between  the  severe  lightning  pains  of  tabes  and  sciatica  the  differences 
are  usually  well  defined. 

Treatment. — The  spinal  column  should  be  carefully  and  systematically  ex- 
amined, for  numerous  cases  have  been  relieved  by  orthopaedic  procedures.  The 
pelvic  organs  should  also  be  investigated.  Constitutional  conditions,  such  as 
rheumatism  and  gout,  should  receive  appropriate  treatment.  In  a  few  cases 
with  pronounced  rheumatic  histor}^  which  come  on  acutely  with  fever,  the 
salicylates  seem  to  do  good.  In  other  instances  they  are  quite  useless.  If 
there  is  a  suspicion  of  syphilis,  the  iodide  of  potassium  should  be  employed, 
and  in  gouty  cases  salines. 

Eest  in  bed  ^vith  fixation  of  the  limb  by  means  of  a  long  splint  is  a  most 
valuable  method  of  treatment  in  many  cases,  one  upon  which  Weir  Mitchell 
has  specially  insisted.  I  have  known  it  to  relieve,  and  in  some  instances  to 
cure,  obstinate  and  protracted  cases  which  had  resisted  all  other  treatment. 
Hydrotherapy  is  sometimes  satisfactory,  particularly  the  warm  baths  or  the 
mud  baths.  Many  cases  are  relieved  by  a  prolonged  residence  at  one  of  the 
thermal  springs. 

Antip}Tin,  antifebrin,  and  quinine  are  of  doubtful  benefit. 

Local  applications  are  more  beneficial.  The  hot  iron  or  the  thermo-cautery 
or  blisters  relieve  the  pain  temporarily.  Deep  injections  into  the  nerves  give 
great  relief  and  may  be  necessary  for  the  pain.  It  is  best  to  use  cocaine  at 
first,  in  doses  of  from  an  eighth  to  a  quarter  of  a  grain.  If  the  pain  is  un- 
bearable morphia  may  be  used,  but  it  is  a  dangerous  remed}^  in  sciatica  and 
should  be  withheld  as  long  as  possible.  The  disease  is  so  protracted,  so  liable 
to  relapse,  and  the  patient's  morale  so  undermined  by  the  constant  worry  and 
the  sleepless  nights,  that  the  danger  of  contracting  the  morphia  habit  is  very 
great.  On  no  consideration  should  the  patient  be  permitted  to  use  the  h}qDO- 
dermic  needle  himself.  It  is  remarkable  how  promptly,  in  some  cases,  the 
injection  of  distilled  water  into  the  nerve  will  relieve  the  pain.  Acupuncture 
may  also  be  tried;  the  needles  should  be  thrust  deeply  into  the  most  painful 
spot  for  a  distance  of  about  2  inches,  and  left  for  from  fifteen  to  twenty 
minutes.  The  injection  of  chloroform  into  the  nerve  has  also  been  recom- 
mended. 

Electricity  is  an  uncertain  remedy.  Sometimes  it  gives  prompt  relief;  in 
other  cases  it  may  be  used  for  weeks  without  the  slightest  benefit.  It  is  most 
serviceable  in  the  chronic  cases  in  which  there  is  wasting  of  the  legs,  and* 
ehould  be  combined  with  massage.     The  galvanic  current  should  be  used;  a 


GENERAL  AND  FUNCTIONAL  DISEASES.  1041 

tlat  electrode  should  be  placed  over  the  sciatic  notch,  and  a  smaller  one  used 
along  the  course  of  the  nerve  and  its  branches.  In  very  obstinate  cases  nerve- 
stretching  may  be  employed.  It  is  sometimes  successful  •  but  in  other  in- 
stances the  condition  recurs  and  is  as  bad  as  ever. 


G.    GENERAL  AND  FUNCTIONAL  DISEASES. 
I.     ACUTE  DELIRIUM  (BeU's  Mania). 

Definition. — Acute  delirium  which  runs  a  rapidly  fatal  course,  with  slight 
fever,  and  in  which  post  mortem  no  lesions  are  found  sufficient  to  account  for 
the  disease. 

Etiological  factors  are  emotional  strain,  mental  shock  and  distress,  physical 
pain,  toxaemia  or  infection.  It  may  occur  during  convalescence  from  fevers. 
It  is  a  rare  disease,  and  almost  all  authors  are  agreed  that,  with  few  exceptions, 
it  is  peculiar  to  women.  Cases  are  reported  by  many  old  writers  under  the 
term  brain  fever  or  phrenitis.  Bell,  at  the  time  Superintendent  of  the  McLean 
Asylum,  described  it  *  accurately  under  the  designation,  "  a  form  of  disease 
resembling  some  advanced  stages  of  mania  and  fever." 

The  disease  may  set  in  abruptly  or  be  preceded  by  a  period  of  irritability, 
restlessness,  and  insomnia.  The  mental  symptoms  develop  with  rapidity  and 
may  quickly  reach  a  grade  of  the  most  intense  frenzy.  There  are  the  wildest 
hallucinations  and  outbreaks  of  great  violence.  The  patient  talks  incessantly, 
but  incoherently  and  unintelligibly.  JSTo  sleep  is  obtained,  and  at  last,  worn 
out  with  the  intensity  of  the  muscular  movements,  the  patient  becomes  utterly 
prostrated  and  assumes  the  sitting  or  recumbent  posture.  There  may  some- 
times be  definite  salaam  movements,  and  in  a  case  which  I  saw  at  Westphal's 
clinic  the  patient  incessantly  made  motions  as  if  working  a  pump  handle.  After 
a  period  of  intense  bodily  excitement,  lasting  for  from  twenty-four  to  thirty- 
six  hours  or  longer,  the  patient  can  be  examined,  and  presents  the  conditions 
which  Bell  described  as  typho-mania.  The  temperature  ranges  from  102°  to 
104°,  or  even  higher.  The  tongue  is  dry,  the  pulse  rapid  and  feeble;  some- 
times there  are  seen  on  the  skin  bullae  and  pustules,  and  frequently  sores  from 
abrasion  and  self-inflicted  injuries.  Toward  the  close  or,  according  to  Spitzka, 
even  during  the  development  of  the  disease  there  may  be  lucid  intervals.  There 
may  be  petechia  on  the  skin,  and  often  there  is  marked  congestion  of  the  face 
and  extremities.  The  duration  of  the  disease  is  variable.  Very  acute  cases 
may  terminate  within  a  week ;  others  persist  for  two  or  even  three  weeks.  The 
course  of  the  disease  is  almost  uniformly  fatal.  The  anatomical  condition  is 
practically  negative,  or  at  any  rate  presents  nothing  distinctive.  There  is  great 
venous  engorgement  of  the  vessels  of  the  meninges  and  of  the  gray  cortex. 
In  two  cases  in  which  I  made  a  careful  microscopical  examination  of  the  gray 
matter  there  were  perivascular  exudation  and  leucocytes  in  the  lymph  sheaths 
and  perigangliar  spaces.  In  the  inspection  of  fatal  cases  of  acute  delirium 
careful  examination  should  be  made  of  the  lungs  and  ileum.  It  should  be 
borne  in  mind  that  in  a  majority  of  the  cases  dying  in  this  manner,  there  is 
engorgement  of  the  bases  of  the  lungs  or  even  deglutition  pneumonia. 

♦  American  Journal  of  Insanity,  1849. 


1042  DISEASES  OF   THE  XERVOUS  SYSTEM. 

The  nature  of  the  disease  is  quire  unknown.  Some  of  the  cases  suggest 
acute  iufe.Tion,  Spitzka  thinks  that  it  is  due  to  an  autochthonous  nerve 
poison. 

Diagnosis, — There  are  several  liiseases  which  may  present  identical  symp- 
t  ::_-.  A?  Bt'-l  :'-:::::'_:-  :u  hi-  rarier.  the  first  glance  in  many  cases  suggests 
r.Tl-rii  i-r'cr.  >  lu:  ;  ;.  :i  v.ii^n  T::e  patient  is  seen  after  the  violence  of  the 
mania  has  suV-ilei.  He  gives  two  instances  of  this  which  were  admitted 
from  a  general  hospital.  Enlargement  of  the  spleen,  the  occurrence  of  spots, 
and  the  history  give  clews  for  the  separation  of  the  cases;  but  there  are  in- 
stances in.  which  it  is  at  first  impossible  to  decide.  Moreover,  typhoid  fever 
may  set  in  with  the  most  intense  delirium.  The  existence  of  fever  is  the  most 
deceptive  symptom,  and  its  combination  with  delirium  and  dry  tongue  so  com- 
monly means  typhoid  fever  that  it  is  very  difficult  to  avoid  error. 

Acute  pneumonia  may  come  on  with  violent  maniacal  delirium  and  the 
pulmonary  symptoms  may  be  entirely  masked. 

Occasionally  acute  uraemia  sets  in  suddenly  with  intense  mania,  and  finally 
subsides  into  a  fatal  coma.  The  condition  of  the  ttrine  and  the  absence  of 
fever  would  be  important  diagnostic  features. 

The  character  of  the  delirium  is  quite  different  from  that  of  mania  a  potu. 
It  may  be  extremely  difficult  to  differentiate  acute  delirium  from  certain  cases 
of  cortical  meningitis  occurring  in  connection  with  pneumonia,  ulcerative 
endocarditis  or  tuberculosis,  or  due  to  extension  from  disease  of  the  ear.  This 
sets  ia  more  frequently  vrith  a  chill,  and  there  may  be  convulsions. 

Treatment. — Even  though  bodily  prostration  is  apt  to  come  on  early  and 
be  profomid,  in  the  case  of  a  robust  man  free  venesection  might  be  tried.  I 
I  have  been  criticised  for  this  advice,  but  repeat  it.  It  is  not  at  all  improb- 
able that  some  of  the  many  cases  of  mania  in  which  Benjamin  Eush  let  blood 
with  such  benefit  belonged  to  this  class  of  affections.  Considering  its  remark- 
a^'le  cahnlns'  influence  in  febrile  delirium,  the  cold  bath  or  the  cold  pack  should 
be  e::.::i:"  "i.  Morphia  and  chloroform  may  be  administered  and  hyoscine 
and  the  bromides  may  be  tried.  iKjafft-Ebing  states  that  Solivetti  has  obtained 
good  results  by  the  use  of  ergotin.  ITnf  ortunately,  as  as}  lum  reports  show,  the 
disease  is  almost  uniformly  fatal. 


II.     PARALYSIS    AGITAI^S. 

(Parkinson's  Disease :  Shaking  Palsy.) 

Defi.nition, — A  chronic  affection  of  the  nervous  system,  characterized  by 
muscular  vreakness.  tremors,  and  rigidity. 

Etiolo^. — Men  are  more  frequently  affected  than  women.  It  rarely 
-  ::ur=  under  forty,  but  instances  have  been  reported  in  which  the  disease  began 
a  :  r:  zhe  twentieth  year.  It  is  by  no  means  an  uncommon  affection.  Direct 
__^rT;i::v  is  rare,  but  the  patients  often  belong  to  families  in  which  there  are 
c:ii::  nervous  affections.  Among  exciting  causes  may  be  mentioned  exposure 
to  c  i  :  ai-l  wet,  and  business  worries  and  anxieties.  In  some  instances  the 
c:~  >-  :  -  i  i"  wed  directly  upon  severe  mental  shock  or  trauma.  Cases  have 
:  r  i-  ::  -  1  after  the  specific  fevers.  Malaria  is  believed  by  some  to  be  an 
:        ::ant  factor,  but  of  this  there  is  no  satisfactory  evidence. 


GENERAL  AND  FUNCTIONAL  DISEASES.  1043 

Morbid  Anatomy. — Xo  constant  lesions  have  been  found.  The  similarity 
between  certain  of  the  features  of  Parkinson's  disease  and  those  of  old  age 
suggest  that  the  affection  may  depend  upon  a  premature  senility  of  certain 
regions  of  the  brain.  Our  organs  do  not  age  uniformly,  but  in  some,  owing  to 
hereditary  disposition,  the  process  may  be  more  rapid  than  in  others.  "  Park- 
inson's disease  has  no  characteristic  lesions,  but  on  the  other  hand  it  is  not  a 
neurosis.  It  has  for  an  anatomical  basis  the  lesions  of  cerebro-spinal  senility, 
which  only  differ  from  those  of  true  senility  in  their  early  onset  and  greater 
intensity"  (Dubief).  The  important  changes  are  doubtless  in  the  cerebral 
cortex. 

Symptoms. — The  disease  begins  gradualb^  usually  in  one  or  other  hand, 
and  the  tremor  may  be  either  constant  or  intermittent.  With  this  may  be  asso- 
ciated weakness  or  stiffness.  At  first  these  symptoms  may  be  present  only 
after  exertion.  Although  the  onset  is  slow  and  gradual  in  nearly  all  cases, 
there  are  instances  in  which  it  sets  in  abruptly  after  fright  or  trauma.  Wlien 
well  established  the  disease  is  very  characteristic,  and  the  diagnosis  can  be  made 
at  a  glance.  The  four  prominent  symptoms  are  tremor,  weakness,  rigidity, 
and  the  attitude. 

Tee:\ior. — This  may  be  in  the  four  extremities  or  confined  to  hands  or 
feet ;  the  head  is  not  so  commonly  affected.  The  tremor  is  usually  marked  in 
the  hands,  and  the  thumb  and  forefinger  display  the  motion  made  in  the  act 
of  rolling  a  pill.  At  the  wrist  there  are  movements  of  pronation  and  supina- 
tion, and,  though  less  marked,  of  fiexion  and  extension.  The  upper-arm  mus- 
cles are  rarely  involved.  In  the  legs  the  movement  is  most  evident  at  the 
ankle-joint,  and  less  in  the  toes  than  in  the  fingers.  Shaking  of  the  head  is 
less  frequent,  but  does  occur,  and  is  usually  vertical,  not  rotatory.  The  rate 
of  oscillation  is  about  five  per  second.  Any  emotion  exaggerates  the  movement. 
The  attempt  at  a  voluntary  movement  may  check  the  tremor  (the  patient  may 
be  able  to  thread  a  needle),  but  it  returns  with  increased  intensity.  The 
trem.ors  cease,  as  a  rule,  during  sleep,  but  persist  when  the  muscles  are  not 
in  use.    The  writing  of  the  patient  is  tremulous  and  zigzag. 

Weakness. — Loss  of  power  is  present  in  all  cases,  and  may  occur  even  be- 
fore the  tremor,  but  is  not  very  striking,  as  tested  by  the  dynamometer,  until 
the  late  stages.  The  weakness  is  greatest  where  the  tremor  is  most  developed. 
The  movements,  too,  are  remarkably  slow.  There  is  rarely  complete  loss  of 
power. 

KiGiDiTT  may  early  be  expressed  in  a  slowness  and  stiffness  in  the  volun- 
tary movements, "which  are  performed  with  some  effort  and  difficulty,  and  all 
the  actions  of  the  patient  are  deliberate.  This  rigidit}^  is  in  all  the  muscles, 
and  leads  ultimately  to  the  characteristic  attitude. 

Attitude  axd  Gait. — The  head  is  bent  forward,  the  back  is  bowed,  and 
the  arms  are  held  away  from  the  body  and  are  somewhat  flexed  at  the  elbow- 
joints.  The  face  is  expressionless,  and  the  movements  of  the  lips  are 
slow.  The  eyebrows  are  elevated,  and  the  whole  expression  is  immobile  or 
mask-like,  the  so-called  Parkinson's  mask.  The  voice,  as  pointed  out  by  Buz- 
zard, is  apt  to  be  shrill  and  piping,  and  there  is  often  a  hesitancy  in  beginning 
a  sentence;  then  the  words  are  uttered  with  rapidity,  as  if  the  patient  was  in 
a  hurry.  This  is  sometimes  in  striking  contrast  to  the  scanning  speech  of 
insular  sclerosis.    The  fingers  are  flexed  and  in  the  position  assumed  when  the 


1044  DISEASES  OF   THE  NERVOUS  SYSTEM. 

hand  is  at  rest;  in  the  hite  stages  the_y  eau  uot  be  cA'tended.  Occasionally 
there  is  overextension  of  the  terminal  phalanges.  The  hand  is  usually  turned 
to"0'ard  the  ulnar  side  and  the  attitude  somewhat  resembles  that  of  advanced 
cases  of  rheumatoid  arthritis.  In  the  late  stages  there  are  contractures  at  the 
elbows,  knees,  and  ankles.  The  movements  of  the  patient  are  characterized 
by  great  deliberation.  He  rises  from  the  chair  slowly  in  the  stooping  atti- 
tude, with  the  head  projecting  forward.  In  attempting  to  walk  the  steps 
are  short  and  hurried,  and,  as  Trousseau  remarks,  he  appears  to  be  running 
after  liis  centre  of  gravity.  This  is  termed  festination  or  propulsion,  in  con- 
tradistinction to  a  peculiar  gait  observed  when  the  patient  is  pulled  backward, 
when  he  makes  a  number  of  steps  and  would  fall  over  if  not  prevented — retro- 
pulsion. 

The  REFLEXES  are  normal  in  most  cases,  but  in  a  few  they  are  exaggerated. 

Of  SENSORY  disturbances  Charcot  has  noted  abnormal  alterations  in  the 
temperature  sense.  The  patient  may  complain  of  subjective  sensations  of  heat, 
either  general  or  local — a  phenomenon  which  may  be  present  on  one  side  only 
and  associated  with  an  actual  increase  of  the  surface  temperature,  as  much 
as  6°  F.  (Gowers).  In  other  instances,  patients  complain  of  cold.  Localized 
sweating  may  be  present.  The  skin,  especially  of  the  forehead,  may  be  thick- 
ened.    The  mental  condition  rarely  shows  any  change. 

Variations  in  the  Symptoms. — The  tremor  may  be  absent,  but  the  rigid- 
ity, weakness,  and  attitude  are  sufficient  to  make  the  diagnosis.  The  disease 
may  be  hemiplegic  in  character,  involving  only  one  side  or  even  one  limb. 
Usually  these  are  but  stages  of  the  disease. 

Diagnosis. — In  well-developed  cases  the  disease  is  recognized  at  a  glance. 
The  attitude,  gait,  stiffness,  and  mask-like  expression  are  points  of  as  much 
importance  as  the  oscillations,  and  usualh'^  serve  to  separate  the  cases  from 
senile  and  other  forms  of  tremor.  Disseminated  sclerosis  develops  earlier,  and 
is  characterized  by  the  nystagmus,  and  the  scanning  speech,  and  does  not  pre- 
sent the  attitude  so  constant  in  paralysis  agitans.  Yet  Schultze  and  Sachs 
have  reported  cases  in  which  the  signs  of  multiple  sclerosis  have  been  asso- 
ciated with  those  of  paralysis.  The  hemiplegic  form  might  be  confounded 
with  post-hemiplegic  tremor,  but  the  history,  the  mode  of  onset,  and  the  greatly 
increased  reflexes  would  be  sufficient  to  distinguish  the  two.  The  Parkinsonian 
face  is  of  great  importance  in  the  diagnosis  of  the  obscure  and  anomalous 
forms. 

The  disease  is  incurable.  Periods  of  improvement  may  occur,  but  the  tend- 
ency is  for  the  affection  to  proceed  progressively  downward.  It  is  a  slow, 
degenerative  process  and  the  cases  last  for  years. 

Treatment. — There  is  no  method  which  can  be  recommended  as  satisfac- 
tory in  any  res]3ect.  Arsenic,  opium,  and  hyoscyamine  may  be  tried,  but  the 
friends  of  the  patient  should  be  told  frankly  that  the  disease  is  incurable, 
and  that  nothing  can  be  done  except  to  attend  to  the  physical  comforts  of  the 
patient.     Eegulated  and  systematized  exercises  should  be  carried  out 

Other  Forms  of  Tremor. 

(a)  Simple  Tremor. — This  is  occasionally  found  in  persons  in  whom  it  is 
impossible  to  assign  any  cause.     It  may  be  transient  or  persist  for  an  indefi- 


GENERAL  AND  FUNCTIONAL  DISEASES.  1045 

nite  time.    It  is  often  extremely  slight,  and  is  aggravated  by  all  causes  which 
lower  the  vitality. 

(5)  Hereditary  Tremor. — C.  L.  Dana  has  reported  remarkable  cases  of 
hereditary  tremor.  It  occurred  in  all  the  members  of  one  family,  and  begin- 
ning in  infancy  continued  without  producing  any  serious  changes. 

(c)  Senile  Tremor. — With  advancing  age  tremulousness  during  muscular 
movements  is  extremely  common,  but  is  rarely  seen  under  seventy.  It  is 
always  a  fine  tremor,  which  begins  in  the  hands  and  often  extends  to  the 
muscles  of  the  neck,  causing  slight  movement  of  the  head. 

(d)  Toxic  tremor  is  seen  chiefly  as  an  efl^ect  of  tobacco,  alcohol,  lead,  or 
mercury;  more  rarely  in  arsenical  or  opium  poisoning.  In  elderly  men  who 
smoke  much  it  may  be  entirely  due  to  the  tobacco.  One  of  the  commonest 
forms  of  this  is  the  alcoholic  tremor,  which  occurs  only  on  movement  and  has 
considerable  range.  Lead  tremor  is  considered  under  lead  poisoning,  of  which 
it  constitutes  a  very  important  symptom. 

(e)  Hysterical  tremor,  which  usually  occurs  under  circumstances  which 
make  the  diagnosis  easy,  will  be  considered  in  the  section  on  hysteria. 

III.  ACUTE  CHOREA. 

(Sydenham's  Chorea;  St.  Vitus's  Dance.) 

Definition. — A  disease  chiefly  afi'ecting  children,  characterized  by  irregular, 
involuntary  contraction  of  the  muscles,  a  variable  amount  of  psychical  dis- 
turbance, and  a  remarkable  liability  to  acute  endocarditis. 

Etiology. — Sex. — Of  554  cases  which  I  analyzed  from  the  Philadelphia 
Infirmary  for  Diseases  of  the  Nervous  System,  71  per  cent  were  in  females 
and  29  per  cent  in  males.  Of  808  Johns  Hopkins  Hospital  cases,  71.2  per 
cent  were  females  (Thayer  and  Thomas). 

Age. — The  disease  is  most  common  between  the  ages  of  five  and  fifteen. 
Of  522  cases,  380  occurred  in  this  period;  84.5  per  cent  in  Thayer  and 
Thomas'  series.  It  is  rare  among  the  negroes  and  native  races  of  America. 
Only  25  of  the  Johns  Hopkins  Hospital  cases  were  in  negroes.  The  cases  are 
most  numerous  when  the  mean  relative  humidity  is  excessive  and  the  baro- 
metric pressure  low   (Lewis). 

Eheumatism. — A  causal  relationship  between  rheumatism  and  chorea  has 
been  claimed  by  many  since  the  time  of  Bright.  The  English  and  French 
writers  maintain  the  closeness  of  this  connection ;  on  the  other  hand,  German 
authors,  as  a  rule,  regard  the  connection  as  by  no  means  very  close.  Of  the 
554  cases,  in  15.5  per  cent  there  was  a  history  of  rheumatism  in  the  family. 
In  88  cases,  15.8  per  cent,  there  was  a  history  of  articular  swelling,  acute  or 
subacute.  In  33  cases  there  were  jiains,  sometimes  described  as  rheumatic,  in 
various  parts,  but  not  associated  with  joint  trouble.  Adding  these  to  those 
with  manifest  articular  trouble,  the  percentage  is  raised  to  nearly  21.  It  is 
rather  remarkable  that  in  our  Baltimore  series  the  percentage  with  a  history 
of  rheumatism  was  the  same — 21.6. 

We  find  two  groups  of  cases  in  which  acute  arthritis  is  present  in  chorea. 
In  one,  the  arthritis  antedates  by  some  months  or  years  the  onset  of  the  chorea, 
and  does  not  recur  before  or  during  the  attack.  In  the  other  group,  the  chorea 
sets  in  with  or  follows  immediately  upon  the  acute  arthritis.    In  some  instances 


1046  DISEASES  OF   THE  NERVOUS  SYSTEM. 

it  is  impossible  to  decide  wlietheT  the  joint  symptoms  or  the  movements  have 
appeared  first.  It  is  difficult  to  differentiate  the  cases  of  irregular  paiiis  with- 
out definite  joint  affection.  It  is  probable  that  many  of  them  are  rheumatic, 
and  yet  I  think  it  vrould  be  a  mistake  to  regard  as  such  all  cases  in  children 
in  which  there  are  complaints  of  vague  paius  in  the  bones  or  muscles — so-called 
growing  pains.  It  should  never  be  forgotten,  however,  that  a  slight  articular 
swelling  may  be  the  sole  manifestation  of  rheumatism  in  a  child — so  slight, 
indeed,  that  the  disease  may  be  entirely  overlooked. 

Heaet-disease. — Endocarditis  is  believed  by  some  writers  to  be  the  cause 
of  the  disease.  The  particles  of  fibrin  and  vegetations  froui  the  valves  pass  as 
emboli  to  the  cerebral  vessels.  On  this  view,  which  we  shall  discuss  later, 
chorea  is  the  result  of  an  embolic  process  occurring  in  the  course  of  a  rheu- 
matic endocarditis. 

IifFECTious  Diseases. — Scarlet  fever  with  artlixitie  manifestations  may 
be  a  direct  antecedent.  Sturges  states  that  a  history  of  previous  whooping- 
cough  occurs  more  frequently  in  choreic  than  in  other  children,  but  I  find 
no  evidence  of  this  in  the  Infirmary  records.  With  the  exception  of  rheumatic 
fever,  there  is  no  intimate  relationship  between  chorea  and  the  acute  diseases 
incident  to  childhood.  It  may  be  noted  in  contrast  to  this  that  the  so-called 
canine  chorea  is  a  common  sequel  of  distemjjer.  Chorea  has  been  known  to 
develop  in  the  course  of  an  acute  pyaemia,  and  to  follow  gonorrhoea  and  puer- 
peral fever. 

Asr^iriA  is  less  often  an  antecedent  than  a  sequence  of  chorea,  and  though 
cases  develop  in  children  who  are  anaemic  and  in  poor  health,  this  is  by  no 
means  the  rule.     Chorea  may  develop  in  chlorotic  girls  at  puberty. 

Pbegnaxct. — A  choreic  patient  may  become  pregnant;  more  frequently 
the  disease  occurs  during  pregnancy;  sometimes  it  develops  post  partum. 
Buist,  of  Dundee  (Trans.  Edin.  Obs.  Soc,  1895),  has  tabulated  carefully  the 
recorded  cases  to  that  date.  Of  226  cases,  in  6  the  chorea  preceded  the  preg- 
nancy; in  105  it  occcurred  during  the  pregnane}^;  in  31  in  recurrent  preg- 
nancies; 45  cases  terminated  fatally,  and  in  16  cases  the  chorea  developed  post 
partum.  The  alleged  frequency  in  illegitimate  primiparse  is  not  borne  out  by 
his  figures.  Begimiing  in  the  first  three  months  were  108  cases,  in  the  second 
three  months  TO  cases,  in  the  last  three  months  25  cases.  The  disease  is  often 
severe,  and  maniacal  symptoms  may  develop. 

A  tendency  to  the  disease  is  found  in  certain  families.  In  80  cases  there 
was  a  history  of  attacks  of  chorea  in  other  members.  In  one  instance  both 
mother  and  grandmother  had  been  affected.  High-strung,  excitable,  nervous 
children  are  especially  liable  to  the  disease.  Fright  is  considered  a  frequent 
cause,  but  in  a  large  majority  of  the  cases  no  close  connection  exists  between 
the  fright  and  the  onset  of  the  disease.  Occasionally  the  attack  sets  in  at 
once.  Mental  worry,  trouble,  a  sudden  grief,  or  a  scolding  may  apj)arently 
be  the  exciting  cause.  The  strain  of  education,  particularly  in  girls  during 
the  third  hemidecade,  is  a  most  important  factor  in  the  etiology  of  the  disease. 
Bright,  intelligent,  active-minded  girls  from  ten  to  fourteen,  ambitious  to  do 
well  at  school,  often  stimulated  in  their  efforts  by  teachers  and  parents,  form 
a  large  contingent  of  the  cases  of  chorea  in  hospital  and  private  practice. 
Sturges  has  called  special  attention  to  this  sclwol-made  chorea  as  one  serious 
evil  in  our  modern  method  of  forced  education.     Imitation,  which  is  men- 


GENERAL  AND  FUNCTIONAL  DISEASES.  1047 

tioned  as  an  exciting  ca^^se,  is  extremely  rare,  and  does  not  appear  to  have 
influenced  the  onset  in  a  single  case  in  the  Infirmary  records. 

The  disease  may  rapidly  follow  an  injury  or  a  slight  surgical  operation. 
Eeflex  irritation  was  believed  to  play  an  important  role  in  the  disease,  particu- 
larly the  presence  of  worms  or  genital  irritation;  but  I  have  met  with  no  in- 
stance in  which  the  disease  could  be  attributed  to  either  of  these  causes.  Local 
spasm,  particularly  of  the  face — the  habit  chorea  of  Mitchell — may  be  asso- 
ciated with  irritation  in  the  nostrils  and  adenoid  growths  in  the  vault  of  the 
pharynx,  as  pointed  out  by  Jacobi. 

It  has  been  claimed  by  Stevens  that  ocular  defects  lie  at  the  basis  of  many 
cases  of  chorea,  and  that  with  the  correction  of  these  the  irregular  movements 
disappear.  The  investigations  of  De  Schweinitz  show  that  ocular  defects  do 
not  occur  in  greater  proportion  in  choreic  than  in  other  children.  A  majority 
of  the  cases  in  which  operation  has  been  followed  by  relief  have  been  instances 
of  tic,  local  or  general. 

Morbid  Anatomy  and  Pathology. — jSJ"o  constant  lesions  have  been  found 
in  the  nervous  system  in  acute  chorea.  Vascular  changes,  such  as  hyaline 
transformation,  exudation  of  leucocytes,  minute  hsemorrhages,  and  thrombosis 
of  the  smaller  arteries,  have  been  described. 

Embolism  of  the  smaller  cerebral  vessels  has  been  found,  and  there  are 
on  record  7  cases  of  embolism  of  the  central  artery  of  the  retina  (H.  M. 
Thomas,  1901).  Based  on  the  presence  of  emboli,  Kirkes  and  others  have 
supported  what  is  known  as  the  embolic  theory  of  the  disease.  Endocarditis 
is  by  far  the  most  frequent  lesion  in  Sydenham's  chorea.  With  no  disease, 
not  excepting  rheumatism,  is  it  so  constantly  associated.  I  have  collected 
from  the  literature  (to  July,  1894)  the  records  of  73  autopsies;  there  were  63 
with  endocarditis.*  The  endocarditis  is  usually  of  the  simple  variety,  but 
the  ulcerative  form  has  occasionally  been  described. 

We  are  still  far  from  a  solution  of  all  the  problems  connected  with  chorea. 
Unfortunately,  the  word  has  been  used  to  cover  a  series  of  totally  diverse  dis- 
orders of  movement,  so  that  there  are  still  excellent  observers  who  hold  that 
chorea  is  only  a  symptom,  and  is  not  to  be  regarded  as  an  etiological  unit.  The 
chorea  of  childhood,  the  disease  which  Sydenham  described,  presents,  however, 
characteristics  so  unmistakable  that  it  must  be  regarded  as  a  definite,  substan- 
tive afEection.  We  can  not  discuss  fully,  but  only  indicate  briefl}^^,  certain  of 
the  theories  which  have  been  advanced  with  regard  to  it.  The  most  generally 
accepted  view  is  that  it  is  a  functional  hrain  disorder  affecting  the  nerve- 
centres  controlling  the  motor  apparatus,  an  instability  of  the  nerve-cells, 
brought  about,  one  supposes  by  hj^Dersemia,  another  by  anasmia,  a  third  hj 
psychical  influences,  a  fourth  hj  irritation,  central  or  peripheral.  Of  the  actual 
nature  of  this  derangement  we  know  nothing,  nor,  indeed,  whether  the  changes 
are  primary  and  the  result  of  a  faulty  action  of  the  cortical  cells  or  whether  the 
impulses  are  secondarily  disturbed  in  their  course  down  the  motor  path.  The 
predominance  of  the  disease  in  females,  and  its  onset  at  a  time  when  the  edu- 
cation of  the  brain  is  rapidly  developing,  are  etiological  facts  which  Sturges 
has  urged  in  favor  of  the  view  that  chorea  is  an  expression  of  functional  insta- 
bility of  the  nerve-centres. 

*  Osier,  Chorea  and  Choreiform  Affections,  1894. 


1048  DISEASES  OF  THE  NERVOUS  SYSTEM. 

The  emki&iic  Hnmry  originiaMj  advaneed  bj  Kirkes  hz&  a  solid  basis 
of  fact,  ibiat  it  is  not  compiielfteiisive  enomgli,  as  all  of  the  cases  can  not  be 
broHgiit  witMn  its  limits.  There  are  instances  without  endocarditis  and 
without,  iso  far  as  can  h&  ascertained,  plugging  of  cerebral  vessels;  and 
tJieipe  are  also  easies  with  extensive  endocarditis  in  "vrhicli  tlie  histological 
examimatiQn.  of  the  braiit,  so  far  as  embolism  is  concerned,  was  negative. 
In  favor  of  the  embolic  view  is  the  experimental  production  in  animals  of 
chorea  hj  Bosenthal,  and  later  by  Money,  by  injecting  fine  particles  into 
the  caiotidsw 

Lately,  as  indeed  might  be  expected,  chorea  has  been  regarded  as  an  infec- 
imsis  iisease.  STothing  definite  has  yet  been  determined.  In  favor  of  this 
view- it  has  beea  "niwed,  as  it  is  impossihle  to  refer  the  chorea  to  endocarditis  or 
the  endoeaiditis  in  aE  cases  to  rheumatism,  that  both  have  their  origin  in  a 
common  eawse,  some  infeetions  agent,  which  is  capable  also,  in  persons  predis- 
posed, of  exciting  articiQlar  disease.  Cases  have  been  reported  in  scarlet  fever 
wiiii  arthritic  manifestations,  in  puerperal  fever,  and  rhenmatism,  also  after 
gQDorrhflea,  and  such  facts  are  suggestive  at  least  of  the  association  of  the 
disease  with,  infective  processes.  Possibly,  as  has  been  suggested  by  some 
writeic^  the  pairalytie  conditions  associated  with  chorea  may  be  analogous  to 
tiiose  which  occur  in  typhoid  and  certain  of  the  infections  diseases.  On  the 
other  hand,  there  are  conditions  extremely  difficult  to  harmonize  with  this 
view.  The  prominent  psychical  element  is  certainly  one  of  the  most  serious 
efcjections,  since  there  can  be  no  doubt  that  ordinary  chorea  may  rapidly  follow 
a  fright  or  a  siadden  emotion. 

S^mptomsL — Three  groups  of  cases  may  be  recognized — ^the  mild,  severe, 
and  maniacal  dboiea. 

MM  Chjorea. — In  this  the  afection  of  the  mnsd^  is  slight,  the  speech 
is  not^s^sju^  disturbed,  and  the  general  health  not  impaired.  Premoni- 
tory symptoms  are  shown  in  restlessness  and  inability  to  sit  still,  a  condition 
Widl  diaiacterized  by  the  term  "  fidgets."  There  are  emotional  disturbances, 
smch  as  crying  s"  ■:-">  :r  sometimes  night-terrors.  There  may  be  pains  in  the 
limbs  and  headiil-r.  Digestive  disturbances  and  an  ami  a  may  be  present.  A 
<3iiange  in  the  temperament  is  frequently  noticed,  and  a  docile,  qniet  child 
may  become  cro^  and  irritable.  After  these  symptoms  have  persisted  for  a 
wei^  or  moie  the  characteristic  involuntary  movements  begin,  and  are  often 
fiist  noticed  at  the  table,  when  the  child  spills  a  tumbler  of  water  or  upsets  a 
platcL  There  may  be  only  awkwardness  or  slight  incoordination  of  voluntary 
movem.eD.ts,  or  constant  irregular  clonic  spasms.  The  Jerky,  irregular  char- 
acter of  the  m.oviran<aits  differentiates  them  from  almost  every  other  disorder 
of  motion.  In  the  mild  cases  only  one  hand,  or  the  hand  and  face,  are  aif eeted, 
aad  it  may  not  spread  to  the  other  side. 

In  the  second  giade,  the  mwere  form,  the  movements  become  general  and 
the  psiisit  may  be  umable  to  get  about  or  to  feed  or  undress  herself,  owing 
to  the  constant,  irregular,  clonic  contractions  of  the  various  muscle  groups. 
The  speech  is  also  affected,  and  for  days  the  child  may  not  be  able  to  talk. 
Often  with  iBie  onset  of  the  severer  symptoms  there  is  loss  of  power  on  one 
side  or  in  the  limb  most  aSected. 

Tlie  Oiiid  and  mosi;  extreme  form,  the  so-called  maniacal  chorea,  or 
ehm-ea  himMdens,  is  tmly  a  terrible  disease,  and  may  develop  out  of  the  ordi- 


GENERAL  AND  FUNCTIONAL  DISEASES.  1049 

nary  form.  These  cases  are  more  common  in  adult  women  and  may  develop 
during  pregnancy. 

Chorea  begins,  as  a  rule,  in  the  hands  and  arms,  then  involves  the  face,  and 
subsequently  the  legs.  The  movements  may  be  confined  to  one  side — ^hemi- 
chorea.  The  attack  begins  of  tenest  on  the  right  side,  though  occasionally  it  is 
general  from  the  outset.  One  arm  and  the  opposite  leg  may  be  involved.  In 
nearly  one-fourth  of  the  cases  speech  is  affected;  this  may  amount  only  to  an 
embarrassment  or  hesitancy,  but  in  other  instances  it  becomes  an  incoherent 
jumble.  In  very  severe  cases  the  child  will  make  no  attempt  to  speak.  The 
inability  is  in  articulation  rather  than  in  phonation.  Paroxysms  of  panting 
and  of  hard  expiration  may  occur,  or  odd  sounds  may  be  produced.  As  a  rule 
the  movements  cease  during  sleep. 

A  prominent  symptom  is  muscular  weakness,  usually  no  more  than  a  con- 
dition of  paresis.  The  loss  of  power  is  slight,  but  the  weakness  may  be  shown 
by  an  enfeebled  grip  or  by  a  dragging  of  the  leg  or  limping.  In  his  original 
account  Sydenham  refers  to  the  "unsteady  movements  of  one  of  the  legs, 
which  the  patient  drags."  There  may  be  extreme  paresis  with  but  few  move- 
ments— the  paralytic  chorea  of  Todd.  Occasionally  a  local  paralysis  or  weak- 
ness remains  after  the  attack. 

It  is  doubtful  whether  choreic  spasms  extend  to  the  muscles  of  organic 
life.  The  japid  action  and  disturbed  rhythm  of  the  heart  present  nothing 
peculiar  to  the  disease,  and  there  is  no  support  for  the  view  that  irregular  con- 
tractions occur  in  the  papillary  muscles. 

Heart  Symptoms'. — Neurotic. — As  so  many  of  the  subjects  of  chorea  are 
nervous  girls,  it  is  not  surprising  that  a  common  symptom  is  a  rapidly  acting 
heart.  Irregularity  is  not  so  special  a  feature  in  chorea  as  rapidity.  The 
patients  seldom  complain  of  pain  about  the  heart. 

Hcemic  Murmurs. — With  angemia  and  debility,  not  uncommon  associates 
of  chorea  in  the  third  or  fourth  week,  we  find  a  corresponding  cardiac  condi- 
tion. The  impulse  is  diffuse,  perhaps  wavy  in  thin  children.  The  carotids 
throb  visibly,  and  in  the  recumbent  posture  there  may  be  pulsation  in  the  cer- 
vical veins.  On  auscultation  a  systolic  murmur  is  heard  at  the  base,  perhaps, 
too,  at  the  apex,  soft  and  blowing  in  quality. 

Endocarditis. — As  in  rheumatism,  so  in  chorea,  acute  valvulitis  rarely 
gives  evidence  of  its  presence  by  symptoms.  It  must  be  sought,  and  clinical 
experience  has  shown  that  it  is  usually  associated  with  murmurs  at  one  or 
other  of  the  cardiac  orifices. 

For  the  guidance  of  the  practitioner  the  following  statements  may  be 
made: 

(1)  In  thin,  nervous  children  a  systolic  murmur  of  soft  quality  is  ex- 
tremely common  at  the  base,  with  accentuation  of  the  second  sound,  particu- 
larly at  the  second  left  costal  cartilage,  and  is  probably  of  no  moment. 

(2)  A  systolic  murmur  of  maximum  intensity  at  the  apex,  and  heard 
also  along  the  left  sternal  margin,  is  not  uncommon  in  anaemic,  enfeebled 
states,  and  does  not  necessarily  indicate  either  endocarditis  or  insufficiency. 

(3)  A  murmur  of  maximum  intensity  at  apex,  with  rough  quality,  and 
transmitted  to  axilla  or  angle  of  scapula,  indicates  an  organic  lesion  of  the 
mitral  valve,  and  is  usually  associated  with  signs  of  enlargement  of  the  heart. 

(4)  When  in  doubt  it  is  much  safer  to  trust  to  the  evidence  of  eye  and 


1050  DISEASES  OF   THE  NERVOUS  SYSTEM. 

hand  than  to  that  of  the  ear.  If  the  apex  heat  is  in  the  normal  position, 
and  the  area  of  dulness  not  increased  yertically  or  to  the  right  of  the  stemmn, 
there  is  probably  no  serious  vahTilar  disease. 

(5)  The  endocarditis  of  chorea  is  almost  invariably  of  the  simple  or 
Trarty  form,  and  in  itself  is  not  dangerous;  but  it  is  apt  to  lead  to  those 
sclerotic  changes  in  the  valve  which  produce  incompetenc}'.  Of  140  patients 
examined  more  than  tvro  years  after  the  attack,  I  found  the  heart  normal  in. 
51 ;  in  17  there  was  functional  disturbance,  and  73  presented  signs  of  organic 
heart-disease. 

(6)  Pericarditis  is  an  occasional  complication  of  chorea,  usually  in  cases 
with  well-marked  rheumatism. 

In  an  analysis  of  the  cases  at  the  Johns  Hopkins  Hospital,  Thayer  found 
evidence  of  involvement  of  the  heart  in  25  per  cent  of  the  out-patients  and 
in  more  than  50  per  cent  of  the  cases  in  the  wards.  Cardiac  involvement  was 
more  common  in  the  cases  with  a  history  of  rheumatism,  and  was  much  more 
frequent  in  the  relapses. 

Sexsort  Distuebances. — Pain  in  the  affected  limbs  is  not  common. 
Occasionally  there  is  soreness  on  pressure.  There  are  cases,  usually  of  hemi- 
chorea,  in  which  pain  in  the  limbs  is  a  marked  s^Tuptom.  AYeir  Mitchell  has 
spoken  of  these  as  painful  choreas.  Tender  points  along  the  lines  of  emergence 
of  the  spinal  nerves  or  along  the  course  of  the  nerves  of  the  limbs  are  rare. 

Psychical  distuebaxces  are  common,  though  in  a  majority  of  the  cases 
slight  in  degree.  Irritability  of  temper,  marked  wilfulness,  and  emotional 
outbreaks  may  indicate  a  complete  change  in  the  character  of  the  child.  There 
is  deficiency  in  the  powers  of  concentration,  the  memory  is  enfeebled,  and  the 
aptitude  for  study  is  lost.  Earely  there  is  progressive  impairment  of  the 
intellect  with  termination  in  actual  dementia.  Acute  melancholia  has  been 
described  (Edes).  Hallucinations  of  sight  and  hearing  may  occur.  Patients 
may  behave  in  an  odd  and  strange  manner  and  do  all  sorts  of  meaningless  acts. 
By  far  the  most  serious  manifestation  of  this  character  is  the  maniacal  de- 
lirium, occasionally  associated  with  the  very  severe  cases — chorea  insaniens. 
Usually  the  motor  disturbance  in  these  cases  is  aggravated,  but  it  has  been 
overlooked  and  patients  have  been  sent  to  an  asylum. 

The  psychical  element  in  chorea  is  apt  to  be  neglected  by  the  practitioner. 
It  is  always  a  good  plan  to  tell  the  parents  that  it  is  not  the  muscles  alone 
of  the  child  which  are  affected,  but  that  the  general  irritability  and  change 
of  disposition,  so  often  found,  really  form  part  of  the  disease. 

The  condition  of  the  reflexes  in  chorea  is  usually  normal.  Trophic 
lesions  rarely  occur  in  chorea  unless,  as  some  writers  have  done,  we  regard 
the  joint  troubles  as  arthropathies  occurring  in  the  course  of  a  cerebro-spinal 
disease. 

Pever,  usually  slight,  was  present  in  all  but  one  of  110  cases  treated  in 
my  wards  (Thayer).  H.  A.  Hare  states  that  in  monochorea  the  tempera- 
ture on  the  affected  side  may  be  elevated;  but  this  is  not  an  invariable  rule. 
Endocarditis  ma}^  occur  with  little  if  any  rise  in  temperature;  but,  on  the 
other  hand,  with  an  acute  arthritis,  severe  endocarditis  or  pericarditis,  and  in 
the  cases  of  maniacal  chorea,  the  fever  may  range  from  102°  to  104°. 

CuTAXEOUs  Affectioxs. — The  pigmentation,  which  is  not  uncommon,  is 
due  to  the  arsenic.    Herpes  zoster  occasionally  occurs.     Certain  skin  eruptions, 


GENERAL  AND  FUNCTIONAL  DISEASES.  1051 

usually  regarded  as  rheumatic  in  character,  are  not  uncommon.  Erythema 
nodosum  has  been  described  and  I  have  seen  several  cases  with  a  purpuric 
urticaria.  There  may,  indeed,  be  the  more  aggravated  condition  of  rheumatic 
purpura,  known  as  Schonlein's  peliosis  rheumatica.  Subcutaneous  fibrous 
nodules,  which  have  been  noted  by  English  observers  in  many  cases  of  chorea, 
associated  with  rheumatism,  are  extremely  rare  in  the  United  States. 

Duration  and  Termination. — From  eight  to  ten  weeks  is  the  average  dura- 
tion of  an  attack  of  moderate  severity.  Chronic  chorea  rarely  follows  the 
minor  disease  which  we  have  been  considering.  The  cases  described  under 
this  designation  in  children  are  usually  instances  of  cerebral  sclerosis  or  Fried- 
reich's ataxia;  but  occasionally  an  attack  which  has  come  on  in  the  ordinary 
way  persists  for  months  or  years,  and  recovery  ultimately  takes  place.  A 
slight  grade  of  chorea,  particularly  noticeable  under  excitement,  may  persist 
for  months  in  nervous  children. 

The  tendency  of  chorea  to  recur  has  been  noticed  by  all  writers  since 
Sydenham  first  made  the  observation.  Of  410  cases  analyzed  for  this  purpose, 
240  had  one  attack,  110  had  two  attacks,  35  three  attacks,  10  four  attacks, 
13  five  attacks,  and  3  six  attacks.     The  recurrence  is  apt  to  be  vernal. 

Eecovery  is  the  rule  in  children.  The  statistics  of  out-patient  depart- 
ments are  not  favorable  for  determining  the  mortality.  A  reliable  estimate 
is  that  of  the  Collective  Investigation  Committee  of  the  British  Medical  Asso- 
ciation, in  which  9  deaths  were  reported  among  439  cases,  about  2  per  cent. 

The  paralysis  rarely  persists.  Mental  dulness  may  be  present  for  a  time, 
but  usually  passes  away ;  permanent  impairment  of  the  mind  is  an  exceptional 
sequence. 

Diagnosis. — There  are  few  diseases  which  present  more  characteristic  feat- 
ures, and  in  a  majority  of  instances  the  nature  of  the  trouble  is  recognized  at 
a  glance;  but  there  are  several  affections  in  children  which  may  simulate  and 
be  mistaken  for  it. 

(a)  Multiple  and  diffuse  cerebral  sclerosis.  The  cases  are  often  mistaken 
for  ordinary  chorea,  and  have  been  described  in  the  literature  as  chorea 
spastica. 

There  are  doubtless  chronic  changes  in  the  cortex.  As  a  rule,  the  move- 
ments are  readily  distinguishable  from  those  of  true  chorea,  but  the  simulation 
is  sometimes  very  close;  the  onset  in  infancy,  the  impaired  intelligence,  in- 
creased reflexes  and  in  some  instances  rigidity,  and  the  chronic  course  of  the 
disease,  separate  them  sharply  from  true  chorea. 

(&)  Friedreich's  ataxia.  Cases  of  this  well-characterized  disease  were  for- 
merly classed  as  chorea.  The  slow,  irregular,  incoordinate  movements,  the 
scoliosis,  the  scanning  speech,  the  early  talipes,  the  nystagmus,  and  the  fam- 
ily character  of  the  disease  are  points  which  should  render  the  diagnosis  easy. 

(c)  In  rare  cases  the  paralytic  form  of  chorea  may  be  mistaken  for  polio- 
myelitis or,  when  both  legs  are  affected,  for  paraplegia  of  spinal  origin;  but 
this  can  be  the  case  only  when  the  choreic  movements  are  very  slight. 

(d)  Hysteria  may  simulate  chorea  minor  most  closely,  and  unless  there 
are  other  manifestations  it  may  be  impossible  to  make  a  diagnosis.  Most 
commonly,  however,  the  movements  in  the  so-called  hysterical  chorea  are 
rhythmic  and  differ  entirely  from  those  of  ordinary  chorea. 

(e)  As  mentioned  above,  the  mental  symptoms  in  maniacal  chorea  may 


1052  .DISEASES  OF  THE  NERVOUS  SYSTEM. 

mask  the  true  nature  of  the  disease  and  patients  have  even  been  sent  to  the 
asylum. 

Treatment. — Abnormally  bright,  active-minded  children  belonging  to  fam- 
ilies Avith  pronounced  neurotic  taint  should  be  carefully  matched  from  the  ages 
of  eight  to  fifteen  and  not  allowed  to  overtax  their  mental  powers.  So  fre- 
quently in  children  of  this  class  does  the  attack  of  chorea  date  from  the  worry 
and  stress  incident  to  school  examinations  that  the  competition  for  prizes  or 
places  should  be  emphatically  forbidden. 

The  treatment  of  the  attack  consists  largely  in  attention  to  hygienic  meas- 
ures, with  which  alone,  in  time,  a  majority  of  the  cases  recover.  Parents 
should  be  told  to  scan  gently  the  faults  and  waywardness  of  choreic  children. 
The  psychical  element,  strongly  developed  in  so  many  eases,  is  best  treated 
by  quiet  and  seclusion.  The  child  should  be  confined  to  bed  in  the  recumbent 
posture,  and  mental  as  well  as  bodily  quiet  enjoined.  In  private  practice  this 
is  often  impossible,  but  with  well-to-do  patients  the  disease  is  always  serious 
enough  to  demand  the  assistance  of  a  skilled  nurse.  Toys  and  dolls  should 
not  be  allowed  at  first,  for  the  child  should  be  kept  amused  without  excitement. 
The  rest  allays  the  hyper-excitability  and  reduces  to  a  minimum  the  possibility 
of  damage  to  the  valve  segments  should  endocarditis  exist.  Time  and  again 
have  I  seen  very  severe  cases  which  had  resisted  treatment  for  weeks  outside 
a  hospital  become  quiet  and  the  movements  subside  after  two  or  three  days  of 
absolute  rest  in  bed. 

The  child  should  be  kept  apart  from  other  children  and,  if  possible,  from 
other  members  of  the  family,  and  should  see  only  those  persons  directly  con- 
cerned with  the  nursing  of  the  case.  In  the  latter  period  of  the  disease  daily 
rubbings  may  be  resorted  to  with  great  benefit. 

The  medical  treatment  of  the  disease  is  unsatisfactory;  with  the  exception 
of  arsenic,  no  remedy  seems  to  have  any  influence  in  controlling  the  progress 
of  the  affection.  Without  any  specific  action,  it  certainly  does  good  in  many 
cases,  probably  by  improving  the  general  nutrition.  It  is  conveniently  given 
in  the  form  of  Fowler's  solution,  and  the  good  effects  are  rarel}"  seen  until 
maximum  doses  are  taken.  It  may  be  given  as  Martin  originally  advised 
(1813)  ;  he  began  "with  five  drops  and  increased  one  drop  every  day,  until 
it  might  begin  to  disagree  vdth  the  stomach  or  bowels."  When  the  dose  of 
15  minims  is  reached,  it  may  be  continued  for  a  week,  and  then  again  in- 
creased, if  necessary,  every  day  or  two,  until  physiological  effects  are  manifest. 
On  the  occurrence  of  these  the  drug  should  be  stopped  for  three  or  four  days. 
The  practice  of  resuming  the  administration  with  smaller  doses  is  rarely  neces- 
sary, as  tolerance  is  usually  established  and  we  can  begin  with  the  dose  which 
the  child  was  taking  when  the  s}Tnptoms  of  saturation  occurred.  I  have  fre- 
quently given  as  much  as  25  minims  three  times  a  day.  Usually  the  signs  of 
saturation  are  trivial  but  plain,  but  in  very  rare  instances  more  serious  s}Tnp- 
toms  develop.  A  fatal  arsenical  neuritis  followed  in  the  case  of  a  child,  aged 
eight,  who  took  seven  drops  of  Fowler's  solution  three  times  a  day  for  ten 
days,  then  stopped  for  a  week,  and  then  took  seven  drops  three  times  a  day  for 
fourteen  days  (Gary  Gamble,  Jr.). 

Of  other  medicines,  strychnine,  tl>e  zinc  compounds,  nitrate  of  silver, 
bromide  of  potassium,*  belladonna,  chloral,  and  especially  cimicifuga,  have 
been  recommended,  and  may  be  tried  in  obstinate  cases. 


GENERAL  AND  FUNCTIONAL  DISEASES.  1053 

For  its  tonic  effect  electricity  is  sometimes  useful*  but  it  is  not  necessary 
as  a  routine  treatment.  The  question  of  gymnastics  is  an  important  one. 
Early  in  the  disease,  when  the  movements  are  active,  they  are  not  advisable; 
but  during  convalescence  carefully  graduated  exercises  are  undoubtedly  bene- 
ficial. It  is  not  well,  however,  to  send  a  choreic  child  to  a  school  gymnasium, 
as  the  stimulus  of  the  other  children  and  the  excitement  of  the  romping, 
violent  play  are  very  prejudicial. 

Other  points  in  treatment  may  be  mentioned.  It  is  important  to  regulate 
the  bowels  and  to  attend  carefully  to  the  digestive  functions.  For  the  anaemia 
so  often  present  preparations  of  iron  are  indicated. 

In  the  severe  cases  with  incessant  movements,  sleeplessness,  dry  tongue, 
and  delirium,  the  important  indication  is  to  procure  rest,  for  which  purpose 
chloral  may  be  freely  given,  and,  if  necessary,  morphia.  Chloroform  inhala- 
tions may  be  necessary  to  control  the  intensity  of  the  paroxysms,  but  the  high 
rate  of  mortality  in  this  class  of  cases  illustrates  how  often  our  best  endeavors 
are  fruitless.  The  wet  pack  is  sometimes  very  soothing  and  should  be  tried. 
As  these  patients  are  apt  to  sink  rapidly  into  a  low  typhoid  state  with  heart 
weakness,  a  supporting  treatment  is  required  from  the  outset. 

Cases  are  found  now  and  then  which  drag  on  from  month  to  month 
without  getting  either  better  or  worse  and  resist  all  modes  of  treatment. 
Change  of  air  and  scene  is  sometimes  followeu  by  rapid  improvement,  and 
in  these  cases  the  treatment  by  rest  and  seclusion  should  always  be  given  a 
full  trial. 

In  all  cases  care  should  be  taken  to  examine  the  nostrils,  and  glaring  ocular 
defects  should  be  properly  corrected  either  by  glasses  or,  if  necessary,  by 
operation. 

After  the  child  has  recovered  from  the  attack,  the  parents  should  be  warned 
that  return  of  the  disease  is  by  no  means  infrequent,  and  is  particularly  liable 
to  follow  overwork  at  school  or  debilitating  influences  of  any  kind.  These 
relapses  are  apt  to  occur  in  the  spring.  Sydenham  advised  purging  in  order 
to  prevent  the  vernal  recurrence  of  the  disease. 

IV.  OTHER  AFFECTIONS  DESCRIBED  AS  CHOREA. 

(a)  Chorea  Major;  Pandemic  Chorea. — The  common  name,  St.  Vitus's 
dance,  applied  to  chorea  has  come  to  us  from  the  middle  ages,  when  under 
the  influence  of  religious  fervor  there  were  epidemics  characterized  by  great 
excitement,  gesticulations,  and  dancing.  For  the  relief  of  these  symptoms, 
when  excessive,  pilgrimages  were  made,  and  in  the  Rhenish  provinces,  particu- 
larly to  the  Chapel  of  St.  Vitus  in  Zebern.  Epidemics  of  this  sort  occurred 
also  during  the  nineteenth  century,  and  descriptions  of  them  among  the  early 
settlers  in  Kentucky  have  been  given  by  Robertson  and  Yandell.  It  was  un- 
fortunate that  Sydenham  applied  the  term  chorea  to  an  affection  in  children 
totally  distinct  from  this  chorea  major,  which  is  in  reality  an  hysterical  mani- 
festation under  the  influence  of  religious  excitement. 

(&)  Habit  Spasm  (Habit  Chorea) ; /Convulsive  Tic  (of  the  French). 

Two  groups  of  cases  may  be  recognized  under  the  designation  of  habit 
spasm — one  in  which  there  are  simply  localized  spasmodic  movements,  and 
the  other  in  which,  in  addition  to  this,  there  are  explosive  utterances  and 


1054  DISEASES  OF   THE  NERVOUS  SYSTEM. 

psychical  symptoms,  a  condition  to  which  French  writers  have  given  the  name 
tic  convulsif. 

(1)  Habit  Spasm. — This  is  found  chiefly  in  childhood,  most  frequently 
in  girls  from  seven  to  fourteen  years  of  age  (Mitchell).  In  its  simplest  form 
there  is  a  sudden,  quick  contraction  of  certain  of  the  facial  muscles,  such  as 
rapid  winking  or  drawing  of  the  mouth  to  one  side,  or  the  neck  muscles  are 

■  involved  and  there  are  unilateral  movements  of  the  head.  The  head  is  given 
a  sudden,  quick  shake,  and  at  the  same  time  the  eyes  wink.  A  not  infrequent 
form  is  the  shrugging  of  one  shoulder.  The  grimace  or  movement  is  repeated 
at  irregular  intervals,  and  is  much  aggravated  by  emotion.  A  short  inspira- 
tory snifE  is  not  an  uncommon  symptom.  The  cases  are  found  most  frequently 
in  children  who  are  "  out  of  sorts,'^  or  who  have  been  growing  rapidly,  or  who 
have  inherited  a  tendency  to  neurotic  disorders.  Allied  to  or  associated  with 
this  are  some  of  the  curious  tricks  of  children.  A  boy  at  my  clinic  was  in  the 
habit  every  few  moments  of  putting  the  middle  finger  into  the  mouth,  biting 
it,  and  at  the  same  time  pressing  his  nose  with  the  forefinger.  Hartley  Cole- 
ridge is  said  to  have  had  a  somewhat  similar  trick,  only  he  bit  his  arm.  In 
all  these  cases  the  habits  of  the  child  should  be  examined  carefully,  the  nose 
and  vault  of  the  pharynx  thoroughly  inspected,  and  the  eyes  accurately  tested. 
As  a  rule  the  condition  is  transient,  and  after  persisting  for  a  few  months 
or  longer  gradually  disappears.  Occasionally  a  local  spasm  persists — twitching 
of  the  eyelids,  or  the  facial  grimace. 

(2)  Impulsive  Tic  (Gilles  de  la  Toueette's  Disease). — This  remark- 
able affection,  often  mistaken  for  chorea,  more  frequently  for  habit  spasm,  ia 
really  a  psychosis  allied  to  hysteria,  though  in  certain  of  its  aspects  it  has 
the  features  of  monomania.  The  disease  begins,  as  a  rule,  in  young  children, 
occurring  as  early  as  the  sixth  year,  though  it  may  develop  after  puberty. 
There  is  usually  a  markedly  neurotic  family  history.  The  special  features  of 
the  complaint  are: 

{a)  Involuntary  muscular  movements,  usually  affecting  the  facial  or 
brachial  muscles,  but  in  aggravated  cases  all  the  muscles  of  the  body  may 
be  involved  and  the  movements  may  be  extremely  irregular  and  violent. 

(&)  Explosive  utterances,  which  may  resemble  a  bark  or  an  inarticulate 
cry.  A  word  heard  may  be  mimicked  at  once  and  repeated  over  and  over 
again,  usually  with  the  involuntary  movements.  To  this  the  term  ecliolalia 
has  been  applied.  A  much  more  distressing  disturbance  in  these  cases  is 
coprolalia,  or  the  use  of  bad  language.  A  child  of  eight  or  ten  may  shock  its 
mother  and  friends  by  constantly  using  the  word  damn  when  making  the 
involuntary  movements,  or  by  uttering  all  sorts  of  obscene  words.  Occasion- 
ally actions  are  mimicked — ecJioTiinesis. 

(c)  Associated  with  some  of  these  cases  are  curious  mental  disturbances; 
the  patient  becomes  the  subject  of  a  form  of  obsession  or  a  fixed  idea.  In 
other  cases  the  fixed  idea  takes  the  form  of  the  impulse  to  touch  objects,  or  it 
is  a  fixed  idea  about  words — onomatomania — or  the  patient  may  feel  compelled 
to  count  a  number  of  times  before  doing  certain  actions — arithmomania. 

The  disease  is  well  marked  and  readily  distinguished  from  ordinary  chorea. 
The  movements  have  a  larger  range  and  are  explosive  in  character.  Tourette 
regards  the  coprolalia  as  the  most  distinctive  feature  of  the  disease.  The 
prognosis  is  doubtfuL    I  have,  however,  known  recovery  to  follow. 


GENERAL  AND  FUNCTIONAL  DLSEASES.  1055 

(c)  Saltatory  Spasm  {Laiah;  Myriachlt;  Jumpers). — Bamberger  has  de- 
scribed a  disease  in  which  when  the  patient  attempted  to  stand  there  were 
strong  contractions  in  the  leg  muscles,  which  caused  a  jumping  or  spring- 
ing motion.  This  occurs  only  when  the  patient  attempts  to  stand.  The 
affection  has  occurred  in  both  men  and  women,  more  frequently  in  the 
former,  and  the  subjects  have  usually  shown  marked  neurotic  tendencies. 
In  many  cases  the  condition  has  been  transitory;  in  others  it  has  persisted 
for  years.  Eemarkable  affections  similar  to  this  in  certain  points  occur 
as  a  sort  of  epidemic  neurosis.  One  of  the  most  striking  of  these  occurs 
among  the  "  jumping  Frenchmen "  of  Maine  and  Canada.  As  described 
by  Beard  and  Thornton,  the  subjects  are  liable  on  any  sudden  emotion 
to  jump  violently  and  utter  a  loud  cry  or  sound,  and  will  obey  any  com- 
mand or  imitate  any  action  without  regard  to  its  nature.  The  condition  of 
echolalia  is  present  in  a  marked  degree.  The  "  jumping  "  prevails  in  certain 
families. 

A  very  similar  disease  prevails  in  parts  of  Eussia  and  in  Java  and  Borneo, 
where  it  is  known  by  the  names  of  myriachit  and  latah,  the  chief  feature  of 
which  is  mimicry  by  the  patient  of  everything  he  sees  or  hears. 

(d)  Chronic  Chorea  {Huntington's  Chorea). — An  affection  characterized 
by  irregular  movements,  disturbance  of  speech,  and  gradual  dementia.  It 
is  frequently  hereditary.  Irving  W.  Lyon  described  it  in  1863  as  chronic 
hereditary  chorea  and  traced  the  disease  through  five  generations.  Hunting- 
ton, of  Pomeroy,  Ohio,  at  the  time  a  practitioner  on  Long  Island,  gave,  in 
1873,  in  three  brief  paragraphs  the  salient  points  in  connection  with  the 
disease — namely,  the  hereditary  nature,  the  association  with  psychical  troubles, 
and  the  late  onset — between  the  thirtieth  and  fortieth  years.  The  disease 
seems  common  in  the  United  States,  and  many  cases  have  been  reported  by 
Clarence  King,  Sinkler,  and  others.  I  have  seen  it  in  two  Maryland  fam- 
ilies within  a  few  years.  Under  the  term  chronic  chorea  may  be  grouped  the 
hereditary  form  and  the  cases  which  come  on  without  family  disposition, 
either  at  middle  life  or,  more  commonly,  in  the  aged — senile  chorea.  It  is 
doubtful  whether  the  cases  in  children  with  chronic  choreiform  movements, 
often  with  mental  weakness  and  spastic  condition  of  the  legs,  should  go  into 
this  category. 

The  hereditary  character  of  the  disease  is  very  striking ;  it  has  been  traced 
through  four  or  five  generations.  Huntington's  father  and  grandfather,  also 
physicians,  had  treated  the  disease  in  the  family  which  he  described.  Osborn, 
of  East  Hampton,  L.  I.,  writes  (Jan.  28th,  1898)  that  the  disease  still  con- 
tinues to  recur  in  certain  families  described  by  Huntington,  as  it  has  done, 
so  it  is  said,  for  fully  two  centuries.  An  identical  affection  occurs  without 
any  hereditary  disposition.  The  age  of  onset  is  late,  rarely  before  the  thirtieth 
or  the  thirty- fifth  year. 

The  symptoms  are  very  characteristic.  The  irregular  movements  are  usu- 
ally first  seen  in  the  hands,  and  the  patient  has  slight  difficulty  in  performing 
delicate  manipulations  or  in  writing.  When  well  established  the  movements 
are  disorderly,  irregular,  incoordinate  rather  than  choreic,  and  have  not  the 
sharp,  brusque  motion  of  Sydenham's  chorea.  In  the  face  there  are  slow, 
involuntary  grimaces.  In  a  well-developed  case  the  gait  is  irregular,  swaying, 
and  somewhat  like  that  of  a  drunken  man.    The  speech  is  slow  and  difficult. 


1056  DISEASES  OF  THE  NERVOUS  SYSTEM. 

the  syllables  are  badh'  pronounced  and  indistinct;,  biit  not  definitely  staccato. 
The  mental  impairment  leads  finally  to  dementia. 

Very  few  autopsies  have  been  made.  Xo  characteristic  lesions  have  been 
found.  Atrophy  of  the  convolutions,  chronic  meningo-encephalitis,  and  vas- 
cular changes  have  usually  been  present,  the  conditions  which  one  would  ex- 
pect to  find  in  chronic  dementia.  The  study  of  two  cases  by  Facklan  (Arch, 
f.  Psychiatric^  30)  confirms  the  view  expressed  in  former  editions  that  the 
disease  is  a  chronic  meningo-encephalitis  with  atrophy  of  the  convolutions. 
The  cord  and  peripheral  nerves  he  foimd  perfectly  healthy.  The  affection  is 
evidently  a  neuro-degenerative  disorder,  and  has  no  connection  with  the  sim- 
ple chorea  of  childhood. 

(e)  Rhythmic  or  Hysterical  Chorea. — This  is  readily  recognized  by  the 
rhjrthmieal  character  of  the  movements.  It  may  affect  the  muscles  of  the 
abdomen,  producing  the  salaam  convulsion,  or  involve  the  sterno-mastoid, 
producing  a  rhythmical  movement  of  the  head,  or  the  psoas,  or  any  group  of 
muscles.     In  its  orderly  rhythm  it  resembles  the  canine  chorea. 

V.     INFANTILE    CONVUIiSIONS  (Eclampsia). 

Convulsive  seizures  similar  to  those  of  epilepsy  are  not  infrequent  in  chil- 
dren and  in  adults.  The  fit  may  indeed  be  identical  with  epilepsy,  from  which 
the  condition  differs  in  that  when  the  cause  is  removed  there  is  no  tendency 
for  the  fits  to  recur.  Occasionally,  however,  the  convulsions  in  children  con- 
tinue and  develop  into  true  epilepsy. 

Etiology. — A  convulsion  in  a  child  may  be  due  to  many  causes,  all  of  which 
lead  to  an  unstable  condition  of  the  nerve-centres,  permitting  sudden,  ex- 
cessive, and  temjDorary  nervous  discharges.  The  following  are  the  most  impor- 
tant of  them : 

(1)  DehiUty,  resulting  usually  from  gastro-intestinal  disturbance.  Con- 
vulsions frequently  supervene  toward  the  close  of  an  attack  of  entero-colitis 
and  recur,  sometimes  proving  fatal.  Morris  J.  Lewis  has  shown  that  the 
death-rate  in  children  from  eclampsia  rises  steadily  with  that  of  gastro-intes- 
tinal disorders. 

(2)  Peripheral  irritation.  Dentition  alone  is  rarely  a  cause  of  convul- 
sions, but  is  often  one  of  several  factors  in  a  feeble,  unhealthy  infant.  The 
greatest  mortality  from  convulsions  is  during  the  first  six  months,  before  the 
teeth  have  really  cut  through  the  gums.  Other  irritative  causes  are  the  over- 
loading of  the  stomach  with  indigestible  food.  It  has  been  suggested  that 
some  of  these  cases  are  toxic,  o"\ving  to  the  absorption  of  poisonous  ptomaines. 
Worms,  to  which  convulsions  are  so  frequently  attributed,  probably  have  little 
influence.    Among  other  sources  possible  are  phimosis  and  otitis. 

(3)  Rickets.  The  observation  of  Sir  William  Jenner  upon  the  associa- 
tion of  rickets  and  convulsions  has  been  amply  confirmed.  The  spasms  may 
be  laryngeal,  the  so-called  child-crowing,  which,  though  convulsive  in  nature, 
can  scarcely  be  reckoned  under  eclampsia.  The  influence  of  this  condition  is 
more  apparent  in  Europe  than  in  the  United  States,  although  rickets  is  a  com- 
mon disease,  particularly  among  the  colored  people.  Spasms,  local  or  gen- 
eral, in  rickets  are  probably  associated  with  the  condition  of  debility  and  mal- 
nutrition and  with  cranio-tabes. 


GENERAL  AND  FUNCTIONAL  DISEASES.  1057 

(4)  Fever.  In  young  children  the  onset  of  the  infectious  diseases  is  fre- 
quently with  convulsions,  which  often  take  the  place  of  a  chill  in  the  adult. 
It  is  not  known  upon  what  they  depend.  Scarlet  fever,  measles,  and  pneu- 
monia are  most  often  preceded  by  convulsions. 

(.5)  Congestion  of  the  brain.  That  extreme  engorgement  of  the  blood- 
vessels may  produce  convulsions  is  shown  by  their  occasional  occurrence  in 
severe  whooping-cough,  but  their  rarity  in  this  disease  really  indicates  how 
small  a  part  mechanical  congestion  plays  in  the  production  of  fits. 

(6)  Severe  convulsions  usher  in  or  accompany  many  of  the  serious  dis- 
eases of  the  nervous  system  in  children.  In  more  than  50  per  cent  of  the  cases 
of  infantile  hemiplegia  the  affection  follows  severe  convulsions.  They  less 
frequently  precede  a  spinal  paralysis.  They  occur  with  meningitis,  tubercu- 
lous or  simple,  and  with  tumors  and  other  lesions  of  the  brain. 

And,  lastly,  convulsions  may  occur  immediately  after  birth  and  persist 
for  weeks  or  months.  In  such  instances  there  has  probably  been  meningeal 
haemorrhage  or  serious  injury  to  the  cortex. 

The  most  important  question  is  the  relation  of  convulsions  in  children 
to  true  epilepsy.  In  Gowers'  figures  of  1,450  cases  of  epilepsy,  the  attacks 
began  in  180  during  the  first  three  years  of  life.  Of  460  cases  of  epilepsy 
in  children  which  I  have  analyzed,  in  187  the  fits  began  within  the  first  three 
years.  Of  the  total  list  the  greatest  number,  74,  was  in  the  first  year.  In 
nearly  all  these  instances  there  was  no  interruption  in  the  convulsions.  That 
convulsions  in  early  infancy  are  necessarily  followed  by  epilepsy  in  after  life 
is  certainly  a  mistake. 

Symptoms. — The  attack  m.a,j  come  on  suddenly  without  any  warning ;  more 
commonly  it  is  preceded  by  a  stage  of  restlessness,  accompanied  by  twitching 
and  perhaps  grinding  of  the  teeth.  It  is  rarely  so  complete  in  its  stages  as 
true  epilepsy.  The  spasm  begins  usually  in  the  hands,  most  commonly  in  the 
right  hand.  The  eyes  are  fixed  and  staring  or  are  rolled  up.  The  body  be- 
comes stiff  and  breathing  is  suspended  for  a  moment  or  two  by  tonic  spasm 
of  the  respiratory  muscles,  in  consequence  of  which  the  face  becomes  congested. 
Clonic  convulsions  follow,  the  eyes  are  rolled  about,  the  hands  and  arms  twitch, 
or  are  fiexed  and  extended  in  rhythmical  movements,  the  face  is  contorted, 
and  the  head  is  retracted.  The  attack  gradually  subsides  and  the  child  sleeps 
or  passes  into  a  state  of  stupor.  Following  indigestion  the  attack  may  be 
single,  but  in  rickets  and  intestinal  disorders  it  is  apt  to  be  repeated.  Some- 
times the  attacks  follow  each  other  with  great  rapidity,  so  that  the  child  never 
rouses  but  dies  in  a  deep  coma.  If  the  convulsion  has  been  limited  chiefiy  to 
one  side  there  may  be  slight  paresis  after  recovery,  or  in  instances  in  which 
the  convulsions  usher  in  infantile  hemiplegia,  when  the  child  arouses,  one  side 
is  completely  paralyzed.  During  the  fit  the  temperature  is  often  raised. 
Death  rarely  occurs  from  the  convulsion  itself,  except  in  debilitated  children  or 
when  the  attacks  recur  with  great  frequency.  In  the  so-called  hydrocephaloid 
state  in  connection  with  protracted  diarrhoea  convulsions  may  close  the  scene. 

Diagnosis. — Coming  on  when  the  subject  is  in  full  health,  the  attack  is 
probably  due  either  to  an  overloaded  stomach,  to  some  peripheral  irritation,  or 
occasionally  to  trauma.  Setting  in  with  high  fever  and  vomiting,  it  may 
indicate  the  onset  of  an  exanthem,  or  occasionally  be  the  primary  symptom  of 
encephalitis,  or  whatever  the  condition  is  which  causes  infantile  hemiplegia, 
68 


1058  DISEASES  OF  THE  NERVOUS  SYSTEM. 

WTien  the  attack  is  associated  with  debility  and  with  rickets  the  diagnosis  is 
easily  made.  The  carpopedal  spasms  and  pseudo-paralytic  rigidity  which  are 
often  associated  with  rickets,  larjTigismus  stridulus,  and  the  hydrocephaloid 
state  are  usually  confined  to  the  hands  and  arms  and  are  intermittent  and  usu- 
ally tonic.  The  convulsions  associated  with  tumor  or  those  which  follow 
infantile  hemiplegia  are  usually  at  first  Jacksonian  in  character.  After  the 
second  year  convulsive  seizures  which  come  on  irregularly  without  apparent 
cause  and  recur  while  the  child  is  apparently  in  good  health,  are  likely  to 
prove  true  epilepsy. 

Prognosis. — Convulsions  play  an  important  part  in  infantile  mortality. 
In  Morris  J.  Lems's  table  of  deaths  in  children  under  ten,  8.5  per  cent  were 
ascribed  to  convulsions.  West  states  that  22.35  per  cent  of  deaths  under  one 
year  are  caused  by  convulsions,  but  this  is  too  high  an  estimate  for  America. 
In  chronic  diarrhoea  convulsions  are  usually  of  ill  omen.  Those  ushering  in 
fevers  are  rarely  serious,  and  the  same  may  be  said  of  the  fits  associated  with 
indigestion  and  peripheral  irritation. 

Treatment. — Every  source  of  irritation  should  be  removed.  If  associated 
with  indigestible  food,  a  prompt  emetic  should  be  given,  followed  by  an  enema. 
The  teeth  should  be  examined,  and  if  the  gum  is  swollen,  hot,  and  tense,  it 
may  be  lanced ;  but  never  if  it  looks  normal.  When  seen  at  first,  if  the  parox- 
ysm is  severe,  no  time  should  be  lost  by  giving  a  hot  bath,  but  chloroform 
should  be  given  at  once,  and  repeated  if  necessary,  A  child  is  so  readily  put 
under  chloroform  and  with  such  a  small  quantity  that  this  procedure  is  quite 
harmless  and  saves  much  valuable  time.  The  practice  is  almost  universal  of 
putting  the  child  into  a  warm  bath,  and  if  there  is  fever  the  head  may  be 
douched  with  cold  water.  The  temperature  of  the  bath  should  not  be  above 
95°  or  96°.  The  very  hot  bath  is  not  suitable,  particularly  if  the  fits  are  due 
to  indigestion.  After  the  attack  an  ice-cap  may  be  placed  upon  the  head.  If 
there  is  much  irritability,  particularly  in  rickets  and  in  severe  diarrhoea,  small 
doses  of  opium  will  be  found  efficacious.  Wlien  the  convulsions  recur  after  the 
child  comes  from  under  the  influence  of  chloroform  it  is  best  to  place  it  rapidly 
under  the  influence  of  opium,  wliich  may  be  given  as  morphia  h}'podermically, 
in  doses  of  from  one-twenty-fifth  to  one-thirtieth  of  a  grain  for  a  child  of  one 
year.  Other  remedies  recommended  are  chloral  by  enema,  in  5-grain  doses,  and 
nitrite  of  am}^.  After  the  attack  has  passed  the  bromides  are  useful,  of  which 
5  to  8  grains  may  be  given  in  a  day  to  a  child  a  year  old.  Eecurring  convul- 
sions, particularly  if  they  come .  on  without  special  cause,  should  receive  the 
most  thorough  and  careful  treatment  with  bromides.  When  associated  with- 
rickets  the  treatment  should  be  directed  to  improving  the  general  condition. 

VI.     EPILEPSY. 

Definition. — An  affection  of  the  nervous  system  characterized  by  attacks 
of  unconsciousness,  with  or  without  convulsions. 

The  transient  loss  of  consciousness  without  convulsive  seizures  is  known 
as,  petit  mal;  the  loss  of  consciousness  with  general  convulsive  seizures  is  known 
as  grand  mal.  Localized  convulsions,  occurring  usually  without  loss  of  con- 
sciousness, are  kno-mi  as  epileptiform,  or  more  frequently  as  Jacksonian  or 
eortical  epilepsy. 


GENERAL  AND  FUNCTIONAL  DISEASES.  1059 

Etiology. — Age. — In  a  large  proportion  of  all  cases  the  disease  begins  be- 
fore puberty.  Of  the  1/150  cases  observed  hj  Gowers,  in  422  the  disease  began 
before  the  tenth  year,  and  three-fourths  of  the  cases  began  before  the  twen- 
tieth year.  Of  460  cases  of  epilepsy  in  children  which  I  have  analyzed  the 
age  of  onset  in  427  was- as  follows:  First  year,  74;  second  year,  62;  third 
year,  51;  fourth  year,  24;  fifth  year,  17;  sixth  year,  18;  seventh  year,  19; 
eighth  year,  23 ;  ninth  year,  17 ;  tenth  year,  27 ;  eleventh  year,  17 ;  twelfth  year, 
18;  thirteenth  year,  15;  fourteenth  year,  21;  fifteenth  year,  34.  Arranged 
in  hemidecades  the  figures  are  as  follows :  From  the  first  to  the  fifth  year,  229  ; 
from  the  fifth  to  the  tenth  year,  104;  from  the  tenth  to  the  fifteenth  year,  95. 
These  figures  illustrate  in  a  striking  manner  the  early  onset  of  the  disease  in 
a  large  proportion  of  the  cases.  It  is  well  always  to  be  suspicious  of  epilepsy 
developing  in  the  adult,  for  in  a  majority  of  such  cases  the  convulsions  are'  due 
to  a  local  lesion. 

Sex. — No  special  influence  appears  to  be  discoverable  in  this  relation,  cer- 
tainly not  in  children.  Of  433  cases  in  my  tables,  232  were  males  and  203 
were  females,  showing  a  slight  predominance  of  the  male  sex.  After  puberty 
unquestionably,  if  a  large  number  of  cases  are  taken,  the  males  are  in  excess. 
The  figures  of  Sieveking  and  Eeynolds  would  tend  to  show  that  the  disease 
is  rather  more  prevalent  in  females  than  in  males. 

Heredity. — Much  stress  has  been  laid  upon  this  by  many  authors  as  an 
important  predisposing  cause,  and  the  statistics  collected  give  from  9  to  over 
40  per  cent.  Gowers  gives  35  per  cent  for  his  cases,  which  have  special  value 
apart  from  other  statistics  embracing  large  numbers  of  epileptics  in  that  they 
were  collected  by  him  in  his  own  practice.  In  our  figures  it  appears  to  play  a 
minor  role.  In  the  Infirmary  list  there  were  only  31  cases  in  which  there  was 
a  history  of  marked  neurotic  taint,  and  only  3  in  which  the  mother  herself 
had  been  epileptic.  In  the  Elwyn  cases,  as  might  be  expected,  the  percentage 
is  larger.  Of  the  126  there  was  in  32  a  family  history  of  nervous  derangement 
of  some  sort,  either  paralysis,  epilepsy,  marked  hysteria,  or  insanity.  It  is 
interesting  to  note  that  in  this  group,  in  which  the  question  of  heredity  is 
carefully  looked  into,  there  were  only  two  in  which  the  mother  had  had 
epilepsy,  and  not  one  in  which  the  father  had  been  affected.  Indeed,  I 
was  not  a  little  surprised  to  find  in  the  list  of  my  cases  that  hereditary 
influences  played  so  small  a  part.  I  have  heard  this  opinion  expressed  by 
certain  French  physicians,  notably  Marie,  who  also  in  writing  upon  the 
question  takes  strong  grounds  against  heredity  as  an  important  factor  in 
epilepsy. 

While,  then,  it  may  be  said  that  direct  inheritance  is  comparatively  un- 
common, yet  the  children  of  neurotic  families  in  which  neuralgia,  insanity, 
and  hysteria  prevail  are  more  liable  to  fall  victims  to  the  disease. 

Chronic  alcoholism  in  the  parents  is  regarded  by  many  as  a  potent  pre- 
disposing factor  in  the  production  of  epilepsy.  Echeverria  has  analyzed  572 
cases  bearing  upon  this  point  and  divided  them  into  three  classes,  of  which 
257  cases  could  be  traced  directly  to  alcohol  as  a  cause;  126  cases  in  which 
there  were  associated  conditions,  such  as  syphilis  and  traumatism;  189  cases 
in  which  the  alcoholism  was  probably  the  result  of  the  epilepsy.  Figures 
equally  strong  are  given  by  Martin,  who  in  150  insane  epileptics  found  83 
with  a  marked  history  of  parental  intemperance.     Of  the  126  Elwyn  cases,  in 


1060  DISEASES  OF  THE  NERVOUS  SYSTEM. 

which  the  family  histor}^  on  this  point  was  carefully  investigated,  a  definite 
statement  was  found  in  only  4  of  the  cases. 

Syphilis. — This  in  the  parents  is  probably  less  a  predisposing  than  an 
actual  cause  of  epilepsy,  which  is  the  direct  outcome  of  local  cerebral  mani- 
festations. There  is  no  reason  for  recognizing  a  special  form  of  syphilitic 
epilepsy.  On  the  other  hand,  convulsive  seizures  due  to  acquired  syphilitic 
disease  of  the  brain  are  very  common. 

Poisoxs. — Alcohol. — Severe  epileptic  convulsions  may  occur  in  steady 
drinkers. 

Of  exciting  causes  fright  is  believed  to  be  important,  but  is  less  so,  I 
think,  than  is  usually  stated.  Trauma  is  present  in  a  certain  number  of  in- 
stances. An  important  group  depends  upon  a  local  disease  of  the  brain  exist- 
ing from  childhood,  as  seen  in  the  post-hemiplegic  epilepsy.  Occasionally  cases 
follow  the  infectious  fevers.  Masturbation  has  been  stated  to  be  a  special 
cause,  but  its  influence  is  probably  overrated.  A  large  group  of  convulsive 
seizures  allied  to  epilepsy  are  due  to  some  toxic  agent,  as  in  lead  poisoning 
and  in  uraemia. 

Eeflex  Causes. — Dentition  and  worms,  the  irritation  of  a  cicatrix,  some 
local  affection,  such  as  adherent  prepuce,  or  a  foreign  body  in  the  ear  or  the 
nose,  are  given  as  causes.  In  many  of  these  cases  the  fits  cease  after  the  re- 
moval of  the  cause,  so  that  there  can  be  no  question  of  the  association  between 
the  two.  In  others  the  attacks  persist.  Genuine  cases  of  reflex  epilepsy  are, 
I  believe,  rare.  A  remarkable  instance  of  it  occurred  at  the  Philadelphia 
Infirmary  for  Diseases  of  the  ]SI"ervous  System  in  the  case  of  a  man  with  a 
testis  in  the  inguinal  canal,  pressure  upon  which  would  cause  a  typical  fit. 
Eemoval  of  the  organ  was  followed  by  cure. 

Cardio-vascular  epilepsy  is  usually  a  manifestation  of  advanced  arterio- 
sclerosis, and  is  associated  with  slow  pulse  (see  Stokes- Adams  Disease). 
There  may  be  palpitation  and  uneasy  sensations  about  the  heart  prior  to  the 
attack.  The  passage  of  a  gall-stone  or  the  removal  of  pleuritic  fluid  may 
induce  a  fit.  Indigestion  and  gastric  troubles  are  extremely  common  in  epi- 
lepsy, and  in  many  instances  the  eating  of  indigestible  articles  seems  to  pre- 
cipitate an  attack.  And  lastly,  epileptic  seizures  may  occur  in  old  people 
without  obvious  cause. 

Symptoms. —  (1)  Grand  Mal. — Preceding  the  fits  there  is  usually  a  local- 
ized sensation,  kno^vn  as  an  aura,  in  some  part  of  the  body.  This  may  be 
somatic,  in  which  the  feeling  comes  from  some  particular  region  in  the  periph- 
ery, as  from  the  finger  or  hand,  or  is  a  sensation  felt  in  the  stomach  or  about 
the  heart.  The  peripheral  sensations  preceding  the  fit  are  of  great  value, 
particularly  those  in  which  the  aura  always  occurs  in  a  definite  region,  as  in 
one  finger  or  toe.  It  is  the  equivalent  of  the  signal  symptom  in  a  fit  from 
a  brain  tumor.  The  varieties  of  these  sensations  are  numerous.  The  epigas- 
tric sensations  are  most  common.  In  these  the  patient  complains  of  an  uneasy 
sensation  in  the  epigastrium  or  distress  in  the  intestines,  or  the  sensation  may 
not  be  unlike  that  of  heart-burn  and  may  be  associated  with  palpitation. 
These  groups  are  sometimes  kno^vn  as  pneumogastric  aurse  or  warnings. 

Of  psychical  aurae  one  of  the  most  common,  as  described  by  Hughlings 
Jackson,  is  the  vague,  dreamy  state,  a  sensation  of  strangeness  or  sometimes 
of  terror.    The  aurse  may  be  associated  with  special  senses;  of  these  the  most 


GENERAL  AND  FUNCTIONAL  DISEASES.  1061 

common  are  the  visual,  consisting  of  flashes  of  light  or  sensations  of  color; 
less  commonly,  distinct  objects  are  seen.  The  auditory  aurae  consist  of  noises 
in  the  ear,  odd  sounds,  musical  tones,  or  occasionally  voices.  Olfactory  and 
gustatory  aurge,  unpleasant  tastes  and  odors,  are  rare. 

Occasionally  the  fit  may  be  preceded  not  by  an  aura,  but  by  certain  move- 
ments ;  the  patient  may  turn  round  rapidly  or  run  with  great  speed  for  a  few 
minutes,  the  so-called  epilepsia  procursiva.  In  one  of  the  Elwyn  cases  the  lad 
stood  on  his  toes  and  twirled  with  extraordinary  rapidity,  so  that  his  features 
were  scarcely  recognizable.  At  the  onset  of  the  attack  the  patient  may  give  a 
loud  scream  or  yell,  the  so-called  epileptic  cry.  The  patient  drops  as  if  shot, 
making  no  effort  to  guard  the  fall.  In  consequence  of  this  epileptics  fre- 
quently injure  themselves,  cutting  the  face  or  head  or  burning  themselves.  In 
the  attack,  as  described  by  Hippocrates,  '^the  patient  loses  his  speech  and 
chokes,  and  foam  issues  from  the  mouth,  the  teeth  are  fixed,  the  hands  are 
contracted,  the  eyes  distorted,  he  becomes  insensible,  and  in  some  cases  the 
bowels  are  affected.  And  these  symptoms  occur  sometimes  on  the  left  side, 
sometimes  on  the  right,  and  sometimes  on  both."  The  fit  may  be  described 
in  three  stages: 

(a)  Tonic  Spasm. — The  head  is  drawn  back  or  to  the  right,  and  the  jaws 
are  fixed.  The  hands  are  clinched  and  the  legs  extended.  This  tonic  contrac- 
tion affects  the  muscles  of  the  chest,  so  that  respiration  is  impeded  and  the 
initial  pallor  of  the  face  changes  to  a  dusky  or  livid  hue.  The  muscles  of 
the  two  sides  are  unequally  affected,  so  that  the  head  and  neck  are  rotated  or 
the  spine  is  twisted.  The  arms  are  usually  flexed  at  the  elbows,  the  hand  at  the 
wrist,  and  the  fingers  are  tightly  clinched  in  the  palm.  This  stage  lasts  only 
a  few  seconds,  and  then  the  clonic  stage  begins. 

(&)  Clonic  stage.  The  muscular  contractions  become  intermittent;  at 
first  tremulous  or  vibratory,  they  gradually  become  more  rapid  and  the 
limbs  are  jerked  and  tossed  about  violently.  The  muscles  of  the  face  are  in 
constant  clonic  spasm,  the  eyes  roll,  the  eyelids  are  opened  and  closed  con- 
vulsively. The  movements  of  the  muscles  of  the  jaw  are  very  forcible  and 
strong,  and  it  is  at  this  time  that  the  tongue  is  apt  to  be  caught  between  the 
teeth  and  lacerated.  The  cyanosis,  marked  at  the  end  of  the  tonic  stage,  grad- 
ually lessens.  A  frothy  saliva,  which  may  be  blood-stained,  escapes  from  the 
mouth.  The  faeces  and  urine  may  be  discharged  involuntarily.  The  duration 
of  this  stage  is  variable.  It  rarely  lasts  more  than  one  or  two  minutes.  The 
contractions  become  less  violent  and  the  patient  gradually  sinks  into  the  con- 
dition of  coma. 

(c)  Coma.  The  breathing  is  noisy  or  even  stertorous,  the  face  congested, 
but  no  longer  intensely  cyanotic.  The  limbs  are  relaxed  and  the  unconscious- 
ness is  profound.  After  a  variable  time  the  patient  can  be  aroused,  but  if 
left  alone  he  sleeps  for  some  hours  and  then  awakes,  complaining  only  of 
slight  headache  or  mental  confusion.  If  the  attack  has  been  severe  petechial 
haemorrhage  may  be  scattered  over  the  neck  and  chest.  In  the  case  of  a 
young  man  in  good  health  in  a  severe  convulsion  both  sub-conjunctival 
spaces  were  entirely  filled  with  blood,  and  free  blood  oozed  from  them  (Walter 
James).     Haemoptysis  is  a  rare  sequel. 

Status  Epilepticus. — This  is  the  climax  of  the  disease,  in  which  attacks 
occur  in  rapid  succession,  and  the  patient  does  not  recover  consciousness.    The 


1062  DISEASES  OF  THE  NERVOUS  SYSTEM. 

pulse,  respiration,  and  temperature  rise  in  the  attack.  It  is  a  serious  condi- 
tion, and  often  proves  fatal. 

After  the  attack  the  reflexes  are  sometimes  absent;  more  frequently  they 
are  increased  and  the  ankle  clonus  can  usually  be  obtained.  The  state  of  the 
urine  is  variable,  particularly  as  regards  the  solids.  The  quantity  is  usually 
increased  after  the  attack,  and  albumin  is  not  infrequently  present. 

Post-epileptic  symptoms  are  of  great  importance.  The  patient  may  be  in 
a  trance-like  condition,  in  which  he  performs  actions  of  which  subsequently 
he  has  no  recollection.  More  serious  are  the  attacks  of  mania,  in  which  the 
patient  is  often  dangerous  and  sometimes  homicidal.  It  is  held  by  good 
authorities  that  an  outbreak  of  mania  may  be  substituted  for  the  fit.  And, 
lastly,  the  mental  condition  of  an  epileptic  patient  is  often  seriously  impaired, 
and  profound  defects  are  common. 

Paralysis,  which  rarely  follows  the  epileptic  fit,  is  usually  hemiplegic  and 
transient.  Slight  disturbances  of  speech  also  may  occur;  in  some  instances, 
forms  of  sensory  aphasia. 

The  attacks  may  occur  at  night,  and  a  person  may  be  epileptic  for  years 
without  knowing  it.  As  Trousseau  truly  remarks,  when  a  person  tells  us  that 
in  the  night  he  has  incontinence  of  urine  and  awakes  in  the  morning  with 
headache  and  mental  confusion,  and  complains  of  difficulty  in  speech  owing  to 
the  fact  that  he  has  bitten  his  tongue,  if  also  there  are  purpuric  spots  on  the 
skin  of  the  face  and  neck,  the  probability  is  very  strong  indeed  that  he  is 
subject  to  nocturnal  epilepsy. 

(2)  Petit  Mal. — This  is  epilepsy  without  the  convulsions.  The  attack 
consists  of  transient  unconsciousness,  which  may  come  on  at  any  time,  accom- 
panied or  unaccompanied  by  a  feeling  of  faintness  and  vertigo.  Suddenly,  for 
example,  at  the  dinner  table,  the  subject  stops  talking  and  eating,  the  eyes 
become  fixed,  and  the  face  slightly  pale.  Anything  which  may  have  been  in 
the  hand  is  usually  dropped.  In  a  moment  or  two  consciousness  is  regained 
and  the  patient  resumes  conversation  as  if  nothing  had  happened.  In  other 
instances  there  is  slight  ineoherency  or  the  patient  performs  some  almost 
automatic  action.  He  may  begin  to  undress  himself  and  on  returning  to  con- 
sciousness find  that  he  has  partially  disrobed.  He  may  rub  his  beard  or  face, 
or  may  spit  about  in  a  careless  way.  In  other  attacks  the  patient  may  fall 
without  convulsive  seizures.  A  definite  aura  is  rare.  Though  transient,  un- 
consciousness and  giddiness  are  the  most  constant  manifestations  of  petit  mal; 
there  are  many  other  equivalent  manifestations,  such  as  sudden  jerkings  in  the 
limbs,  sudden  tremor,  or  a  sudden  visual  sensation.  Gowers  mentions  no  less 
than  seventeen  different  manifestations  of  petit  mal.  Occasionally  there  are 
cases  in  which  the  patient  has  a  sensation  of  losing  his  breath  and  may  even 
get  red  in  the  face.    I  have  seen  such  attacks  also  in  children. 

After  the  attack  the  patient  may  be  dazed  for  a  few  seconds  and  perform 
certain  automatic  actions,  which  may  seem  to  be  volitional.  As  mentioned, 
undressing  is  a  common  action,  but  all  sorts  of  odd  actions  may  be  performed, 
some  of  which  are  awkward  or  even  serious.  One  of  my  patients  after  an 
attack  was  in  the  habit  of  tearing  anything  he  could  lay  hands  on,  particularly 
books.  Violent  actions  have  been  committed  and  assaults  made,  frequently 
giving  rise  to  questions  which  come  before  the  courts.  This  condition  has  been 
termed  masked  epilepsy,  or  epilepsia  larvata. 


GENERAL  AND  FUNCTIONAL  DISEASES.  1063 

In  a  majority  of  the  cases  of  petit  mal  convulsions  finally  occur,  at  first 
slight,  but  ultimately  the  grand  mal  becomes  well  developed,  and  the  attacks 
may  then  alternate. 

(3)  Jacksonian  Epilepsy. — This  is  also  known  as  cortical,  symptomatic, 
or  partial  epilepsy.  It  is  distinguished  from  the  ordinary  epilepsy  by  the 
important  fact  that  consciousness  is  retained  or  is  lost  late.  The  attacks  are 
usually  the  result  of  irritative  lesions  in  the  motor  zone,  though  there  are 
probably  also  sensory  equivalents  of  this  motor  form.  In  a  typical  attack  the 
spasm  begins  in  a  limited  muscle  group  of  the  face,  arm,  or  leg.  The  zygomatic 
muscles,  for  instance,  or  the  thumb  may  twitch,  or  the  toes  may  first  be  moved. 
Prior  to  the  twitching  the  patient  may  feel  a  sensation  of  numbness  or  tingling 
in  the  part  affected.  The  spasm  extends  and  may  involve  the  muscles  of  one 
limb  only  or  of  the  face.  The  patient  is  conscious  throughout  and  watches, 
often  with  interest,  the  march  of  the  spasm. 

The  onset  may  be  slow,  and,  as  in  a  case  which  I  have  reported,  there  may 
be  time  for  the  patient  to  place  a  pillow  on  the  floor,  so  as  to  be  as  com- 
fortable as  possible  during  the  attack.  The  spasms  may  be  localized  for  years, 
but  there  is  a  great  risk  that  the  partial  epilepsy  may  become  general.  The 
condition  is  due,  as  a  rule,  to  an  irritative  lesion  in  the  motor  zone.  Thus  of 
107  cases  analyzed  by  Eoland,  there  were  48  of  tumor,  21  instances  of  inflam- 
matory softening,  14  instances  of  acute  and  chronic  meningitis,  and  8  cases 
of  trauma.  The  remaining  instances  were  due  to  haemorrhage  or  abscess,  or 
were  associated  with,  sclerosis  cerebri.  Two  other  conditions  may  be  mentioned, 
which  may  cause  typical  Jacksonian  epilepsy — namely,  uraemia  and  progressive 
paralysis  of  the  insane.  A  considerable  number  of  the  cases  of  Jacksonian 
epilepsy  are  found  in  children  following  hemiplegia,  the  so-called  post-hemi- 
plegic  epilepsy.  The  convulsions  usually  begin  on  the  aifected  side,  either  in 
the  arm  or  leg,  and  the  fit  may  be  unilateral  and  without  loss  of  consciousness. 
Ultimately  they  become  more  severe  and  general. 

Diagnosis. — In  major  epilepsy  the  suddenness  of  the  attack,  the  abrupt  loss 
of  consciousness,  the  order  of  the  tonic  and  clonic  spasm,  and  the  relaxation 
of  the  sphincters  at  the  height  of  the  attack  are  distinctive  features.  The 
convulsive  seizures  due  to  uraemia  are  epileptic  in  character  and  usually  readily 
recognized  by  the  existence  of  greatly  increased  tension  and  the  condition  of 
the  urine.  Practically  in  young  adults  hysteria  causes  the  greatest  difficulty, 
and  may  closely  simulate  true  epilepsy.  The  table  on  page  1064,  from  Gowers' 
work,  draws  clearly  the  chief  differences  between  them. 

Recurring  epileptic  seizures  in  a  person  over  thirty  who  has  not  had  pre- 
vious attacks  is  always  suggestive  of  organic  disease.  According  to  H.  C. 
Wood,  whose  opinion  is  supported  by  that  of  Fournier,  in  9  cases  out  of  10 
the  condition  is  due  to  syphilis. 

Petit  mal  must  be  distinguished  from  attacks  of  syncope,  and  the  vertigo 
of  Meniere's  disease,  of  a  cardiac  lesion,  and  of  indigestion.  In  these  cases 
there  is  no  actual  loss  of  consciousness,  which  forms  a  characteristic  though  not 
an  invariable  feature  of  petit  mal. 

JacTcsonian  epilepsy  has  features  so  distinctive  and  peculiar  that  it  is  at 
once  recognized.  It  is,  however,  by  no  means  easy  always  to  determine  upon 
what  the  spasm  depends.  Irritation  in  the  motor  centres  may  be  due  to  a  great 
variety  of  causes,  among  which  tumors  and  localized  meningo-encephalitis  are 


1064 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


the  most  frequent;  but  it  must  not  be  forgotten  that  in  uraemia  localized 
epilepsy  may  occur.  The  most  typical  Jacksonian  spasms  also  are  not  infre- 
quent in  general  paresis  of  the  insane. 


Epileptic. 


Hystkroid. 


Apparent  cause  . . . 
Warning 

Onset 

Scream 

Convulsion 

Biting 

Micturition 

Defecation 

Talking 

Duration 

Restraint  necessary 
Termination 


none. 

any,  but  especially  unilateral 
or  epigastric  aurse. 

always  sudden. 

at  onset. 

rigidity  followed  by  "jerk- 
ing," rarely  rigidity  alone. 

tongue. 

frequent. 

occasional, 

never. 

a  few  minutes. 

to  prevent  accident, 
spontaneous. 


emotion. 

palpitation,  malaise,  choking,  bi- 
lateral foot  aura. 

often  gradual. 

during  course. 

rigidity  or  "  struggling,"  throwing 
about  of  limbs  or  head,  arching 
of  back. 

lips,  hands,  or  other  people  and 
things. 

never. 

never. 

frequent. 

more  than  ten  minutes,  often 
much  longer. 

to  control  violence. 

spontaneous  or  induced  (water, 
etc.). 


Prognosis. — This  may  be  given  to-day  in  the  words  of  Hippocrates :  "  The 
prognosis  in  epilepsy  is  unfavorable  when  the  disease  is  congenital,  and  when 
it  endures  to  manhood,  and  when  it  occurs  in  a  grown  person  without  any 
previous  cause.  .  .  .  The  cure  may  be  attempted  in  young  persons,  but  not 
in  old."  W.  A.  Turner  concludes  from  recent  studies  that  of  cases  beginning 
under  ten  years  few  are  arrested,  whereas  of  those  beginning  at  puberty  the 
opposite  is  true.  Cases  beginning  between  the  twentieth  and  thirty-fifth  years 
give  few  arrests.    After  thirty-five  the  outlook  is  good. 

Death  during  the  fit  rarely  occurs,  but  it  may  happen  if  the  patient  falls 
into  the  water  or  if  the  fit  comes  on  while  he  is  eating.  Occasionally  the  fits 
seem  to  stop  spontaneously.  This  is  particularly  the  case  in  the  epilepsy  in 
children  which  has  followed  the  convulsions  of  teething  or  of  the  fevers.  Fre- 
quency of  the  attacks  and  marked  mental  disturbance  are  unfavorable  indi- 
cations. Hereditary  predisposition  is  apparently  of  no  moment  in  the  prog- 
nosis. The  outlook  is  better  in  males  than  in  females.  The  post-hemiplegic 
epilepsy  is  rarely  arrested.  Of  the  cases  coming  on  in  adults,  those  due  to 
syphilis  and  to  local  affections  of  the  brain  allow  a  more  favorable  prognosis. 

Treatment. — General. — In  the  case  of  children  the  parents  should  be 
made  to  understand  from  the  outset  that  epilepsy  in  the  great  majority  of 
cases  is  an  incurable  affection,  so  that  the  disease  may  interfere  as  little  as 
possible  with  the  education  of  the  child.  The  subjects  need  firm  but  kind 
treatment.  Indulgence  and  yielding  to  caprices  and  whims  are  followed  by 
weakening  of  the  moral  control,  which  is  so  necessajy  in  these  cases.  The 
disease  does  not  incapacitate  a  person  for  all  occupation.  It  is  much  better 
for  epileptics  to  have  some  definite  pursuit.  There  are  many  instances  in 
which  they  have  been  persons  of  extraordinary  mental  and  bodily  vigor,  as, 
for  example,  Julius  Csesar  and  Napoleon.  One  of  the  most  distressing  features 
in  epilepsy  is  the  gradual  mental  impairment  which  follows  in  a  certain  num- 
ber of  cases.     If  such  patients  become  extremely  irritable  or  show  signs  of 


GENERAL  AND  FUNCTIONAL  DISEASES.  1065 

violence  they  should  be  placed  under  supervision  in  an  asylum.  Marriage 
should  be  forbidden  to  epileptics.  During  the  attack  a  cork  or  bit  of  rubber 
should  be  placed  between  the  teeth  and  the  clothes  should  be  loosened.  The 
patient  should  be  in  the  recumbent  posture.  As  the  attack  usually  passes  off 
with  rapidity,  no  special  treatment  is  necessary,  but  in  cases  in  which  the 
convulsion  is  prolonged  a  few  whiffs  of  chloroform  or  nitrite  of  amyl  or  a 
hypodermic  of  a  quarter  of  a  grain  of  morphia  may  be  given. 

Dietetic. — The  old  authors  laid  great  stress  upon  regimen  in  epilepsy. 
The  important  point  is  to  give  the  patient  a  light  diet  at  fixed  hours,  and 
on  no  account  to  permit  overloading  of  the  stomach.  Meat  should  not  be 
given  more  than  once  a  day.  There  are  cases  in  which  animal  food  seems 
injurious.  A  strict  vegetable  diet  has  been  warmly  recommended.  The  patient 
should  not  go  to  sleep  until  the  completion  of  gastric  digestion. 

Medicinal. — The  bromides  are  the  only  remedies  which  have  a  special 
influence  upon  the  disease.  Either  the  sodium  or  potassium  salt  may  be  given. 
Sodium  bromide  is  probably  less  irritating  and  is  better  borne  for  a  long  period. 
It  may  be  given  in  milk,  in  which  it  is  scarcely  tasted.  In  all  instances  the 
dilution  should  be  considerable.  In  adults  it  is  well  taken  in  soda  water  or  in 
some  mineral  water.  The  dose  for  an  adult  should  be  from  half  a  drachm 
to  a  drachm  and  a  half  daily.  As  Seguin  recommends,  it  is  often  best  to  give 
but  a  single  dose  daily,  about  four  to  six  hours  before  the  attacks  are  most 
likely  to  occur.  For  instance,  in  the  case  of  nocturnal  epilepsy  a  drachm 
should  be  given  an  hour  or  two  after  the  evening  meal.  If  the  attack  occurs 
early  in  the  morning,  the  patient  should  take  a  full  dose  when  he  awakes. 
When  given  three  times  a  day  it  is  less  disturbing  after  meals.  Each  case 
should  be  carefully  studied  to  determine  how  much  bromide  should  be  used. 
The  individual  susceptibility  varies  and  some  patients  require  more  than  others. 
Fortunately,  children  take  the  drug  well  and  stand  proportionately  larger  doses 
than  adults.  Saturation  is  indicated  by  certain  unpleasant  effects,  particu- 
larly drowsiness,  mental  torpor,  and  gastric  and  cardiac  distress.  Loss  of 
palate  reflex  is  one  of  the  earliest  indications  that  the  system  is  under  the 
influence  of  the  bromides,  and  is  a  condition  which  should  be  attained.  A 
very  unpleasant  feature  is  the  development  of  acne,  which,  however,  is  no  indi- 
cation of  bromism.  Seguin  states  that  the  tendency  to  this  is  much  dimin- 
ished by  giving  the  drug  largely  diluted  in  alkaline  waters  and  administering 
from  time  to  time  full  doses  of  arsenic.  To  be  effectual  the  treatment  should 
be  continued  for  a  prolonged  period  and  the  cases  should  be  incessantly  watched 
in  order  to  prevent  bromism.  The  medicine  should  be  continued  for  at  least 
two  years  after  the  cessation  of  the  fits;  indeed,  Seguin  recommends  that  the 
reduction  of  the  bromides  should  not  be  begun  until  the  patient  has  been 
three  years  without  any  manifestations.  Written  directions  should  be  given 
to  the  mother  or  to  the  friends  of  the  patient,  and  he  should  not  himself  be 
held  responsible  for  the  administration  of  the  medicine.  A  book  should  be 
provided  in  which  the  daily  number  of  attacks  and  the  amount  of  medicine 
taken  should  be  noted.  The  addition  of  belladonna  to  the  bromide  is  warmly 
recommended  by  Black,  of  Glasgow.  In  very  obstinate  cases  Fleehsig  uses 
opium,  5  or  6  grains,  in  three  doses  daily ;  then  at  the  end  of  six  weeks  opium 
is  stopped  and  the  bromides  in  large  amounts,  75  to  100  grains  daily,  are  used 
for  two  months. 
G9 


1066  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Among  other  remedies  which  have  been  recommended  as  controlling  epi- 
lepsj  are  chloral,  cannabis  indica,  zinc,  nitroglycerin,  and  borax.  Nitrogly- 
cerin is  sometimes  advantageous  in  petit  mal,  but  is  not  of  much  service  in 
the  major  form.  To  be  beneficial  it  must  be  given  in  full  doses,  from  2  to  5 
minims  of  the  1-per-cent  solution,  and  increased  until  the  physiological  effects 
are  produced.  Counter- irritation  is  rarely  advisable.  When  the  aura  is  very 
definite  and  constant  in  its  onset,  as  from  the  hand  or  from  the  toe,  a  blister 
about  the  part  or  a  ligature  tightly  applied  may  stop  the  oncoming  fit.  In 
children,  care  should  be  taken  that  there  is  no  source  of  peripheral  irritation. 
In  boys,  adherent  prepuce  may  occasionally  be  the  cause.  The  irritation  of 
teething,  the  presence  of  worms,  and  foreign  bodies  in  the  ears  or  nose  have 
been  associated  with  epileptic  seizures. 

The  subjects  of  a  chronic  and,  in  most  cases,  a  hopelessly  incurable  disease, 
epileptic  patients  form  no  small  portion  of  the  unfortunate  victims  of  charla- 
tans and  quacks,  who  prescribe  to-day,  as  in  the  time  of  the  father  of  medicine, 
"  purifications  and  spells  and  other  illiberal  practices  of  like  kind." 

Surgical. — In  Jacksonian  epilepsy  the  propriety  of  surgical  interference 
is  universally  granted.  It  is  questionable,  however,  whether  in  the  epilepsy 
following  hemiplegia,  considering  the  anatomical  condition,  it  is  likely  to  be 
of  any  benefit.  In  idiopathic  epilepsy,  when  the  fit  starts  in  a  certain  region 
— ^the  thumb,  for  instance — and  the  signal  symptom  is  invariable,  the  centre 
controlling  this  part  may  be  removed.  This  procedure  has  been  practised  by 
Macewen,  Horsley,  Keen,  and  others,  but  time  alone  can  determine  its  value. 
The  traumatic  epilepsy,  in  which  the  fit  follows  fracture,  is  much  more  hopeful. 

The  operation,  per  se,  appears  in  some  cases  to  have  a  curative  effect.  Thus 
of  50  cases  of  trephining  for  epilepsy  in  which  nothing  abnormal  was  found  to 
account  for  the  symptoms,  25  were  reported  as  cured  and  18  as  improved.  The 
operations  have  not  been  always  on  the  skull,  and  White  has  collected  an  inter- 
esting series  in  which  various  surgical  procedures  have  been  resorted  to,  often 
with  curative  effect,  such  as  ligation  of  the  carotid  artery,  castration,  tracheot- 
omy, excision  of  the  superior  cervical  ganglia,  incision  of  the  scalp,  circum- 
cision, etc. 

The  feasibility  of  State  colonization  of  epileptics  on  a  self-supporting  basis 
has  been  demonstrated  by  the  success  of  the  Craig  Colony  at  Sonyea,  New 
York. 

VII.    MIGRAINE  (Hemicrania ;  Sick  Headache). 

Definition. — A  paroxysmal  affection  characterized  by  severe  headache,  usu- 
ally unilateral,  and  often  associated  with  disorders  of  vision. 

Etiology. — The  disease  is  frequently  hereditary  and  has  occurred  through 
several  generations.  Women  and  the  members  of  neurotic  families  are  most 
frequently  attacked.  It  is  an  affection  from  which  many  distinguished  men 
have  suffered  and  have  left  on  record  an  account  of  the  disease,  notably  the 
astronomer  Airy.  Edward  Liveing's  work  is  the  standard  authority  upon 
which  most  of  the  subsequent  articles  have  been  based.  A  gouty  or  rheumatic 
taint  is  present  in  many  instances.  Sinkler  has  called  special  attention  to  the 
frequency  of  reflex  causes.  Migraine  has  long  been  known  to  be  associated  with 
uterine  and  menstrual  disorders.     Nutritive  disturbances  are  common,  and 


GENERAL  AND  FUNCTIONAL  DISEASES.  1067 

attempts  have  been  made  by  Haig  and  others  to  associate  the  attacks  with 
disturbed  uric-acid  output.  Certainly  the  amount  of  uric  acid  excreted  just 
prior  to  and  during  an  attack  is  reduced.  Others  regard  the  disease  as  a 
toxaemia  from  disordered  intestinal  digestion.  Many  of  the  headaches  from 
eye-strain  are  of  the  hemicranial  type;  but  it  is  impossible  to  regard  this, 
as  Gould  and  others  would  do,  as  the  sole  factor.  Cases  have  been  described 
in  connection  with  adenoid  growths  in  the  pharynx,  and  particularly  with 
abnormal  conditions  of  the  nose.  Many  of  the  attacks  of  severe  headaches 
in  children  are  of  this  nature,  and  the  eyes  and  nostrils  should  be  exam- 
ined with  great  care.  Sinkler  refers  to  a  case  in  a  child  of  two  years,  and 
Gowers  states  that  a  third  of  all  the  cases  begin  between  the  fifth  and  tenth 
years  of  age.  The  direct  influences  inducing  the  attack  are  very  varied. 
Powerful  emotions  of  all  sorts  are  the  most  potent.  Mental  or  bodily  fatigue, 
digestive  disturbances,  or  the  eating  of  some  particular  article  of  food  may  be 
followed  by  the  headache.  The  paroxysmal  character  is  one  of  the  most 
striking  features,  and  the  attacks  may  recur  on  the  same  day  every  week, 
every  fortnight,  or  every  month.  Headaches  of  the  migraine  type  may  recur 
for  years  in  connection  with  chronic  Bright's  disease. 

Symptoms. — Premonitory  signs  are  present  in  many  cases,  and  the  patient 
can  tell  when  an  attack  is  coming  on.  Eemarkable  prodromata  have  been 
described,  particularly  in  connection  with  vision.  Apparitions  may  appear — 
visions  of  animals,  such  as  mice,  dogs,  etc.  Transient  hemianopia  or  scotoma 
may  be  present.  In  other  instances  there  is  spasmodic  action  of  the  pupil  on 
the  affected  side,  which  dilates  and  contracts  alternately,  the  condition  known 
as  liippus.  Frequently  the  disturbance  of  vision  is  only  a  blurring,  or  there 
are  balls  of  light,  or  zigzag  lines,  or  the  so-called  fortification  spectra  (teichop- 
sia),  which  may  be  illuminated  with  gorgeous  colors.  Disturbances  of  the 
other  senses  are  rare.  Numbness  of  the  tongue  and  face  and  occasionally  of 
the  hand  may  occur  with  tingling.  More  rarely  there  are  cramps  or  spasms 
in  the  muscles  of  the  affected  side.  Transient  aphasia  has  also  been  noted. 
Some  patients  show  marked  psychical  disturbance,  either  excitement  or,  more 
commonly,  mental  confusion  or  great  depression.  Dizziness  occurs  in  some 
cases.  The  headache  follows  a  short  time  after  the  prodromal  symptoms  have 
appeared.  It  is  cumulative  and  expansile  in  character,  beginning  as  a  localized 
small  spot,  which  is  generally  constant  either  on  the  temple  or  forehead  or  in 
the  eyeball.  It  is  usually  described  as  of  a  penetrating,  sharp,  boring  charac- 
ter. The  pain  gradually  spreads  and  involves  the  entire  side  of  the  head, 
sometimes  the  neck,  and  may  pass  into  the  arm.  In  some  cases  both  sides 
are  afi^ected.  ISTausea  and  vomiting  are  common  symptoms.  If  the  attack 
comes  on  when  the  stomach  is  full,  vomiting  usually  gives  relief.  'Vasomotor 
symptoms  may  be  present.  The  face,  for  instance,  may  be  pale,  and  there  may 
be  a  marked  difference  between  the  two  sides.  Subsequently  the  face  and  ear 
on  the  affected  side  may  become  a  burning  red  from  the  vaso-dilator  influences. 
The  pulse  may  be  slow.  The  temporal  artery  on  the  affected  side  may  be  firm 
and  hard,  and  in  a  condition  of  arterio-sclerosis — a  fact  which  has  been  con- 
firmed anatomically  by  Thoma.  Few  affections  are  more  prostrating  than 
migraine,  and  during  the  paroxysm  the  patient  may  scarcely  be  able  to  raise 
the  head  from  the  pillow.    The  slightest  noise  or  light  aggravates  the  condition. 

The  duration  of  the  entire  attack  is  variable.    The  severer  forms  usually 


1068  DISEASES  OF   THE  NERVOUS  SYSTEM. 

incapacitate  the  patient  for  at  least  three  days.  In  other  instances  the  entire 
attack  is  over  in  a  day.  The  disease  recurs  for  years,  and  in  cases  with  a 
marked  hereditary  tendency  may  persist  throughout  life.  In  women  the 
attacks  often  cease  after  the  climacteric,  and  in  men  after  the  age  of  fifty. 
Two  of  the  greatest  sufferers  I  have  known,  who  had  recurring  attacks  every 
few  weeks  from  early  boyhood,  now  have  complete  freedom. 

The  nature  of  the  disease  is  unknown.  Liveing's  view,  that  it  is  a  nerve 
storm  or  form  of  periodic  discharge  from  certain  sensory  centres,  and  is  related 
to  epilepsy,  has  found  much  favor.  According  to  this  view,  it  is  the  sensory 
equivalent  of  a  true  epileptic  attack.  Mollendorf,  Latham,  and  others  regard 
it  as  a  vaso-motor  neurosis,  and  hold  that  the  early  symptoms  are  due  to  vaso- 
constrictor and  the  later  symptoms  to  vaso-dilator  influences.  The  fact  of  the 
development  of  arterio-sclerosis  in  the  arteries  of  the  afi^ected  side  is  a  point 
of  interest  hearing  upon  this  view. 

Treatment. — The  patient  is  fully  aware  of  the  causes  which  precipitate  an 
attack.  Avoidance  of  excitement,  regularity  in  the  meals,  and  moderation  in 
diet  are  important  rules.  I  have  known  cases  greatly  benefited  by  a  strict 
vegetable  diet.  The  treatment  should  be  directed  toward  the  removal  of  the 
conditions  upon  which  the  attacks  depend.  In  children  much  may  be  done 
by  watchfulness  and  care  on  the  part  of  the  mother  in  regulating  the  bowels 
and  watching  the  diet  of  the  child.  Errors  of  refraction  should  be  adjusted. 
On  no  account  should  such  children  be  allowed  to  compete  in  school  for  prizes. 
A  prolonged  course  of  bromides  sometimes  proves  successful.  If  anemia  is 
present,  iron  and  arsenic  should  be  given.  When  the  arterial  tension  is  in- 
creased a  course  of  nitroglycerin  may  be  tried.  Not  too  much,  however,  should 
be  expected  of  the  preventive  treatment  of  migraine.  In  a  very  large  proportion 
of  the  cases  the  headaches  recur  in  spite  of  all  we  (including  the  refractionists) 
can  do,  Herter  advises,  so  soon  as  the  patient  has  any  intimation  of  the  attack, 
to  wash  out  the  stomach  with  water  at  105°,  and  to  give  a  brisk  saline  cathartic. 
During  the  paroxysm  the  patient  should  be  kept  in  bed  and  absolutely  quiet. 
If  the  patient  feels  faint  and  nauseated,  a  small  cup  of  hot,  strong  coffee  or  30 
drops  of  chloroform  give  relief.  Cannabis  indica  is. probably  the  most  satis- 
factory remedy.  Seguin  recommends  a  prolonged  course  of  the  drug.  Anti- 
pyrin,  antifebrin,  and  phenacetin  have  been  much  used  of  late.  When  given 
early,  at  the  very  outset  of  the  paroxysm,  they  are  sometimes  effective.  Small, 
repeated  doses  are  more  satisfactory.  Of  other  remedies,  caffeine,  in  5-grain 
doses  of  the  citrate,  nux  vomica,  and  ergot  have  been  recommended.  Elec- 
tricity does  not  appear  to  be  of  much  service.  And  lastly,  in  obstinate  cases, 
an  ordinary  tape  seton  may  be  inserted  through  the  skin  at  the  back  of  the 
neck,  to  be  worn  for  three  months,  a  plan  of  treatment  which  has  the  strongest 
possible  recommendation  from  Mr.  Whitehead,  of  Manchester. 

VIII.    NEURALGIA. 

Definition. — A  painful  affection  of  the  nerves,  due  either  to  functional 
disturbance  of  their  central  or  peripheral  extremities  or  to  neuritis  in  their 
course. 

Etiology. — Members  of  neuropathic  families  are  most  subject  to  the  disease. 
It  affects  women  more  than  men.    Children  are  rarely  attacked.    Of  all  causes^ 


GENERAL  AND  FUNCTIONAL  DISEASES.  1069 

debility  is  the  most  frequent.  It  is  often  the  first  indication  of  an  enfeebled 
nervous  system.  The  various  forms  of  anaemia  are  frequently  associated  with 
neuralgia.  It  may  be  a  prominent  feature  at  the  onset  of  certain  acute  dis- 
eases, particularly  typhoid  fever.  Malaria  has  been  thought  to  be  a  potent 
cause  (0.  W.  Holmes'  Boylston  Essay),  but  it  has  not  been  shown  that  neural- 
gia is  more  frequent  in  malarial  districts,  and  the  error  has  probably  arisen 
from  regarding  periodicity  as  a  special  manifestation  of  paludism.  It  occa- 
sionally occurs  in  malarial  cachexia.  Exposure  to  cold  is  a  cause  in  very 
susceptible  persons.  Eeflex  irritation,  particularly  from  carious  teeth,  and 
disease  of  the  antrum  and  frontal  sinuses,  are  common  causes  of  neuralgia  of 
the  fifth  nerve.  The  disease  occurs  sometimes  in  rheumatism,  gout,  lead  poi- 
soning, and  diabetes.  Persistent  neuralgia  may  be  a  feature  of  latent  Blight's 
disease. 

Symptoms. — Before  the  onset  of  the  pain  there  may  be  uneasy  sensations, 
sometimes  tingling  in  the  part  which  will  be  affected.  The  pain  is  localized 
to  a  certain  group  or  division  of  nerves,  usually  affecting  one  side.  The  pain 
is  not  constant,  but  paroxysmal,  and  is  described  as  stabbing,  burning,  or 
darting  in  character.  The  skin  may  be  exquisitely  tender  in  the  affected 
region,  particularly  over  certain  points  along  the  course  of  the  nerve,  the 
so-called  tender  points.  Movements,  as  a  rule,  are  painful.  Trophic  and 
vaso-motor  changes  may  accompany  the  paroxysm;  the  skin  may  be  cool,  and 
subsequently  hot  and  burning;  occasionally  local  oedema  or  erythema  occurs. 
More  remarkable  still  are  the  changes  in  the  hair,  which  may  become  blanched 
(canities),  or  even  fall  out.  Fortunately,  such  alterations  are  rare.  Twitch- 
ings  of  the  muscles,  or  even  spasms,  may  be  present  during  the  paroxysm. 
After  lasting  a  variable  time — from  a  few  minutes  to  many  hours — the  attack 
subsides.  Kecurrence  may  be  at  definite  intervals — every  day  at  the  same  hour, 
or  at  intervals  of  two,  three,  or  even  seven  days.  Occasionally  the  paroxysms 
develop  only  at  the  catamenia.  This  periodicity  is  quite  as  marked  in  non- 
malarial  as  in  malarial  regions. 

Clinical  Vakieties,  Depending  on  the  Nerve  Eoots  Aeeected. 

(1)  Trigeminal  Neuralgia;  Tic  Douloureux. — A  distinction  must  be  drawn 
between  the  minor  and  major  neuralgias  of  the  fifth  cranial  nerve.  The  former 
may  merely  be  symptomatic  of  the  involvement  of  one  or  another  of  its  periph- 
eral branches  in  some  disease  process — the  pressure  of  a  tumor,  carious  teeth, 
or  a  neuritis  due  to  the  proximity  of  suppurative  processes  in  the  bony  sinuses, 
etc.  There  may  be  referred  neuralgic  pains  in  this  area  from  morbid  processes 
within  the  cranium,  or  from  visceral  disease  elsewhere.  A  painful  neuralgia 
may  follow  an  attack  of  zoster  in  any  division  of  the  fifth  nerve. 

The  typical  tic  douloureux,  epileptiform  neuralgia,  or  "  neuralgia  quinti 
major/'  as  it  has  been  called  by  Henry  Head,  whose  article  in  Allbutt's  System 
should  be  consulted,  is  probably  a  primary  affection  of  the  nerve.  The  disease 
starts  in  middle  life,  without  obvious  cause,  as  a  simple  neuralgia  in  one  of 
the  trigeminal  branches,  and  from  a  particular  spot  the  pain  radiates  through 
the  course  of  one  of  the  nerves.  The  pain  is  of  sudden  onset,  violent  and 
paroxysmal  in  character.  There  are  periods  of  remission,  which  at  first  may 
extend  over  several  months,  and  in  which  the  paroxysms  do  not  occur,  but 


1070  DISEASES  OF  THE  NERVOUS  SYSTEM. 

these  intervals  of  release  shorten  after  each  successive  attack.  The  attacks 
themselves  are  of  ever  increasing  severity  and  longer  duration.  The  paiu 
finally  invades  the  territory  of  adjoining  nerves  and  ultimately,  after  years, 
may  extend  over  the  entire  trigeminal  distribution.  Though  by  sympathy  there 
may  be  pain  outside  of  the  fifth  nerve  area,  particularly  in  the  occipital  region, 
in  true  tic  douloureux,  the  pain  remains  limited  to  the  distribution  of  one 
trigeminal  nerve,  and  probably  never  becomes  bilateral.  In  advanced  cases 
the  paroxysms  follow  one  another  rapidly  and  without  assignable  cause,  and  in 
the  intervals  the  patient  may  never  be  quite  free  from  pain.  They  are  inaug- 
urated by  almost  any  form  of  external  stimulus,  by  a  draught  of  air,  by  move- 
ment of  the  facial  muscles  or  of  the  tongue  in  speaking,  by  touching  the  skin, 
particularly  over  those  points  from  which  the  pain  seems  to  take  its  origin, 
by  the  act  of  swallowing,  especially  when  the  pain  involves  the  mucous  mem- 
brane field  of  distribution  of  the  nerve.  It  is  not  a  self-limited  disease.  In 
some  instances  the  neuralgia  reaches  such  a  frightful  intensity  that  it  renders 
the  patient's  life  insupportable.  In  former  years  suicide  was  not  an  uncom- 
mon consequence. 

Xo  anatomical  lesion  that  may  be  considered  peculiar  to  the  disease  has 
been  described. 

In  the  more  severe  cases  medicinal  forms  of  treatment  are  unavailing. 
Surgical  measures  must  be  resorted  to,  and  peripheral  operations  on  the  nerves 
most  affected  often  give  complete,  though  only  temporary,  relief.  Extirpation 
of  the  Gasserian  ganglion,  as  first  proposed  by  Krause  and  Hartley,  must  be 
contemplated.  Complete  restoration  to  health  and  permanent  freedom  from 
pain  seem  always  to  follow  its  complete  removal. 

(3)  Cervico-occipital  neuralgia  involves  the  posterior  branches  of  the  first 
four  cervical  nerves,  particularly  the  inferior  occipital,  at  the  emergence  of 
which  there  is  a  painful  point  about  half-way  between  the  mastoid  process  and 
the  first  cervical  vertebra.  It  may  be  caused  by  cold,  and  these  nerves  are 
often  affected  in  cervical  caries.  Surgical  measures  may  be  required  if  the  pain 
is  severe.  Krause  has  devised  an  operation  for  division  and  evulsion  of  the 
affected  nerves. 

(3)  Cervico-brachial  neuralgia  involves  the  sensory  nerves  of  the  brachial 
plexus,  particularly  in  the  cubital  division.  When  the  circumflex  nerve  is  in- 
volved the  pain  is  in  the  deltoid.  The  pain  is  most  commonly  about  the 
shoulder  and  down  the  course  of  the  ulnar  nerve.  There  is  usually  a  marked 
tender  point  upon  this  nerve  at  the  elbow.  This  form  rarely  follows  cold, 
but  more  frequently  results  from  rheumatic  affections  of  the  joints,  and 
trauma, 

(4)  Neuralgia  of  the  phrenic  nerve  is  rare.  It  is  sometimes  found  in 
pleurisy  and  in  pericarditis.  The  pain  is  chiefly  at  the  lower  part  of  the 
thorax  on  a  line  with  the  iusertion  of  the  diaphragm,  and  here  may  be  painful 
points  on  deep  pressure.  Full  inspiration  is  painful,  and  there  is  great  sensi- 
tiveness on  coughing  or  in  the  performance  of  any  movement  by  which  the 
diaphragm  is  suddenly  depressed. 

(5)  Intercostal  Neuralgia. — Xext  to  the  tic  douloureux  this  is  the  most 
important  form.  It  is  most  frequent  in  women  and  very  common  in  hysteria. 
Post-zoster  neuralgias  are  common  in  this  situation.  The  possibility  of  spinal 
disease,  of  tumor,  caries,  or  aneurism  must  always  be  borne  in  mind. 


GENERAL  AND  FUNCTIONAL  DISEASES.  1071 

(6)  Lumbar  Neuralgia. — The  affected  nerves  are  the  posterior  fibres  of  the 
lumbar  plexus,  particularly  the  ilio-scrotal  branch.  The  pain  is  in  the  region 
of  the  iliac  crest,  along  the  inguinal  canal,  in  the  spermatic  cord,  and  in  the 
scrotum  or  labium  majus.  The  affection  known  as  irritable  testis,  probably  a 
neuralgia  of  this  nerve,  may  be  very  severe  and  accompanied  by  syncopal 
sensations. 

(7)  Coccydynia. — This  is  regarded  as  a  neuralgia  of  the  coccygeal  plexus. 
It  is  most  common  in  women,  and  is  aggravated  by  the  sitting  posture.  It 
is  very  intractable,  and  may  necessitate  the  removal  of  the  coccyx,  an  operation, 
however,  which  is  not  always  successful.  Neuralgias  of  the  nerves  of  the  leg 
have  already  been  considered. 

(8)  Neuralgias  of  the  Nerves  of  the  Feet. — ^Many  of  these  cases  accompany 
varying  degrees  of  flat-foot.  The  condition  is  brought  about  by  weakness  or 
fatigue  of  the  muscles  supporting  the  arches  of  the  foot,  which  consequently 
settle  until  the  strain  of  the  superimposed  body-weight  falls  upon  the  liga- 
mentous and  aponeurotic  attachments  between  the  metatarsal  and  tarsal  bones. 
Eest,  massage,  exercises,  and  orthopaedic  measures  are  indicated. 

Painful  Heel. — Both  in  women  and  men  there  may  be  about  the  heel 
severe  pains  which  interfere  seriously  with  walking — the  pododynia  of  S.  D. 
Gross.  There  may  be  little  or  no  swelling,  no  discoloration,  and  no  affection 
of  the  joints. 

Plantar  Neuralgia. — This  is  often  associated  with  a  definite  neuritis, 
such  as  follows  typhoid  fever,  and  has  been  seen  in  an  aggravated  form  in 
caisson  disease  (Hughes).  The  pain  may  be  limited  to  the  tips  of  the  toes 
or  to  the  ball  of  the  great  toe.  Numbness,  tingling,  and  hypersesthesia  or 
sweating  may  occur  with  it.  Following  the  cold-bath  treatment  in  typhoid 
fever  it  is  not  uncommon  for  patients  to  complain  of  great  sensitiveness  in 
the  toes. 

Metatarsalgia. — Thomas  G-.  Morton's  "painful  affection  of  the  fourth 
metatarso-phalangeal  articulation  "  is  a  peculiar  and  very  trying  disorder,  seen 
most  frequently  in  women,  and  usually  in  one  foot.  Morton  regards  it  as  due 
to  a  pinching  of  the  metatarsal  nerve.  The  condition  usually  requires  oper- 
ation. The  red,  painful  neuralgia — erythromelalgia — is  described  under  the 
vaso-motor  and  trophic  disturbances. 

(9)  Visceral  Neuralgias. — The  more  important  of  these  have  already  been 
referred  to  in  connection  with  the  cardiac  and  the  gastric  neuroses.  They  are 
most  frequent  in  women,  and  are  constant  accompaniments  of  neurasthenia 
and  hysteria.  The  pains  are  most  common  in  the  pelvic  region,  particularly 
about  the  ovaries.  Nephralgia  is  of  great  interest,  for,  as  has  already  been 
mentioned,  the  symptoms  may  closely  simulate  those  of  stone. 

Treatment  of  Neuralgia. — In  general,  causes  of  reflex  irritation  should  be 
carefully  removed.  The  neuralgia,  as  a  rule,  recurs  unless  the  general  health 
improves ;  so  that  tonic  and  hygienic  measures  of  all  sorts  should  be  employed. 
Often  a  change  of  air  or  surroundings  will  relieve  a  severe  neuralgia.  I  have 
known  obstinate  cases  to  be  cured  by  a  prolonged  residence  in  the  mountains, 
with  an  out-of-door  life  and  plenty  of  exercise.  A  strict  vegetable  diet  will 
sometimes  relieve  the  neuralgia  or  headache  of  a  gouty  person.  Of  general 
remedies,  iron  is  often  a  specific  in  the  cases  associated  with  chlorosis  and 
anaemia.     Arsenic,  too,  is  very  beneficial  in  these  forms,  and  should  be  given 


1072  DISEASES  OF  THE  NERVOUS  SYSTEM. 

in  ascending  doses.  The  value  of  quinine  has  been  much  overrated.  It  prob- 
ably has  no  more  influence  than  any  other  bitter  tonic,  except  in  the  rare 
instances  in  which  the  neuralgia  is  definitely  associated  with  malarial  poison- 
ing. Strychnine,  cod-liver  oil,  and  phosphorus  are  also  advantageous.  Of 
remedies  for  the  pain,  antipyrin,  antifebrin,  and  phenacetin  should  first  be 
tried,  for  they  are  sometimes  of  service.  Morphia  should  be  given  with  great 
caution,  and  only  after  other  remedies  have  been  tried  in  vain.  On  no  con- 
sideration should  the  patient  be  allowed  to  use  the. hypodermic  syringe.  Gel- 
semium  is  highly  recommended.  Of  nerve  stimulants,  valerian  and  ether, 
which  often  act  well  together,  may  be  given.  Alcohol  is  a  valuable  though 
dangerous  remedy,  and  should  not  be  ordered  for  women.  In  the  minor  form 
of  trigeminal  neuralgia  nitroglycerin  in  large  doses  may  be  tried.  Dana  has 
seen  good  results  follow  rest  with  large  doses  of  strychnia  given  hypodermi- 
cally.  Aconitia  in  doses  of  from  one  two-hundredth  to  one  one-hundred-and- 
fiftieth  of  a  grain  may  be  tried.  In  gouty  and  rheumatic  subjects  cannabis 
indica  and  cimicifuga  are  recommended  with  the  lithium  salts. 

Of  local  applications,  the  thermo-cautery  is  invaluable,  particularly  in 
zona  and  the  more  chronic  forms  of  neuralgia.  Acupuncture  may  be  used. 
Chloroform  liniment,  camphor  and  chloral,  menthol,  the  oleates  of  morphia, 
atropia,  and  belladonna  used  with  lanolin  may  be  tried.  Freezing  over  the 
tender  point  with  ether  spray  is  sometimes  successful.  The  continuous  cur- 
rent may  be  used.  The  sponges  should  be  warm,  and  the  positive  pole  should 
be  placed  near  the  seat  of  the  pain.  The  strength  of  the  current  should  be 
such  as  to  cause  a  slight  tingling  or  burning,  but  not  pain. 

Many  of  the  more  intractable  forms  of  neuralgia  can  be  relieved  only  by 
surgical  treatment. 

IX.    PROFESSIONAL.    SPASMS;    OCCUPATION 
NEUROSES. 

The  continuous  and  excessive  use  of  the  muscles  in  performing  a  certain 
movement  may  be  followed  by  an  irregular,  involuntary  spasm  or  cramp,  which 
may  completely  check  the  performance  of  the  action.  The  condition  is  found 
most  frequently  in  writers,  hence  the  term  writer's  cramp  or  scrivener's  palsy; 
but  it  is  also  common  in  piano  and  violin  players  and  in  telegraph  operators. 
The  spasms  occur  in  many  other  persons,  such  as  milkmaids,  weavers,  and 
cigarette-rollers. 

The  most  common  form  is  writer's  cramp,  which  is  much  more  frequent 
in  men  than  in  women.  Of  75  cases  of  impaired  writing  power  reported  by 
Poore,  all  of  the  instances  of  undoubted  writer's  cramp  were  in  men.  Morris 
J.  Lewis  states  that  in  the  United  States,  in  the  telegrapher's  cramp,  women, 
who  are  employed  a  great  deal  in  telegraphy,  are  much  less  frequently  affected 
(only  4  out  of  43  cases).  Persons  of  a  nervous  temperament  are  more  liable 
to  the  disease.     Occasionally  it  follows  slight  injury, 

Gowers  states  that  in  a  majority  of  the  cases  a  faulty  method  of  writing 
has  been  employed,  using  either  the  little  finger  or  the  wrist  as  the  fixed  point. 
Persons  who  write  with  the  middle  of  the  forearm  or  the  elbow  as  the  fixed 
point  are  rarely  affected. 

ISTo  anatomical  changes  have  been  found.    The  most  reasonable  explanation 


GENERAL  AND  FUNCTIONAL  DLSEASES.  1073 

of  the  disease  is  that  it  results  from  a  deranged  action  of  the  nerve-centres 
presiding  over  the  muscular  movements  involved  in  the  act  of  writing,  a  con- 
dition which  has  been  termed  irritable  weakness.  "  The  education  of  centres 
which  may  be  widely  separated  from  each  other  for  the  performance  of  any 
delicate  movement  is  mainly  accomplished  by  lessening  the  lines  of  resistance 
between  them,  so  that  the  movement,  which  was  at  first  produced  by  a  con- 
siderable mental  effort,  is  at  last  executed  almost  unconsciously.  If,  there- 
fore, through  prolonged  excitation,  this  lessened  resistance  be  carried  too  far, 
there  is  an  increase  and  irregular  discharge  of  nerve  energy,  which  gives  rise 
to  spasm  and  disordered  movement.  According  to  this  view,  the  muscular 
weakness  is  explained  by  an  impairment  of  nutrition  accompanying  that  of 
function,  and  the  diminished  f aradic  excitability  by  the  nutritional  disturbance 
descending  the  motor  nerves "  (Gay). 

Symptoms. — These  may  be  described  under  five  heads  (Lewis). 

(a)  Cramp  or  Spasm. — This  is  often  an  early  symptom  and  most  com- 
monly affects  the  forefinger  and  thumb;  or  there  may  be  a  combined  move- 
ment of  flexion  and  adduction  of  the  thumb,  so  that  the  pen  may  be  twisted 
from  the  grasp  and  throvru  to  some  distance.  Weir  Mitchell  has  described 
a  lock-spasm,  in  which  the  fingers  become  so  firmly  contracted  upon  the  pen 
that  it  can  not  be  removed. 

(6)  Paresis  and  Paralysis. — This  may  occur  with  the  spasm  or  alone. 
The  patient  feels  a  sense  of  weakness  and  debility  in  the  muscles  of  the  hand 
and  arm  and  holds  the  pen  feebly.  Yet  in  these  circumstances  the  grasp  of 
the  hand  may  be  strong  and  there  may  be  no  paralysis  for  ordinary  acts. 

(c)  Tremor. — This  is  most  commonly  seen  in  the  forefinger  and  may  be 
a  premonitory  symptom  of  atrophy.  It  is  not  an  important  symptom,  and  is 
rarely  sufficient  to  produce  disability. 

(d)  Pain. — Abnormal  sensations,  particularly  a  tired  feeling  in  the  mus- 
cles, are  very  constantly  present.  Actual  pain  is  rare,  but  there  may  be  irregu- 
lar shooting  pains  in  the  arm.  Numbness  or  soreness  may  exist.  If,  as  some- 
times happens,  a  subacute  neuritis  develops,  there  may  be  pain  over  the  nerves 
and  numbness  or  tingling  in  the  fingers. 

(e)  Vaso-motor  Disturbances. — These  may  occur  in  severe  cases.  There 
may  be  hypersesthesia.  Occasionally  the  skin  becomes  glossy,  or  there  is  a 
condition  of  local  asphyxia  resembling  chilblains.  In  attempting  to  write,  the 
hand  and  arm  may  become  fiushed  and  hot  and  the  veins  increased  in  size. 
Early  in  the  disease  the  electrical  reactions  are  normal,  but  in  advanced  cases 
there  may  be  diminution  of  faradic  and  sometimes  increase  in  the  galvanic 
irritability. 

Diagnosis. — A  well-marked  case  of  writer's  cramp  or  palsy  could  scarcely 
be  mistaken  for  any  other  affection.  Care  must  be  taken  to  exclude  the  exist- 
ence of  any  cerebro-spinal  disease,  such  as  progressive  muscular  atrophy  or 
hemiplegia.  The  physician  is  sometimes  consulted  by  nervous  persons  who 
fancy  they  are  becoming  subject  to  the  disease  and  complain  of  stiffness  or 
weakness  without  displaying  any  characteristic  features. 

Prognosis. — The  course  of  the  disease  is  usually  chronic.  If  taken  in 
time  and  if  the  hand  is  allowed  perfect  rest,  the  condition  may  improve  rapidly, 
but  too  often  there  is  a  strong  tendency  to  recurrence.  The  patient  may  learn 
to  write  with  the  left  hand,  but  this  also  may  after  a  time  be  attacked. 


1074  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Treatment. — Various  prophylactic  measures  have  been  advised.  As  men- 
tioned, it  is  important  that  a  proper  method  of  writing  be  adopted.  Gowers 
suggests  that  if  all  persons  wrote  from  the  shoulder  ^vriter's  cramp  would 
practically  not  occur.  Various  devices  have  been  invented  for  relieving  the 
fatigue,  but  none  of  them  are  very  satisfactory.  The  use  of  the  type-writer 
has  diminished  very  much  the  frequency  of  scrivener's  palsy.  Rest  is  essential. 
'No  measures  are  of  value  without  this.  Massage  and  manipulation,  when 
combined  with  systematic  gymnastics,  give  the  best  results.  Poore  recommends 
the  galvanic  current  applied  to  the  muscles,  which  are  at  the  same  time  rhyth- 
mically exercised.  In  very  obstinate  cases  the  condition  remains  incurable. 
I  saw  a  few  years  ago  a  distinguished  gynaecologist  who  had  had  writer's 
cramp  twenty  years  before,  and  who  had  tried  all  sorts  of  treatment,  including 
Wolff's  method,  without  any  avail.  He  still  has  it  in  aggravated  form, 
but  he  can  do  all  the  finer  manipulations  of  operative  work  without  any 
difficulty. 

The  nutrition  of  the  patients  is  apt  to  be  much  impaired,  and  cod-liver  oil, 
strychnia,  and  other  tonics  will  be  found  advantageous.  Local  applications  are 
of  little  benefit.    Tenotomy  and  nerve-stretching  have  been  abandoned. 

X.     TETANY. 

Definition. — An  affection  characterized  by  peculiar  bilateral  tonic  spasms 
of  the  extremities,  either  paroxysmal  or  continued. 

Etiology. — The  disease  occurs  under  very  different  conditions,  of  which 
the  following  classification  of  Frankl-Hochwart  is  the  most  satisfactory: 

(a)  Tetany  of  Adults. — (1)  Epidemic  tetany,  also  known  as  rheumatic 
tetany,  idiopathic  workman's  tetany  or  shoemaker's  cramp.  In  certain  parts  of 
the  Continent  of  Europe  the  disease  has  prevailed  widely,  particularly  in  the 
winter  season.  Von  Jacksch,  who  has  described  an  epidemic  form  occurring 
in  young  men  of  the  working  classes,  sometimes  with  slight  fever,  regards  the 
disease  as  infectious.  This  form  is  acute,  lasting  only  two  or  three  weeks,  and 
rarely  proving  fatal. 

(2)  Tetany  of  gastric  and  intestinal  disorders,  as  dyspepsia,  gastrectasis, 
diarrhoea,  and  helminthiasis.  The  form  associated  with  dilatation  of  the  stom- 
ach is  rare,  not  more  than  30  cases  having  been  reported. 

(3)  Tetany  of  the  acute  infectious  diseases  (typhoid,  cholera,  influenza, 
measles,  scarlatina,  etc.).  In  some  typhoid  epidemics  many  cases  have  occurred. 

(4)  Tetany  following  poisoning  from  chloroform,  morphia,  ergot,  lead, 
alcohol,  and  uraemia.    Isolated  examples  of  each  have  been  reported. 

( 5 )  Tetany  may  also  develop  during  pregnancy  or  recur  in  successive  preg- 
nancies. From  its  occurrence  in  nursing  women.  Trousseau  called  it  "  nurse's 
contracture." 

(6)  Tetany  following  removal  of  the  thyroid  gland  is  probably  due  to  a 
removal  of  the  parathyroid  bodies  at  the  same  time.  Before  these  bodies  were 
known  to  have  any  physiological  function  it  was  supposed  that  the  removal  of 
the  thyroid  alone  might  produce  tetany,  and  many  post-operative  cases  of  this 
sort,  like  those  from  Billroth's  clinic,  have  been  recorded.  James  Stewart  has 
reported  an  instance  in  which  with  the  tetany  there  were  symptoms  of  myxoe- 
dema  and  no  trace  of  the  thyroid  gland. 


GENERAL  AND  FUNCTIONAL  DISEASES.  1075 

(7)  Tetany  may  complicate  other  nervous  disorders,  as  Basedow's  disease, 
cerebral  tumor,  cysts  of  the  cerebellum,  and  syringomyelia. 

(6)  Tetany  in  Children. — Tetany  bears  a  definite  relation  to  gastro- 
intestinal disorders,  acute  infections,  and  rickets  in  childhood. 

In  the  United  States  true  tetany  is  an  extremely  rare  disease.  Griffith,  in 
1895,  collected  77  cases,  among  which  cases  of  carpo-pedal  spasm  are  included. 
During  the  past  ten  years  an  additional  70  cases  have  appeared  in  American 
literature.  In  my  wards  at  the  Johns  Hopkins  Hospital  there  were  8  cases 
of  undoubted  tetany;  4  complicating  dilatation  of  the  stomach,  2  hyperacidity 
without  dilatation,  1  case  with  chronic  diarrhoea,  and  1  occurring  in  repeated 
pregnancies  and  lactation. 

Morbid  Anatomy. — The  nature  of  the  disease  is  unknown.  E.  Peters  found 
in  8  post-mortems  an  interstitial  neuritis  of  the  extradural  connective  tissue, 
affecting  both  motor  and  sensory  nerves.  Since  the  work  of  Gley,  Vassale  and 
Generali,  and  others,  it  has  been  well  established  that  the  tetany  following 
extirpation  of  the  thyroid  is  due  not  to  the  loss  of  the  thyroid  function,  but  to 
the  coincident  removal  of  the  parathyroid  glands.  Differences  in  the  behavior 
of  carnivorous  and  herbivorous  animals  in  this  respect  are  due  to  the  fact  that 
while  in  the  carnivora  the  glands  are  attached  to  the  thyroid,  in  the  herbivora 
two  of  them  lie  at  a  distant  point.  The  function  of  the  parathyroid  seems  to 
consist  in  the  neutralization  of  a  poison  produced  in  the  course  of  metabolism. 
When  the  parathyroids  are  removed  this  free  poison  acts  upon  the  central 
nervous  system  and  produces  tetany.  Spontaneous  tetany  is  apparently  the 
result  of  the  production  of  so  much  of  this  unknown  poison  that  the  nor- 
mal parathyroids  are  insufficient  to  neutralize  it.  In  a  case  of  tetany  follow- 
ing gastric  dilatation  in  an  old  man  who  died  in  my  service  at  the  Johns 
Hopkins  Hospital,  the  parathyroid  cells  were  found  by  MacCallum  to  be 
actively  proliferating.  Up  to  the  present  time  there  is  no  definite  proof  that 
any  other  diseases  are  dependent  upon  lesions  of  the  parathyroids. 

Symptoms. — In  cases  associated  with  general  debility  or  in  children  with 
rickets  the  spasm  is  limited  to  the  hands  and  feet.  The  fingers  are  bent  at  the 
metaearpo-phalangeal  joint,  extended  at  the  terminal  joints,  pressed  close  to- 
gether, and  the  thumb  is  contracted  in  the.  palm  of  the  hand.  The  wrist  is 
flexed,  the  elbows  are  bent,  and  the  arms  are  folded  over  the  chest.  In  the 
lower  limbs  the  feet  are  extended  and  the  toes  adducted.  The  muscles  of  the 
face  and  neck  are  less  commonly  involved,  but  in  severe  cases  there  may  be 
trismus,  and  the  angles  of  the  mouth  are  drawn  out.  The  skin  of  the  hands 
and  feet  is  sometimes  tense  and  oedematous.  The  spasms  are  usually  parox- 
ysmal and  last  for  a  variable  time.  In  children  the  attack  may  pass  off  in  a 
few  hours.  In  some  of  the  more  severe  chronic  cases  in  adults  the  stiffness  and 
contracture  may  continue  or  even  increase  for  many  days,  and  the  attack  may 
last  as  long  as  two  weeks.  In  the  acute  cases  the  temperature  may  be  elevated 
and  the  pulse  quickened.  In  the  severe  paroxysms  there  may  be  involvement 
of  the  muscles  of  the  back  and  of  the  thorax,  inducing  dyspnoea  and  cyanosis. 
Certain  additional  features,  valuable  in  diagnosis,  are  present. 

Trousseau's  symptom :  "  So  long  as  the  attack  is  not  over,  the  paroxysms 
may  be  reproduced  at  will.  This  is  effected  by  simply  compressing  the  affected 
parts,  either  in  the  direction  of  their  principal  nerve  trunks  or  over  their 
blood-vessels,  so  as  to  impede  the  venous  or  arterial  circulation." 


1076  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Chvostek's  symptom  is  shown  in  the  remarkable  increase  in  the  mechanical 
excitability  of  the  motor  nerves,  A  slight  tap,  for  example,  in  the  course  of 
the  facial  nerve  will  throw  the  muscles  to  which  it  is  distributed  into  active 
contraction.  Erb  has  shown  that  the  electrical  irritability  of  the  motor  nerves, 
especially  to  the  galvanic  current,  is  also  greatly  increased,  and  Hofmann  has 
demonstrated  the  heightened  excitability  of  the  sensory  nerves,  the  slightest 
pressure  on  which  may  cause  pargesthesia  in  the  region  of  distribution. 

Diagnosis. — The  disease  is  readily  recognized.  It  is  a  mistake  to  call 
instances  of  carpo-pedal  spasm  of  children  true  tetany.  It  is  common  to  find 
in  rickety  children  or  in  cases  of  severe  gastro-intestinal  catarrh  a  transient 
spasm  of  the  fingers  or  even  of  the  arms.  By  many  authors  these  are  consid- 
ered cases  of  mild  tetany,  and  there  are  all  grades  in  rickety  children  between 
the  simple  carpo-pedal  spasm  and  the  condition  in  which  the  four  extremities 
are  involved ;  but  it  is  well,  I  think,  to  limit  the  term  tetany  to  the  more  severe 
affection. 

With  true  tetanus  the  disease  is  scarcely  ever  confounded,  as  the  commence- 
ment of  the  spasm  in  the  extremities,  the  attitude  of  the  hands,  and  the  etio- 
logical factors  are  very  different.    Hysterical  contractures  are  usually  unilateral. 

Treatment. — In  the  case  of  children  the  condition  with  which  the  tetany 
is  associated  should  be  treated.  Baths  and  cold  sponging  are  recommended 
and  often  relieve  the  spasm  as  promptly  as  in  child-crowing.  Bromide  of 
potassium  may  be  tried.  In  severe  cases  chloroform  inhalations  may  be  given. 
Massage,  electricity,  and  the  spinal  ice-bag  have  also  been  used  with  success. 
Cases,  however,  may  resist  all  treatment,  and  the  spasms  recur  for  many  years. 
The  thyroid  extract  should  be  tried.  Gottstein  reports  relief  in  a  case  of  long 
standing,  and  Bramwell  reports  one  case  of  operative  tetany  and  one  of  the 
idiopathic  form  successfully  treated  in  this  way. 

In  gastric  tetany,  especially  when  due  to  dilatation  of  the  stomach,  the 
mortality  is  high,  and  recovery  without  operative  interference  is  rare:  of  27 
cases  collected  by  Eiegel,  16  terminated  fatally.  Cunningham  collected  8  cases 
treated  surgically,  with  a  mortality  of  37.5  per  cent,  as  compared  with  70  per 
cent  treated  by  medical  means.  Eegular,  systematic  lavage  with  large  quan- 
tities of  saline  or  mildly  antiseptic  solutions  is  sometimes  beneficial. 

XI.    HYSTERIA. 

Definition. — A  state  in  which  ideas  control  the  body  and  produce  morbid 
changes  in  its  functions  (Mobius). 

Etiology. — The  affection  is  more  common  in  women,  and  usually  appears 
first  about  the  time  of  puberty,  but  the  manifestations  may  continue  until  the 
menopause,  or  even  until  old  age.  Men,  however,  are  by  no  means  exempt, 
and  of  late  years  hysteria  in  the  male  has  attracted  much  attention.  It  occurs 
in  all  races,  but  is  much  more  prevalent,  particularly  in  its  severer  forms,  in 
members  of  the  Latin  race.  In  the  United  States  the  milder  grades  are  com- 
mon, but  the  graver  forms  are  rare  in  comparison  with  the  frequency  with 
which  they  are  seen  in  France. 

Children  under  twelve  years  of  age  are  not  very  often  affected,  but  the 
disease  may  be  well  marked  as  early  as  the  fifth  or  sixth  year.  One  of  the 
saddest  chapters  in  the  history  of  human  deception,  that  of  the  Salem  witches, 


GENERAL  AND  FUNCTIONAL  DISEASES.  1077 

might  be  headed  hysteria  in  children^  since  tlie  tragedy  resulted  directly  from 
the  hysterical  pranks  of  girls  under  twelve  years  of  age. 

Of  predisposing  causes,  two  are  important — heredity  and  education.  The 
former  acts  by  endowing  the  child  with  a  mobile,  abnormally  sensitive  nervous 
organization.  We  see  cases  most  frequently  in  families  with  marked  neuro- 
pathic tendencies,  the  members  of  which  have  suffered  from  neuroses  of  vari- 
ous sorts.  Education  at  home  too  often  fails  to  inculcate  habits  of  self-control. 
A  child  grows  to  girlhood  with  an  entirely  erroneous  idea  of  her  relations  to 
others,  and  accustomed  to  have  every  whim  gratified  and  abundant  sympathy 
lavished  on  every  woe,  however  trifling,  she  reaches  womanhood  with  a  moral 
organization  unfitted  to  withstand  the  cares  and  worries  of  every-day  life.  At 
school,  between  the  ages  of  twelve  and  fifteen,  the  most  important  period  in 
her  life,  when  the  vital  energies  are  absorbed  in  the  rapid  development  of  the 
body,  she  is  often  cramming  for  examinations  and  cooped  in  close  school-rooms 
for  six  or  eight  hours  daily.  The  result  too  frequently  is  an  active,  bright  mind 
in  an  enfeebled  body,  ill  adapted  to  subserve  the  functions  for  which  it  was 
framed,  easily  disordered,  and  prone  to  react  abnormally  to  the  ordinary  stimuli 
of  life.  Among  the  more  direct  influences  are  emotions  of  various  kinds, 
fright  occasionally,  more  frequently  love  affairs,  grief,  and  domestic  worries. 
Physical  causes  less  often  bring  on  hysterical  outbreaks,  but  they  may  follow 
directly  upon  an  injury  or  develop  during  the  convalescence  from  an  acute 
illness  or  be  associated  with  disease  of  the  generative  organs.  The  name 
hysteria  indicates  how  important  was  believed  to  be  the  part  played  by  the 
uterus  in  the  causation  of  the  disease.  Opinions  differ  a  good  deal  on  this 
question,  but  undoubtedly  in  many  cases  there  are  ovarian  and  uterine  disorders 
the  rectification  of  which  sometimes  cures  the  disease.  Sexual  excess,  particu- 
larly masturbation,  is  an  important  factor,  both  in  girls  and  boys. 

Symptoms. — A  useful  division  is  into  the  convulsive  and  non-convulsive 
varieties. 

Convulsive  Hysteria. 

(a)  MiNOE  Forms. — The  attack  most  commonly  follows  emotional  disturb- 
ance. It  may  set  in  suddenly  or  be  preceded  by  symptoms,  called  by  the  laity 
"  hysterical,^'  such  as  laughing  and  crying  alternately,  or  a  sensation  of  con- 
striction in  the  neck,  or  of  a  ball  rising  in  the  throat — the  globus  hystericus. 
Sometimes,  preceding  the  convulsive  movements,  there  may  be  painful  sensa- 
tions arising  from  the  pelvic,  abdominal,  or  thoracic  regions.  From  the  de- 
scription these  sensations  resemble  auras.  They  become  more  intense  with  the 
rising  sensation  of  choking  in  the  neck  and  difficulty  in  getting  breath,  and  the 
patient  falls  into  a  more  or  less  violent  convulsion.  It  will  be  noticed  that 
the  fall  is  not  sudden,  as  in  epilepsy,  but  the  subject  goes  down,  as  a  rule, 
easily,  often  picking  a  soft  spot,  like  a  sofa  or  an  easy-chair,  and  in  the  move- 
ments apparently  exercises  care  to  do  herself  no  injury.  Yet  at  the  same  time 
she  appears  to  be  quite  unconscious.  The  movements  are  clonic  and  disorderly, 
consisting  of  to-and-fro  motions  of  the  trunk  or  pelvic  muscles,  while  the  head 
and  arms  are  thrown  about  in  an  irregular  manner.  The  paroxysm  after  a 
few  minutes  slowly  subsides,  then  the  patient  becomes  emotional,  and  gradually 
regains  consciousness.  When  questioned  the  patient  may  confess  to  having 
some  knowledge  of  the  events  which  have  taken  place,  but,  as  a  rule,  has  no 


1078  DISEASES  OF   THE  NERVOUS  SYSTEM. 

accurate  recollection.  During  the  attack  the  abdomen  may  be  much  distended 
with  flatus,  and  subsequently  a  large  amount  of  clear  urine  may  be  passed. 
These  attacks  vary  greatly  in  character.  There  may  be  scarcely  any  move- 
ments of  the  limbs,  but  after  a  nerve  storm  the  patient  sinks  into  a  torpid, 
semi-unconsciousness  condition,  from  which  she  is  roused  with  great  difficulty. 
In  some  cases  from  this  state  the  patient  passes  into  a  condition  of  catalepsy. 
(&)  Major  Forms;  Hystero-epilepsy. — This  condition  has  been  espe- 
cially studied  by  Charcot  and  his  pupils.  Typical  instances  passing  through 
the  various  phases  are  very  rare  in  the  United  States  and  in  England.  The 
attack  is  initiated  by  certain  prodromata,  chiefly  minor  hysterical  manifesta- 
tions, either  foolish  or  unseemly  behavior,  excitement,  sometimes  dyspeptic 
symptoms  with  tympanites,  or  frequent  micturition.  Areas  of  hyperesthesia 
may  at  this  time  be  marked,  the  so-called  hysterogenic  spots  so  elaborately  de- 
scribed by  Eichet.  These  are  usually  symmetrical  and  situated  over  the  upper 
dorsal  vertebra,  and  in  front  in  a  series  of  symmetrically  placed  spots  on  the 
chest  and  abdomen,  the  most  marked  being  those  in  the  inguinal  regions  over 
the  ovaries.  Painful  sensations  or  a  feeling  of  oppression  and  a  globus  rising 
in  the  throat  may  be  complained  of  prior  to  the  onset  of  the  convulsion,  which, 
according  to  French  writers,  has  four  distinct  stages :  ( 1 )  Epileptoid  condition, 
which  closely  simulates  a  true  epileptic  attack  with  tonic  spasm  (often  leading 
to  opisthotonus),  grinding  of  the  teeth,  congestion  of  the  face,  followed  by 
clonic  convulsions,  gradual  relaxation,  and  coma.  This  attack  lasts  rather 
longer  than  a  true  epileptic  attack.  (3)  Succeeding  this  is  the  period  which 
Charcot  has  termed  downism,  in  which  there  is  an  emotional  display  and  a 
remarkable  series  of  contortions  or  of  cataleptic  poses.  (3)  Then  in  typical 
cases  there  is  a  stage  in  which  tne  patient  assumes  certain  attitudes  expressive 
of  the  various  passions — ecstasy,  fear,  beatitude,  or  erotism.  (4)  Finally  con- 
sciousness returns  and  the  patient  enters  upon  a  stage  in  which  she  may  display 
very  varied  symptoms,  chiefly  manifestations  of  a  delirium  with  the  most 
extraordinary  hallucinations.  Visions  are  seen,  voices  heard,  and  conversations 
held  with  imaginary  persons.  In  this  stage  patients  will  relate  with  the  ut- 
most solemnity  imaginary  events,  and  make  extraordinar}^  and  serious  charges 
against  individuals.  This  sometimes  gives  a  grave  aspect  to  these  seizures,  for 
not  only  will  the  patient  at  this  stage  make  and  believe  the  statements,  but 
when  recovery  is  complete  the  hallucination  sometimes  persists.  I  have  rarely 
seen  in  the  United  States  attacks  having  this  orderly  sequence.  Much  more 
commonly  the  convulsions  succeed  each  other  at  intervals  for  several  days  in 
succession.  Here  we  have  a  striking  difference  between  hystero-epilepsy  and 
true  epilepsy.  In  the  latter  the  status  epilepticus,  if  persistent,  is  always 
serious,  associated  with  fever,  and  frequently  fatal,  while  in  hystero-epilepsy 
attacks  may  recur  for  days  without  special  danger  to  life.  After  an  attack 
of  hystero-epilepsy  the  patient  may  sink  into  a  state  of  trance  or  lethargy,  in 
which  she  may  remain  for  days. 

Non-convulsive  Forms. 

So  complex  and  varied  is  the  clinical  picture  of  hysteria  that  various  mani- 
festations are  best  considered  according  to  the  systems  which  are  involved. 

Disorders  of  Motion. —  (a)  Paralyses. — These  may  be  hemiplegic,  para- 
plegic, or  monoplegic.     Hysterical  diplegia  is  extremely  rare.     The  (paralysis 


GENERAL  AND  FUNCTIONAL  DISEASES.  1079 

either  sets  in  abruptly  or  gradually,  and  may  take  weeks  to  attain  its  full 
development.  There  is  no  type  or  form  of  organic  paralysis  which  may  not 
he  simulated  in  hysteria.  According  to  Weir  Mitchell,  the  hemiplegias  are 
four  times  more  frequent  on  the  left  than  on  the  right  side.  The  face  is  not 
affected;  the  neck  may  be  involved,  but  the  leg  suffers  most.  Sensation  is 
either  lessened  or  lost  on  the  affected  side.  The  hysterical  paraplegia  is  more 
common  than  hemiplegia.  The  loss  of  power  is  not  absolute;  the  legs  can 
usually  be  moved,  but  do  not  support  the  patient.  The  reflexes  may  be  in- 
creased, though  the  knee-jerk  is  often  normal.  A  spurious  ankle  clonus  may 
sometimes  be  present.  The  feet  are  usually  extended  and  turned  inward  in  the 
equino-varus  position.  The  muscles  do  not  waste  and  the  electrical  reactions 
are  normal.  Other  manifestations,  such  as  paralysis  of  the  bladder  or  aphonia, 
are  usually  associated  with  the  hysterical  paraplegia.  Hysterical  monoplegias 
may  be  facial,  crural,  or  brachial.  A  condition  of  ataxia  sometimes  occurs 
with  paresis.  The  incoordination  may  be  a  marked  feature,  and  there  are 
usually  sensory  manifestations. 

(6)  Contractures  and  Spasms. — There  is  an  extraordinary  variety  of  spas- 
modic affections  in  hysteria,  of  which  the  most  common  are  the  following: 
The  hysterical  contractures  may  attack  almost  any  group  of  voluntary  muscles 
and  be  of  the  hemiplegie,  paraplegic,  or  monoplegic  type.  They  may  come 
on  suddenly  or  slowly,  persist  for  months  or  years,  and  disappear  rapidly.  The 
contracture  is  most  commonly  seen  in  the  arm,  which  is  flexed  at  the  elbow 
and  wrist,  while  the  fingers  tightly  grasp  the  thumb  in  the  palm  of  the  hand; 
more  rarely  the  terminal  phalanges  are  hyperextended  as  in  athetosis.  It  may 
occur  in  one  or  in  both  legs,  more  commonly  in  one.  The  ankle  clonus 
is  present;  the  foot  is  inverted  and  the  toes  are  strongly  flexed.  These  cases 
may  be  mistaken  for  lateral  sclerosis  and  the  difficulty  in  diagnosis  may  really 
be  very  great.  The  spastic  gait  is  very  typical,  and  with  the  exaggerated  knee- 
jerk  and  ankle  clonus  the  picture  may  be  characteristic.  In  1879  I  frequently 
showed  such  a  case  at  the  Montreal  General  Hospital  as  a  typical  example  of 
lateral  sclerosis.  The  condition  persisted  for  more  than  eighteen  months  and 
then  disappeared  completely.  Other  forms  of  contracture  may  be  in  the 
muscles  of  the  hip,  shoulder,  or  neck ;  more  rarely  in  those  of  the  jaws — hys- 
terical trismus — or  in  the  tongue.  Eemarkable  indeed  are  the  local  contrac- 
tures in  the  diaphragm  and  abdominal  muscles,  producing  a  phantom  tumor, 
in  which  just  below  and  in  the  neighborhood  of  the  umbilicus  is  a  flrm,  appar- 
ently solid  growth.  According  to  Gowers,  this  is  produced  by  relaxation  of 
the  recti  and  a  spasmodic  contraction  of  the  diaphragm,  together  with  infla- 
tion of  the  intestines  with  gas  and  an  arching  forward  of  the  vertebral  column. 
They  are  apt  to  occur  in  middle-aged  women  about  the  menopause,  and  are 
frequently  associated  with  the  symptoms  of  spurious  pregnancy — pseudo-cyesis. 
The  resemblance  to  a  tumor  may  be  striking,  and  I  have  known  skilful  diag- 
nosticians to  be  deceived.  The  only  safeguard  is  to  be  found  in  complete 
anaesthesia,  when  the  tumor  entirely  disappears.  Some  years  ago  I  went  by 
chance  into  the  operating-room  of  a  hospital  and  found  a  patient  on  the  table 
under  chloroform  and  the  surgeon  prepared  to  perform  ovariotomy.  The 
tumor,  however,  had  completely  disappeared  with  full  anaesthesia.  Mitchell 
has  reported  an  instance  of  a  phantom  tumor  in  the  left  pectoral  region  just 
above  the  breast,  which  was  tender,  hard,  and  dense. 


1080  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Clonic  spasms  are  more  common  in  hysteria  in  this  country  than  contrac- 
tures. The  following  are  the  important  forms:  Rhythmic  hysterical  spasm. 
This,  unfortunately,  is  sometimes  known  as  rhythmic  chorea  or  hysterical 
chorea.  The  movements  may  be  of  the  arm,  either  flexion  and  extension,  or, 
more  rarely,  pronation  and  supination.  Clonic  contractions  of  the  sterno- 
eleido-mastoid  or  of  the  muscles  of  the  jaws  or  of  the  rotatory  muscles  of  the 
head  may  produce  rhythmic  movements  of  these  parts.  The  spasm  may  be  in 
one  or  both  psoas  muscles,  lifting  the  leg  in  a  rh}i:hmic  manner  eight  or  ten 
times  in  a  minute.  In  jDther  instances  the  muscles  of  the  trunk  are  atfected, 
and  every  few  moments  there  is  a  bowing  movement — salaam  convulsions — or 
the  muscles  of  the  back  may  contract,  causing  strong  arching  of  the  vertebral 
column  and  retraction  of  the  head.  These  movements  may  often  alternate,  as 
in  a  case  in  my  wards,  in  which  the  patient  on  fine  days  had  regular  salaam 
convulsions,  while  on  wet  days  the  rhythmic  spasm  was  in  the  muscles  of  the 
back  and  neck.  Mitchell  has  described  a  rotatory  spasm  in  which  the  patient 
rotated  involuntarily,  usually  to  the  left.  More  unusual  cases  are  those  in 
which  the  contractions  closely  simulate  paramyoclonus  multiplex.  Hysterical 
athetosis  is  a  rare  form  of  spasm.  Tremor  may  be  a  purely  hysterical  mani- 
festation, occurring  either  alone  or  with  paralysis  and  contracture.  It  most 
commonly  involves  the  hands  and  arms;  more  rarely  the  head  and  legs.  The 
movements  are  small  and  quick.  In  the  ty^e  described  by  Eendu  the  tremor 
may  or  may  not  persist  during  repose,  but  it  is  increased  or  provoked  by  voli- 
tional movements.  Volitional  or  intentional  tremor  may  exist,  simulating 
closely  the  movements  of  insular  sclerosis.  Buzzard  states  that  many  instances 
of  this  disease  in  young  girls  are  mistaken  for  hysteria. 

DisoEDEES  OF  Sexsation. — AncEsthesia  is  most  common,  and  usually  con- 
fined to  one  half  of  the  body.  It  may  not  be  noticed  by  the  patient.  Usually 
it  is  accurately  limited  by  the  middle  line  and  involves  the  mucous  surfaces  and 
deeper  parts.  The  conjunctiva,  however,  is  often  spared.  There  may  be  hemi- 
anopia.  This  sjmiptom  may  come  on  slowly  or  follow  a  convulsive  attack. 
Sometimes  the  various  sensations  are  dissociated  and  the  anesthesia  may  be 
only  to  pain  and  to  touch.  The  skin  of  the  affected  side  is  usually  pale  and 
cool,  and  a  pin-prick  may  not  be  followed  by  blood.  With  the  loss  of  feeling 
there  may  be  loss  of  muscular  power.  Curious  trophic  changes  may  be  present, 
as  in  an  interesting  case  of  Weir  Mitchell's,  in  which  there  was  unilateral 
swelling  of  the  hemiplegic  side. 

A  phenomenon  to  which  much  attention  has  been  paid  is  that  of  transfer- 
ence. By  metallotherapy,  the  application  of  certain  metals,  the  ansesthesia 
or  analgesia  can  be  transferred  to  the  other  side  of  the  body.  It  has  been 
shown,  however,  that  this  phenomenon  may  be  caused  b}^  the  electro-magnet 
and  by  wood  and  various  other  agents,  and  is  probably  entirely  a  mental  effect. 
The  subject  has  no  practical  importance,  but  it  remains  an  interesting  and 
instructive  chapter  in  Gallic  medical  history. 

Hypercesthesia. — Increased  sensitiveness  and  pains  occur  in  various  parts 
of  the  body.  One  of  the  most  frequent  complaints  is  of  pain  in  the  head, 
usually  over  the  sagittal  suture,  less  frequently  in  the  occiput.  This  is  de- 
scribed as  agonizing,  and  is  compared  to  the  driving  of  a  nail  into  the  part; 
hence  the  name  clavus  hystericus.  ISTeuralgias  are  common.  Hypergesthetic 
areas,  the  hysterogenic  points,  exist  on  the  skin  of  the  thorax  and  abdomen, 


GENERAL  AND  FUNCTIONAL  DISEASES.  1081 

pressure  upon  which  may  cause  minor  manifestations  or  even  a  convulsive 
attack.  Increased  sensitiveness  exists  in  the  ovarian  region,  but  is  not  pecul- 
iar to  hysteria.  Pain  in  the  back  is  an  almost  constant  complaint  of  hysterical 
patients.  The  sensitiveness  may  be  limited  to  certain  spinous  processes,  or  it 
may  be  diffuse.  In  hysterical  women  the  pains  in  the  abdomen  may  simulate 
those  of  gastralgia  and  of  gastric  ulcer,  or  the  condition  may  be  almost  identical 
with  that  of  peritonitis ;  more  rarely  the  abdominal  pains  closely  resemble  those 
of  appendix  disease. 

Special  Senses. — Disturbances  of  taste  and  smell  are  not  uncommon  and 
may  cause  a  good  deal  of  distress.  Of  ocular  symptoms,  retinal  hypergesthesia 
is  the  most  common,  and  the  patients  always  prefer  to  be  in  a  darkened  roon;. 
Eetraction  of  the  field  of  vision  is  common  and  usually  follows  a  convulsive 
seizure.  It  may  persist  for  years.  The  color  perception  may  be  normal  even 
with  complete  anaesthesia,  and  in  America  the  achromatopsia  does  not  seem 
to  be  nearly  so  common  an  hysterical  manifestation  as  in  Europe.  Hysterical 
deafness  may  be  complete  and  may  alternate  or  come  on  at  the  same  time  with 
hysterical  blindness.  Hysterical  amaurosis  may  occur  in  children.  One  must 
carefully  distinguish  between  functional  loss  of  power  and  simulation. 

Visceral  Manifestations. — Respiratory  Apparatus. — Of  disturbances  in 
the  respiratory  rhythm,  the  most  frequent,  perhaps,  is  an  exaggeration  of  the 
deeper  breath,  which  is  taken  normally  every  fifth  or  sixth  inspiration,  or 
there  may  be  a  "  catching "  breathing,  such  as  is  seen  when  cold  water  is 
poured  over  a  person.  In  hysterical  dyspnoea  there  is  no  special  distress  and 
the  pulse  is  normal.  In  what  is  known  as  the  syndrome  of  Briquet  there  is 
shortness  of  breath,  suppression  of  the  voice,  and  paralysis  of  the  diaphragm. 
The  anhelation  is  extreme.  In  rare  instances  there  is  bradypnoea.  Among 
laryngeal  manifestations  aphonia  is  frequent  and  may  persist  for  months  or 
even  years  without  other  special  symptoms  of  the  disease.  Spasm  of  the 
muscles  may  occur  with  violent  inspiratory  efforts  and  great  distress,  and 
may  even  lead  to  cyanosis.  Hiccough,  or  sounds  resembling  it,  may  be  present 
for  weeks  or  months  at  a  time.  Among  the  most  remarkable  of  the  respiratory 
manifestations  are  the  hysterical  cries.  These  may  mimic  the  sounds  produced 
by  animals,  such  as  barking,  mewing,  or  grunting,  and  in  France  epidemics 
of  them  have  been  repeatedly  observed.  Extraordinary  cries  may  be  produced, 
either  inspiratory  or  expiratory.  I  saw  at  Wagner's  clinic  at  Leipsic  a  girl  of 
thirteen  or  fourteen,  who  had  for  many  weeks  given  utterance  to  a  remarkable 
inspiratory  cry  somewhat  like  the  whoop  of  whooping-cough,  but  so  intense 
that  it  was  heard  at  a  long  distance.  It  was  incessant,  and  the  girl  was  worn 
to  a  skeleton.    Attacks  of  gaping,  yawning,  and  sneezing  may  also  occur. 

The  hysterical  cough  is  a  frequent  symptom,  particularly  in  young  girls. 
It  may  occur  in  paroxysms,  but  is  often  a  dry,  persistent,  croaking  cough, 
extremely  monotonous  and  unpleasant  to  hear.  Sir  Andrew  Clark  has  called 
attention  to  a  loud,  barking  cough  (cynoiex  hehetica)  occurring  about  the 
time  of  puberty,  chiefly  in  boys  belonging  to  neurotic  families.  The  attacks, 
which  last  about  a  minute,  recur  frequently. 

There  is  a  peculiar  form  of  haemoptysis  which  may  be  very  deceptive  and 
lead  to  the  diagnosis  of  pulmonary  disorders.  Wagner  describes  the  sputum 
as  a  pale-red  fluid — ^not  so  bright  in  color  as  in  ordinary  haemoptysis;  on  set- 
tling it  presents  a  reddish-brown  sediment.    It  contains  particles  of  food,  pave- 


1082  DISEASES  OF  THE  NERVOUS  SYSTEM. 

ment  epithelium,  red  corpuscles,  and  micrococci,  but  no  cylindrical  or  ciliated 
epithelium.    It  probably  comes  from  the  mouth  or  pharynx. 

Digestive  System. — Disturbed  or  depraved  appetite,  dyspepsia,  and  gastric 
pains  are  common  in  hysterical  patients.  The  patient  may  have  difficulty  in 
swallowing  the  food,  apparently  from  spasm  of  the  gullet.  There  are  instances 
in  which  the  food  seems  to  be  expelled  before  it  reaches  the  stomach.  In  other 
cases  there  is  incessant  gagging.  In  the  hysterical  vomiting  the  food  is  regur- 
gitated without  much  effort  and  without  nausea.  This  feature  may  persist  for 
years  without  great  disturbance  of  nutrition.  The  most  striking  and  remark- 
able digestive  disturbance  in  hysteria  is  the  anorexia  nervosa  described  by  Sir 
William  Gull.  "  To  call  it  loss  of  appetite — anorexia — but  feebly  character- 
izes the  symptom.  It  is  rather  an  annihilation  of  appetite,  so  complete  that 
it  seems  in  some  cases  impossible  ever  to  eat  again.  Out  of  it  grows  an 
antagonism  to  food  which  results  at  last  and  in  its  worst  forms  in  spasm  on 
the  approach  of  food,  and  this  in  turn  gives  rise  to  some  of  those  remarkable 
cases  of  survival  for  long  periods  without  food"  (Mitchell).  There  are  three 
special  features  in  anorexia  nervosa :  First,  and  most  important,  a  psychical 
state,  usually  depressant,  occasionally  excited  and  restless.  It  is  not  always 
hysterical,  and  the  condition  should  not  rightly  be  considered  here.  Secondly, 
stomach  symptoms,  loss  of  appetite,  regurgitation,  vomiting,  and  the  whole 
series  of  phenomena  associated  with  nervous  dyspepsia.  Thirdly,  emaciation, 
which  reaches  a  grade  seen  only  in  cancer  and  dysentery.  The  patient  finally 
takes  to  bed,  and  in  extreme  cases  lies  upon  one  side  with  the  thighs  and  legs 
flexed,  and  contractures  may  occur.  Food  is  either  not  taken  at  all  or  only 
upon  urgent  compulsion.  The  skin  becomes  wasted,  dry,  and  covered  with 
bran-like  scales.  No  food  may  be  taken  for  several  weeks  at  a  time,  and 
attempts  to  feed  may  be  followed  by  severe  spasms.  Although  the  condition 
looks  so  alarming,  these  cases,  when  removed  from  their  home  surroundings 
and  treated  by  Weir  Mitchell's  method,  sometimes  recover  in  a  remarkable 
way.  It  may  take  many  months  before  any  improvement  is  noted.  Death, 
however,  may  follow  with  extreme  emaciation.  In  a  fatal  case  under  my  care 
the  girl  weighed  only  49  pounds.    No  lesions  were  found  post  mortem. 

Hysterical  tympanites  is  a  common  feature,  caused  usually  by  tonic  con- 
traction of  the  diaphragm  and  retraction  of  the  other  abdominal  muscles.  It 
may  be  associated  with  the  condition  of  peristaltic  unrest  (Kussmaul).  Fre- 
quent discharges  of  faeces  may  be  due  to  disturbance  in  either  the  small  or 
large  bowel.  An  obstinate  form  of  diarrhoea  is  found  in  some  hysterical 
patients,  which  proves  very  intractable  and  is  associated  especially  with  the 
taking  of  food.  It  seems  an  aggravated  form  of  the  looseness  of  bowels  to 
which  so  many  nervous  people  are  subject  on  emotion  or  of  the  tendency  which 
some  have  to  diarrhoea  immediately  after  eating.  An  entirely  different  form 
is  that  produced  by  what  Mitchell  calls  the  irritable  rectum,  in  which  scybala 
are  passed  frequently  during  the  day,  sometimes  with  great  violence.  Con- 
stipation is  more  frequent,  however,  and  may  be  due  to  a  loss  of  power  in  the 
muscles  of  the  bowel,  or  in  the  abdominal  muscles.  In  extreme  cases  the 
bowels  may  not  be  moved  for  two  or  three  weeks,  leading  to  great  accumula- 
tion of  faeces.  Other  disturbances  are  ano-spasm  or  intense  pain  in  the  rectum 
apart  from  any  fissure.  Hysterical  ileus  and  faecal  vomiting  are  among  the 
most  remarkable  of  hysterical  phenomena.     Following  a  shock  there  are  con- 


GENERAL  AND  FUNCTIONAL  DISEASES.  1083 

stipation,  tympanites,  vomiting,  sometimes  lia3matemesis.  The  constipation 
grows  worse,  everything  taken  by  the  mouth  is  rejected,  the  vomitus  jjecomes 
faecal  in  character,  even  scybala  are  brought  up,  and  suppositories  and  enemata 
are  vomited.  The  symptoms  may  continue  for  weeks  and  then  gradually  sub- 
side. Laparotomy — even  thrice  in  one  patient — has  shown  a  perfectly  normal- 
looking  condition  of  the  bowels  (Parkes  Weber). 

Cardio-vascular. — Rapid  action  of  the  heart  on  the  slightest  emotion,  with 
or  without  the  subjective  sensation  of  palpitation,  is  often  a  source  of  great 
distress.  A  slow  pulse  is  less  frequent.  Pains  about  the  heart  may  simulate 
angina.  Flushes  in  various  parts  are  among  the  most  common  symptoms. 
Sweating  may  occur,  or  the  sehorrhoea  nigricans,  causing  a  darkening  of  the 
skin  of  the  eyelids. 

Among  the  more  remarkable  vaso-motor  phenomena  are  the  so-called  stig- 
mata or  ha3morrhages  in  the  skin,  such  as  were  present  in  the  celebrated  case 
of  Louise  Lateau.  In  many  cases  these  are  undoubtedly  fraudulent,  but  if, 
as  appears  credible,  such  bleeding  may  exist  in  the  hypnotic  trance,  there  seems 
no  reason  to  doubt  its  occurrence  in  the  trance  of  prolonged  religious  ecstasy. 

Joint  Affections. — To  Sir  Benjamin  Brodie  and  Sir  James  Paget  we 
owe  the  recognition  of  these  extraordinary  manifestations  of  hysteria.  Per- 
haps no  single  afEection  has  brought  more  discredit  upon  the  profession,  for 
the  cases  are  very  refractory,  and  finally  fall  into  the  hands  of  a  charlatan  or 
faith-healer,  under  whose  touch  the  disease  may  disappear  at  once.  Usually 
it  affects  the  knee  or  the  hip,  and  may  follow  a  trifling  injury.  The  joint  is 
usually  fixed,  sensitive,  and  swollen.  The  surface  may  be  cool,  but  sometimes 
the  local  temperature  is  increased.  To  the  touch  it  is  very  sensitive  and 
movement  causes  great  pain.  In  protracted  cases  the  muscles  about  the  joint 
are  somewhat  wasted,  and  in  consequence  it  looks  larger.  The  pains  are  often 
nocturnal,  at  which  time  the  local  temperature  may  be  much  increased.  While, 
as  a  rule,  neuromimetic  joints  yield  to  proper  management,  there  are  inter- 
esting instances  in  the  literature  in  which  organic  change  has  succeeded  the 
functional  disturbance.  In  the  remarkable  case  reported  in  Weir  Mitchell's 
lectures,  the  hysterical  features  were  pronounced,  and,  on  account  of  the  chron- 
icity,  the  disease  of  the  knee-joint  was  considered  organic  by  such  an  authority 
as  Billroth.  Sands  found  the  joint  surfaces  normal,  and  the  thickening  to  be 
due  to  inflammatory  products  outside  the  capsule. 

Intermittent  hydrarthrosis  may  be  a  manifestation  of  hysteria,  occurring 
in  the  knee  or  other  joints,  sometimes  with  transient  paresis. 

Mental  Symptoms. — Janet  makes  suggestion  the  keystone  of  the  mental 
condition  in  hysteria,  the  test,  indeed,  of  its  existence;  and  in  his  recent 
Harvard  Lectures  On  Hysteria  he  states  that  suggestion  "  presents  itself 
experimentally  or  accidentally  only  with  hystericals,  and  inversely  all  hys- 
tericals  present  this  same  phenomenon  in  a  higher  or  lower  degree."  Another 
striking  peculiarity  is  the  perversion  of  the  moral  nature.  Not  the  slightest 
dependence  can  be  placed  upon  the  statements  of  hysterical  patients.  This 
appears  to  result  partly,  but  not  wholly,  from  a  morbid  craving  for  sympathy. 

Hysterical  patients  may  become  insane  and  display  persistent  hallucina- 
tions and  delirium,  alternating  perhaps  with  emotional  outbursts  of  an  aggra- 
vated character.  For  weeks  or  months  they  may  be  confined  to  bed,  entirely 
oblivious  to  their  surroundings,  with  a  delirium  which  may  simulate  that  of 


1084  DISEASES  OF  THE  NERVOUS  SYSTEM. 

delirium  tremens,  particularly  in  being  associated  with  loathsome  and  un- 
pleasant animals.  The  nutrition  may  be  maintained,  but  in  these  cases  there 
is  always  a  very  heaxj,  foul  breath.  With  seclusion  and  care  recovery  usually 
takes  place  within  three  or  four  months.  At  the  onset  of  these  attacks  and 
during  convalescence  the  patients  must  be  incessantly  watched,  as  a  suicidal 
tendency  is  by  no  means  uncommon.  I  have  been  accustomed  to  speak  of  this 
condition  as  the  status  hystericus. 

Of  hysterical  manifestations  in  the  higher  centres  that  of  trance  is  the 
most  remarkable.  This  may  develop  spontaneously  without  any  convulsive 
seizure,  but  more  frequently,  in  America  at  least,  it  follows  hysteroid  attacks. 
Catalepsy  may  be  present,  a  condition  in  which  the  limbs  are  plastic  and 
remain  in  any  position  in  which  they  are  placed. 

The  Metabolism  in  Htsteeia. — The  studies  of  Gilles  de  la  Tourette  and 
Cathelineau,  under  Charcot's  direction,  have  shown  that  in  the  ordinary  forms 
of  hysteria  the  urine  does  not  show  quantitative  or  qualitative  changes,  but 
in  the  severer  types,  characterized  by  convulsions,  etc.,  there  are  important 
modifications :  reduction  in  the  urates  and  phosphates ;  the  ratio  of  the  earthy 
to  the  alkaline  phosphates,  normally  1 :  3,  is  1 :  2,  or  even  1 :  1.  The  urine  is 
also  reduced  in  amount.  They  think  that  these  changes  might  sometimes  serve 
to  differentiate  convulsive  hysteria  from  epilepsy,  in  which  there  is  always  an 
increase  in  the  solid  constituents  after  a  seizure. 

Hysteeical  Fever. — In  hysteria  the  temperature,  as  a  rule,  is  normal. 
The  cases  with  fever  may  be  grouped  as  follows:  (a)  Instances  in  which  the 
fever  is  the  sole  manifestation.  These  are  rare,  but  I  have  seen  at  least  two 
cases  in  which  the  chronic  course,  the  retention  of  the  nutrition,  and  the 
entirely  negative  condition  of  the  organs  left  no  other  diagnosis  possible.  In 
a  case  which  I  had  under  observation  the  patient  had  for  four  or  five  years  an 
afternoon  rise  of  temperature,  reaching  usually  to  103°  or  103°.  She  was  well 
nourished  and  presented  no  pronounced  hysterical  symptoms,  beyond  a  form 
of  interrupted  sighing  respiration  so  often  seen  in  hysteria.  There  was  a 
marked  neurotic  history  on  one  side  of  the  family. 

(&)  Cases  of  hysterical  fever  with  spurious  local  manifestations.  These 
are  very  troublesome  and  deceptive  cases.  The  patient  may  be  suddenly  taken 
ill  with  pain  in  various  regions  and  elevation  of  temperature.  The  case  may 
simulate  meningitis.  There  may  be  pain  in  the  head,  vomiting,  contracted 
pupils,  and  retraction  of  the  neck — symptoms  which  may  persist  for  weeks — 
and  some  anomalous  manifestation  during  convalescence  may  alone  indicate 
to  the  physician  that  he  has  had  to  deal  with  a  case  of  hysteria,  and  has  not, 
as  he  perhaps  flattered  himself,  cured  a  case  of  meningitis.  Mary  Putnam 
Jacobi,  in  an  article  on  hysterical  fever,  mentions  a  case  in  the  service  of 
Cornil  which  was  admitted  with  dyspnoea,  slight  cyanosis,  and  a  temperature 
of  39°  C.  The  condition  proved  to  be  hysterical.  There  is  also  an  hysterical 
pseudo-phthisis  with  pain  in  the  chest,  slight  fever,  and  the  expectoration  of  a 
blood-stained  mucus.    The  cases  of  hysterical  peritonitis  may  also  show  fever. 

(c)  Hysterical  Hyperpyrexia. — It  is  a  suggestive  fact  that  the  cases  of 
paradoxical  temperatures  reported  of  late  years,  in  which  the  thermometer  has 
registered  112°  to  120°  or  more,  have  been  in  women.  Fraud  has  been  prac- 
tised in  some  of  these,  but  others  have  to  be  accepted,  though  their  explanation 
is  impossible  under  our  known  laws. 


GENERAL  AND  FUNCTIONAL  DISEASES.  1085 

Diagnosis. — Inquiry  into  the  occurrence  of  previous  manifestations  and 
the  mental  conditions  may  give  important  information.  These  questions,  as 
a  rule,  should  not  be  asked  the  mother,  who  of  all  others  is  least  likely  to  give 
satisfactory  information  about  the  patient's  condition.  The  occurrence  of  the 
globus  hystericus,  of  emotional  attacks,  of  weeping  and  crying,  are  always 
suggestive.  The  points  of  difference  between  the  convulsive  attacks  and  true 
epilepsy  were  referred  to  in  their  description,  and  as  a  rule  little  difficulty  is 
experienced  in  distinguishing  between  the  two  conditions.  The  hysterical 
paralyses  are  very  variable  and  apt  to  be  associated  with  anesthesia.  The 
contractures  may  at  times  be  very  deceptive,  but  the  occurrence  of  areas  of 
anaesthesia,  of  retraction  of  the  visual  field,  and  the  development  of  minor 
hysterical  manifestations,  give  valuable  indications.  The  contractures  disap- 
pear under  full  anaesthesia.  Special  care  must  be  taken  not  to  confound  the 
spastic  paraplegia  of  hysteria  with  lateral  sclerosis. 

The  visceral  manifestations  are  usually  recognized  without  much  difficulty. 
The  practitioner  has  constantly  to  bear  in  mind  the  strong  tendency  in  hys- 
terical patients  to  practise  deception. 

Treatment. — The  prophylaxis  in  hysteria  may  be  gathered  from  the  re- 
marks on  the  relation  of  education  to  the  disease.  The  successful  treatment 
of  hysteria  demands  qualities  possessed  by  few  physicians.  The  first  element 
is  a  due  appreciation  of  the  nature  of  the  disease  on  the  part  of  the  physician 
and  friends.  It  is  pitiable  to  think  of  the  misery  which  has  been  inflicted  on 
these  unhappy  victims  by  the  harsh  and  unjust  treatment  which  has  resulted 
from  false  views  of  the  nature  of  the  trouble;  on  the  other  hand,  worry  and 
ill-health,  often  the  wrecking  of  mind,  body,  and  estate,  are  entailed  upon 
the  near  relatives  in  the  nursing  of  a  protracted  case  of  hysteria.  The  minor 
manifestations,  attacks  of  the  vapors,  the  crying  and  weeping  spells,  are  not 
of  much  moment  and  rarely  require  treatment.  The  physical  condition  should 
be  carefully  looked  into  and  the  mode  of  life  regulated  so  as  to  insure  system 
and  order  in  everything.  A  congenial  occupation  offers  the  best  remedy  for 
many  of  these  manifestations.  Any  functional  disturbance  should  be  attended 
to  and  a  course  of  tonics  prescribed.  Special  attention  should  be  paid  to  the 
action  of  the  bowels. 

Valerian  and  asafcetida  are  often  of  service.  For  the  pains  in  various 
parts,  particularly  in  the  back,  the  thermo-cautery  and  static  electricity  will 
be  found  invaluable.  Morphia  should  be  withheld.  In  the  convulsive  seizures, 
particularly  in  the  minor  forms,  it  is  often  best,  after  settling  the  patient 
comfortably,  to  leave  her.  When  she  comes  to,  and  finds  herself  alone  and 
without  sympathy,  the  attacks  are  less  likely  to  be  repeated.  There  is,  as  a 
rule,  no  cure  for  the  hysterical  manifestations  of  women,  otherwise  in  good 
health,  who  are,  as  Mitchell  says,  "  fat  and  ruddy,  with  sound  organs  and 
good  appetites,  but  ever  complain  of  pains  and  aches,  and  ever  liable  on  the 
least  emotional  disturbance  to  exhibit  a  quaint  variety  of  hysterical  phe- 
nomena." 

To  treat  hysteria  as  a  physical  disorder  is  radically  wrong.  It  is  essentially 
a  mental  and  emotional  anomaly,  and  the  important  element  in  the  treatment 
is  moral  control.  At  home,  surrounded  by  loving  relatives  who  misinterpret 
entirely  the  symptoms  and  have  no  appreciation  of  the  nature  of  the  disease, 
the  severer  forms  of  hysteria  can  rarely  be  cured.     The  necessary  control  is 


1086  DISEASES  OF   THE  NERVOUS  SYSTEM. 

impossible ;  hence  the  special  value  of  the  method  introduced  by  Weir  Mitchell, 
which  is  particularly  applicable  to  the  advanced  cases  which  have  become 
chronic  and  bedridden.  The  treatment  consists  in  isolation,  rest,  diet,  massage, 
and  electricity.  Separation  from  friends  and  sympathetic  relatives  must  be 
absolute,  and  can  rarely,  if  ever,  be  obtained  in  the  individual's  home.  An 
essential  element  in  the  treatment  is  an  intelligent  nurse.  No  small  share 
of  the  success  which  has  attended  the  author  of  this  plan  has  been  due  to  the 
fact  that  he  has  persistently  chosen  as  his  allies  bright,  intelligent  women.  The 
details  of  the  plan  are  as  follows:  The  patient  is  confined  to  bed  and  not 
allowed  to  get  up,  nor,  at  first,  in  aggravated  cases,  to  read,  write,  or  even  to 
feed  herself.  Massage  is  used  daily,  at  first  for  twenty  minutes  or  half  an 
hour,  subsequently  for  a  longer  period.  It  is  essential  as  a  substitute  for  exer- 
cise. The  induction  current  is  applied  to  the  various  muscles  and  to  the  spine. 
Its  use,  however,  is  not  so  essential  as  that  of  massage.  The  diet  may  at  first 
be  entirely  of  milk,  4  ounces  every  two  hours.  It  is  better  to  give  skimmed 
milk,  and  it  may  be  diluted  with  soda  water  or  barley  water  and,  if  necessary, 
peptonized.  After  a  week  or  ten  days  the  diet  may  be  increased,  the  amount 
of  milk  still  being  kept  up.  A  chop  may  be  given  at  midday,  a  cup  of  coffee 
or  cocoa  with  toast  or  bread  and  butter  or  a  biscuit  with  the  milk.  The 
patients  usually  fatten  rapidly  as  the  solid  food  is  added,  and  with  the  gain 
there  is,  as  a  rule,  a  diminution  or  cessation  of  the  nervous  symptoms.  The 
milk  is  the  essential  element  in  the  diet,  and  is  in  itself  amply  sufficient. 

The  remarkable  results  obtained  by  this  method  are  now  universally  recog- 
nized. The  plan  is  more  applicable  to  the  lean  than  to  fat,  fiabby  hysterical 
patients.  Not  only  is  it  suitable  for  the  more  obstinate  varieties  with  bodily 
manifestations,  but  in  the  cases  with  mental  symptoms  the  seclusion  and  sepa- 
ration from  relatives  and  friends  are  particularly  advantageous.  In  the  hys- 
terical vomiting  Debove's  method  of  forced  feeding  may  be  used  with  benefit. 
For  the  innumerable  minor  manifestations  and  for  the  simulations  the  indi- 
cations for  treatment  are  usually  clear.  All  hysterical  patients  are  subject 
to  suggestion,  and  hypnotism  has  been  used  extensively.  In  cases  of  contrac- 
tion and  of  paralysis  it  is  often  of  great  help.  Suggestion  alone,  without  the 
induction  of  the  hypnotic  state,  may  suffice  to  cure  hysterical  paralysis.  In 
careful  hands  it  may  be  used,  always  remembering  that  hypnotism  is  a  two- 
edged  sword  with  which  many  good  men  in  the  profession  have  been  sore 
smitten,  and  many  patients  more  hurt  than  helped. 

XII.    NEURASTHENIA    (Psychasthenia). 

Definition. — A  condition  of  weakness  or  exhaustion  of  the  nervous  system, 
giving  rise  to  various  forms  of  mental  and  bodily  inefficiency. 

The  term,  an  old  one,  but  first  popularized  by  Beard,  covers  an  ill-defined, 
motley  group  of  symptoms,  which  may  be  either  general  and  the  expression 
of  derangement  of  the  entire  system,  or  local,  limited  to  certain  organs ;  hence 
the  terms  cerebral,  spinal,  cardiac,  and  gastric  neurasthenia. 

Etiology. — The  causes  may  be  grouped  as  hereditary  and  acquired. 

(a)  Hereditary. — We  do  not  all  start  in  life  with  the  same  amount  of 
nerve  capital.  Parents  who  have  led  irrational  lives,  indulging  in  excesses  of 
various  kinds,  or  who  have  been  the  subjects  of  nervous  complaints  or  of  mental 


GENERAL  AND  FUNCTIONAL  DISEASES.  1087 

trouble,  may  transmit  to  their  children  an  organization  which  is  defective  in 
what,  for  want  of  a  better  term,  we  must  call  "  nerve  force."  Such  individuals 
start  handicapped  with  a  neuropathic  predisposition,  and  furnish  a  consider- 
able proportion  of  our  neurasthenic  patients.  As  van  Gieson  sonorously  puts 
it,  "  the  potential  energies  of  the  higher  constellations  of  their  association 
centres  have  been  squandered  by  their  ancestors." 

Besides  such  forms  of  hereditary  neuropathy,  which  we  have  to  look  upon 
as  instances  of  injury  to  the  germ-plasm  derived  from  one  or  both  of  the 
parents,  there  have  to  be  considered  those  cases  in  which  during  intra-uterine 
life  there  have  been  conditions  which  interfered  with  the  proper  development 
and  nutrition  of  the  embryo.  So  long  as  these  individuals  are  content  to  trans- 
act a  moderate  business  with  their  life  capital,  all  may  go  well,  but  there  is 
no  reserve,  and  in  the  exigencies  of  modern  life  these  small  capitalists  go  under 
and  come  to  us  as  bankrupts. 

(&)  Acquired. — The  functions,  though  perverted  most  readily  in  persons 
who  have  inherited  a  feeble  organization,  may  also  be  damaged  in  persons  with 
no  neuropathic  predisposition  by  exercise  which  is  excessive  in  proportion  to 
the  strength — i.  e.,  by  strain.  The  cares  and  anxieties  attendant  upon  the 
gaining  of  a  livelihood  may  be  borne  without  distress,  but  in  many  persons  the 
strain  becomes  excessive  and  is  first  manifested  as  worry.  The  individual  loses 
the  distinction  between  essentials  and  non-essentials,  trifles  cause  annoyance, 
and  the  entire  organism  reacts  with  unnecessary  readiness  to  slight  stimuli, 
and  is  in  a  state  which  the  older  writers  called  irritable  weakness.  If  such 
a  condition  be  taken  early  and  the  patient  given  rest,  the  balance  is  quickly 
restored.  In  this  group  may  be  placed  a  large  proportion  of  the  neurasthenics 
which  we  see  among  business  men,  teachers,  and  journalists.  Neurasthenia 
may  follow  the  infectious  diseases,  particularly  influenza,  typhoid  fever,  and 
syphilis.  The  abuse  of  certain  drugs,  alcohol,  tobacco,  morphine  may  lead  to 
a  high  grade  of  neurasthenia,  though  the  drug  habit  is  more  often  a  result 
rather  than  a  cause  of  the  neurasthenia.  Other  causes  more  subtle,  yet  potent, 
and  less  easily  dealt  with,  are  the  worries  attendant  upon  love  affairs,  religious 
doubts,  and  the  sexual  passion.  Sexual  excesses  have  undoubtedly  been  exag- 
gerated as  a  cause  of  neurasthenia,  but  that  they  are  responsible  in  a  number 
of  instances  is  certain. 

The  traumatic  forms,  especially  those  following  upon  railway  accidents, 
will  be  separately  considered. 

Symptoms. — These  are  extremely  varied,  and  may  be  general  or  localized; 
more  often  a  combination  of  both.  The  appearance  of  the  patient  is  sug- 
gestive, sometimes  characteristic,  but  difficult  to  describe.  Important  informa- 
tion can  be  gained  by  the  physician  if  he  observe  the  patient  closely  as  he 
enters  the  room — the  way  he  is  clothed,  the  manner  in  which  he  holds  his 
body,  his  facial  expression,  and  the  humor  which  he  is  in.  Loss  of  weight  and 
slight  angemia  may  be  present.  The  physical  debility  may  reach  a  high  grade 
and  the  patient  may  be  confined  to  bed.  Mentally  the  patients  are  usually  low- 
spirited  and  despondent;  women  are  frequently  emotional. 

The  local  s}Tnptoms  may  dominate  the  situation,  and  there  have  accordingly 
been  described  a  whole  series  of  types  of  the  disease — cerebral,  spinal,  cardio- 
vascular, gastric,  and  sexual.  In  all  forms  there  is  a  striking  lack  of  accord- 
ance between  the  symptoms  of  which  the  patient  complains  and  the  objective 


1088  DISEASES  OF  THE  NERVOUS  SYSTEM. 

changes  discoverable  by  the  j)hysician.  In  nearly  every  clinical  type  of  the 
disease  the  predominant  symptoms  are  referable  to  pathological  sensations  and 
the  psychic  effects  of  these.  Imperfect  sleep  is  also  complained  of  by  a  majority 
of  patients^  or,  if  not  complained  of,  is  found  to  exist  on  inquiry. 

In  the  cerebral  or  psychic  form  the  sjonptoms  are  chiefly  connected  with 
an  inability  to  perform  the  ordinary  mental  work.  Thus  a  row  of  fignires  can 
not  be  correctly  added,  the  dictation  or  the  writing  of  a  few  letters  is  a  source 
of  the  greatest  worry,  the  transaction  of  petty  details  in  business  is  a  painful 
effort,  and  there  is  loss  of  power  of  fixed  attention.  With  this  condition  there 
may  be  no  headache,  the  appetite  may  be  good,  and  the  patient  may  sleep  well. 
As  a  rule,  however,  there  are  sensations  of  fulness  and  weight  or  flushes,  if  not 
actual  headache.  Sleeplessness  is  a  frequent  concomitant  of  the  cerebral  form, 
and  may  be  the  first  manifestation.  Some  of  these  patients  are  good-tempered 
and  cheerful,  but  a  majority  are  moody,  irritable,  and  depressed. 

Hypergesthesia,  especially  to  sensations  of  pain,  is  one  of  the  main  charac- 
teristics of  almost  all  neurasthenic  individuals.  The  sensations  are  nearly 
always  referred  to  some  special  region  of  the  body — the  skin,  eye  muscles,  the 
joints,  the  blood-vessels,  or  the  viscera.  It  is  frequently  possible  to  localize 
a  number  of  points  painful  to  pressure  (Yalleix's  points).  In  some  pa- 
tients there  is  marked  vertigo,  occasionally  even  resembling  that  of  Meniere's 
disease. 

If  such  pathological  sensations  continue  for  a  long  time  the  mood  and 
character  of  the  patient  gradually  alter.  The  so-called  "  irritable  humor " 
develops.  Many  obnoxiously  egoistic  individuals  met  with  in  daily-  life  are  in 
reality  examples  of  psychic  neurasthenia.  Everything  is  complained  of.  The 
patient  demands  the  greatest  consideration  for  his  condition ;  he  feels  that  he 
has  been  deeply  insulted  if  his  desires  are  not  always  immediately  granted. 
He  may  at  the  same  time  have  but. little  consideration  for  others.  Indeed,  in 
the  severer  forms  of  the  disease  he  may  show  a  malicious  pleasure  in  attempt- 
ing to  make  people  who  seem  happier  than  himself  uncomfortable.  Such 
patients  complain  frequently  that  they  are  "  misunderstood  "  by  their  fellows. 

In  many  cases  the  so-called  "  anxiety  conditions  "  gradually  come  on ;  one 
scarcely  ever  sees  a  case  of  advanced  neurasthenia  without  the  existence  of 
some  form  of  "  anxiety."  In  the  simpler  forms  of  anxiety  (nosophobic)  there 
may  be  only  a  fear  of  impending  insanity  or  of  approaching  death  or  of  apo- 
plexy. More  frequently  the  anxious  feeling  is  localized  somewhere  in  the  body 
— in  the  precordial  region,  in  the  head,  in  the  abdomen,  in  the  thorax,  or  more 
rarely  in  the  extremities. 

In  some  cases  the  anxiety  becomes  intense  and  the  patients  are  restless,  and 
declare  that  they  do  not  know  what  to  do  with  themselves.  They  may  throw 
themselves  upon  a  bed,  crying  and  complaining,  and  making  convulsive  move- 
ments with  the  hands  and  feet.  Suicidal  tendencies  are  not  uncommon  in 
such  cases,  and  patients  may  in  desperation  actually  take  their  own  lives. 

Involuntary  mental  activity  naay  be  very  troublesome;  the  patient  com- 
plains that  when  he  is  overtired  thoughts  which  he  can  not  stop  or  control 
run  through  his  head  with  lightning-like  rapidity.  In  other  cases  there  is 
marked  absence  of  mind,  the  individual's  mind  being  so  filled  up  owing  to 
the  overexcitability  of  latent  memory  pictures  that  he  is  unable  to  form  the 
proper  associations  for  ideas  called  up  by  external  stimuli.     Sometimes  a 


GENERAL  AND  FUNCTIONAL  DISEASES.  1089 

patient  complains  that  a  definite  word,  a  name,  a  numl^er,  a  melod}',  or  a  song 
keeps  running  in  his  head  in  spite  of  all  he  can  do  to  abolish  it. 

In  the  severer  cases  of  psychic  neurasthenia  the  so-called  "  phobias  "  are 
common.  The  most  frequent  form  perhaps  is  agoraphobia^  in  which  patients 
the  moment  they  come  into  an  open  space  are  oppressed  by  an  exaggerated 
feeling  of  anxiety.  They  seem  "  frightened  to  death/'  and  commence  to 
tremble  all  over;  they  complain  of  compression  of  the  thorax  and  palpitation 
of  the  heart.  They  may  break  into  profuse  perspiration  and  assert  that  they 
feel  as  though  chained  to  the  ground  or  that  they  can  not  move  a  step.  It  is 
remarkable  that  in  some  such  cases  the  open  space  can  be  crossed  if  the  indi- 
vidual be  accompanied  by  some  one,  even  by  a  child,  or  if  he  carry  a  stick  or 
an  umbrella  I  Other  people  are  afraid  to  be  left  alone  (monophobia),  espe- 
cially in  a  closed  compartment  (claustrophobia). 

The  fear  of  people  and  of  society  is  known  as  anthropophobia.  A  whole 
series  of  other  phobias  have  been  described — batophobia,  or  the  fear  that  high 
things  will  fall;  pathophobia,  or  fear  of  disease;  siderodromophobia,  or  fear 
of  a  railway  journey;  siderophobia  or  astrophobia,  fear  of  thunder  and  light- 
ning. Occasionally  we  meet  with  individuals  who  are  afraid  of  everything  and 
every  one — victims  of  the  so-called  pantophobia. 

The  special  senses  may  be  disturbed,  particularly  vision.  An  aching  or 
weariness  of  the  eyeballs  after  reading  a  few  minutes  or  flashes  of  light  are 
common  symptoms.  The  "  irritable  eye,"  the  so-called  nervous  or  neurasthenic 
asthenopia,  is  familiar  to  every  family  physician.  According  to  Binswanger^ 
the  essence  of  the  asthenopic  disturbance  consists  in  pathological  sensations 
of  fatigue  in  the  ciliary  muscles  or  the  medial  recti. 

There  may  be  acoustic  disturbances — hyperalgesia  and  even  true  hyper- 
acusia. 

One  of  the  most  common  of  all  the  symptoms  of  neurasthenia  is  the  pressure 
in  the  head  complained  of  by  these  patients.  This  symptom,  variously  de- 
scribed, may  be  diffuse,  but  is  more  frequently  referred  to  some  one  region — 
frontal,  temporal,  parietal,  or  occipital. 

When  the  spinal  symptoms  predominate — spinal  irritation  or  spinal  neuras- 
thenia— in  addition  to  many  of  the  features  just  mentioned,  the  patients  com- 
plain of  weariness  on  the  least  exertion,  of  weakness,  pain  in  the  back, 
intercostal  neuralgiform  pains,  and  of  aching  pains  in  the  legs.  There  may 
be  spots  of  local  tenderness  on  the  spine.  The  rachialgia  may  be  spontaneous, 
or  may  be  noticed  only  on  pressure  or  movement.  Occasionally  there  may  be 
disturbances  of  sensation,  particularly  a  feeling  of  numbness  and  tingling,  and 
the  reflexes  may  be  increased.  Visceral  neuralgias,  especially  in  connection 
with  the  genital  organs,  are  frequently  met  with.  The  aching  pain  in  the 
back  or  in  the  back  of  the  neck  is  the  most  constant  complaint  in  these  cases. 
In  women  it  is  often  impossible  to  say  whether  this  condition  is  one  of  neuras- 
thenia or  hysteria.  It  is  in  these  cases  that  the  disturbances  of  muscular 
activity  are  most  pronounced,  and  in  the  French  writings  amyosthenia  particu- 
larly plays  an  important  role.  The  symptoms  may  be  irritative-  or  paretic,  or 
a  combination  of  both.  Disturbances  of  coordination  are  not  uncommon  in 
the  severer  forms.  These  are  particularly  prone  to  involve  the  associated 
movements  of  the  eye  muscles  leading  to  asthenopic  lack  of  accommodation. 
Drooping  of  one  eyelid  is  very  common,  probably  owing  to  insufficient  inner- 
70  ■ 


1090  DISEASES  OF  THE  NERVOUS  SYSTEM. 

vation  on  the  part  of  the  sympathetic  rather  than  to  paresis  of  the  oculo- 
motor nerve.  Occasionally  Eomberg's  symptom  may  be  present^  and  the 
patient,  or  even  his  physician,  may  fear  a  beginning  tabes.  More  rarely  there 
is  disturbance  of  such  finely  coordinated  acts  as  writing  and  articulation,  not 
unlike  those  seen  at  the  onset  of  general  paresis.  Such  symptoms  are  always 
alarming,  and  the  greatest  care  must  be  taken  in  establishing  a  diagnosis. 
That  they  may  be  the  symptoms  of  pure  neurasthenia,  however,  can  no  longer 
be  doubted. 

The  reflexes  in  neurasthenia  are  usually  increased,  the  deep  reflexes  espe- 
cially never  being  absent.  The  condition  of  the  superficial  reflexes  is  less 
constant,  though  these,  too,  are  usually  increased.  The  pupils  are  often  dilated, 
and  the  reflexes  are  usually  normal.  There  may  be  inequality  of  the  pupils 
in  neurasthenia,  a  point  which  Pelizaeus  has  especially  emphasized.  Errors 
in  refraction  are  common,  the  correction  of  which  may  give  great  relief. 

In  another  type  of  cases  the  muscular  weakness  is  extreme,  and  may  go  on 
even  to  complete  motor  helplessness.  Very  thorough  examination  is  necessary 
before  deciding  as  to  the  nature  of  the  affection,  since  in  some  instances  serious 
mistakes  have  been  made.  Here  belong  the  atremia  of  Neftel,  the  akinesia 
algera  of  Mobius,  and  the  neurasthenic  form  of  astasia  ahasia  described  by 
Binswanger. 

In  other  cases  the  cardio-vascular  symptoms  are  the  most  distressing,  and 
may  occur  with  only  slight  disturbance  of  the  cerebro-spinal  functions,  though 
the  conditions  are  nearly  always  combined.  Palpitation  of  the  heart,  irregular 
and  very  rapid  action  (neurasthenic  tachycardia),  and  pains  and  oppressive 
feelings  in  the  cardiac  region  are  the  most  common  symptoms.  The  slightest 
excitement  may  be  followed  by  increased  action  of  the  heart,  sometimes  asso- 
ciated with  sensations  of  dizziness  and  anxiety,  and  the  patients  frequently 
have  the  idea  that  they  suffer  from  serious  disease  of  this  organ.  Attacks  of 
pseudo-angina  may  occur. 

Vaso-motor  distur'bances  constitute  a  special  feature  of  many  cases. 
Flushes  of  heat,  especially  in  the  head,  and  transient  hypersemia  of  the  skin 
may  be  very  distressing  symptoms.  Profuse  sweating  may  occur,  either  local 
or  general,  and  sometimes  nocturnal.  The  pulse  may  show  interesting  features, 
owing  to  the  extreme  relaxation  of  the  peripheral  arterioles.  The  arterial 
throbbing  may  be  everywhere  visible,  almost  as  much  as  in  aortic  insufficiency. 
The  pulse,  too,  may  under  these  circumstances  have  a  somewhat  water-hammer 
quality.  The  capillary  pulse  may  be  seen  in  the  nails,  on  the  lips,  or  on  the 
margins  of  a  line  drawn  upon  the  forehead,  and  I  have  on  several  occasions 
seen  pulsation  in  the  veins  of  the  back  of  the  hand.  A  characteristic  symptom 
in  some  cases  is  the  throbbing  aorta.  This  "  preternatural  pulsation  in  the 
epigastrium,"  as  Allan  Burns  calls  it,  may  be  extremely  forcible  and  suggest 
the  existence  of  abdominal  aneurism.  The  subjective  sensations  associated 
with  it  may  be  very  unpleasant,  particularly  when  the  stomach  is  empty. 

In  women  especially,  and  sometimes  in  men,  the  peripheral  blood-vessels 
are  contracted,  the  extremities  are  cold,  the  nose  is  red  or  blue,  and  the  face 
has  a  pinched  expression.  These  patients  feel  much  more  comfortable  when 
the  cutaneous  vessels  are  distended,  and  resort  to  various  means  to  favor  this 
(wearing  of  heavy  clothing,  use  of  diffusible  stimulants). 

The  general  features  of  gastro-intestinal  neurasthenia  have  been  dealt  with 


GENERAL  AND  FUNCTIONAL  DISEASES.  1091 

under  the  section  of  nervous  dyspepsia.  The  connection  of  these  cases  with 
dilatation  of  the  stomach,  floating  kidney,  and  the  condition  which  Glenard 
calls  enteroptosis  has  already  been  mentioned. 

Sexual  neurasthenia  is  a  condition  in  which  there  is  an  irritable  weakness 
of  the  sexual  organs  manifested  by  nocturnal  emissions,  unusual  depression 
after  intercourse,  and  often  by  a  distressing  dread  of  impotence.  The  mental 
condition  of  these  patients  is  most  pitiable,  and  they  fall  an  easy  prey  to 
quacks  and  charlatans  of  all  kinds. 

Spermatorrhoea  is  the  bugbear  of  the  majority.  They  complain  of  con- 
tinued losses,  usually  without  accompanying  pleasurable  sensations.  After 
defecation  or  micturition  there  may  be  seminal  discharges.  Microscopic  ex- 
amination sometimes  reveals  the  presence  of  spermatozoa.  Actual  nervous 
impotence  is  not  uncommon.  The  "  painful  testicle  "  is  a  well-known  neuras- 
thenic phenomenon.  In  the  severer  cases,  especially  those  bearing  the  stig- 
mata of  degeneration,  there  may  be  evidence  of  sexual  perversion. 

In  females  it  is  common  to  find  a  tender  ovary,  and  painful  or  irregular 
menstruation. 

In  all  forms  of  neurasthenia  the  condition  of  the  urine  is  important. 
Many  cases  are  complicated  with  the  symptoms  of  the  condition  known  as 
lithsemia,  and  so  marked  may  this  be  that  some  have  indeed  made  a  special 
form  of  lithsemic  neurasthenia.  Polyuria  may  be  present,  but  is  more  com- 
mon in  hysteria.  With  disturbed  digestion  the  urates  and  oxalates  may  be 
in  excess. 

Diagnosis. — PsycJiasthenia. — ^TJnder  this  term  Janet  would  separate  from 
neurasthenia  the  cases  characterized  by  mental,  emotional,  and  physical  dis- 
turbances, imperative  ideas,  phobias  of  all  sorts,  doubts,  enfeebled  will,  imcon- 
trollable  movements,  and  many  of  the  borderland  features  of  the  insanity  of 
young  persons.  It  is  really  an  inherited  psychoneurosis,  while  neurasthenia 
is  usually  acquired.  Obsessions  of  all  sorts  characterize  the  condition  and 
there  may  be  a  feeling  of  unreality  and  even  of  loss  of  personality.  How  com- 
plicated the  condition  may  be  is  shown  from  the  following  varieties  distin- 
guished by  Janet:  (1)  The  doubter,  in  whom  obsessive  ideas  are  not  very 
precise,  more  of  the  nature  of  a  general  indication  rather  than  a  specific  idea, 
such  as  a  craze  for  research,  for  explanation,  for  computing.  (2)  The  scru- 
pulous, whose  obsessions  are  of  a  moral  nature.  Their  manias  are  of  literal- 
ness  of  statement,  of  exact  truth,  of  conjuration,  of  reparation,  of  symbols, 
etc.  (3)  The  criminal,  whose  obsessive  ideas  are  of  homicide,  theft,  and  other 
overt  acts.  The  impulsive  idea  is  stronger  in  this  than  in  the  other  varieties. 
(4)  The  inebriates,  dipsomaniac,  morphinomaniac,  etc.,  in  whom  the  impulse 
seems  to  be  least  resistible.  (5)  The  genesically  perverted.  (6)  Delirious 
psychasthenia,  a  condition  in  which  a  delirious  state  of  mind  occurs,  connected 
with  the  obsession. 

The  anxiety  conditions  and  various  phobias,  as  well  as  the  difEerent 
varieties  of  tic  and  the  occupation  neuroses  when  they  accompany  neuras- 
thenia, are  regarded  as  complications  dependent  in  the  majority  of  instances 
upon  faulty  heredity. 

Neurasthenia  is  a  disease  above  all  others  which  has  to  be  diagnosed  from 
the  subjective  statements  of  the  patient,  and  from  an  observation  of  his  general 
behavior  rather  than  from  the  physical  examination.     The  physical  examina- 


1092  DISEASES  OF  THE  NERVOUS  SYSTEM. 

tion  is  of  the  highest  importance  in  excluding  other  diseases  likely  to  be 
confounded  with  it.  That  somatic  changes  occur  and  that  physical  signs  are 
often  to  be  made  out  is  very  true,  and  we  owe  to  Lowenfeld  especially  a  careful 
discussion  of  these  points,  but  there  is  nothing  typical  or  pathognomonic  in 
these  objective  changes. 

The  hj-pochondriac  differs  from  the  neurasthenic  in  the  excessive  psychic 
distortion  of  the  pathological  sensations  to  which  he  is  subject.  He  is  the 
victim  of  actual  delusions  regarding  his  condition. 

The  confusion  of  neurasthenia  with  hj'Steria  is  still  more  frequent;  in 
women  especially  a  diagnosis  of  hysteria  is  often  made  when  in  reality  the 
condition  is  one  of  neurasthenia.  In  the  absence  of  hysterical  paroxj^sms,  of 
crises,  and  of  those  marked  emotional  and  intellectual  characteristics  of  the 
hysterical  individual  the  diagnosis  of  hysteria  should  not  be  made.  Of  course, 
in  many  of  the  cases  of  hysteria  definite  hysterical  stigmata  (hysterical  paral- 
yses, convulsions,  contractures,  anaesthesias,  alterations  in  the  visual  field,  etc.) 
are  present,  and  the  diagnosis  is  not  difficult. 

Epilepsy  is  not  likel}*  to  be  confounded  with  neurasthenia  if  there  be  defi- 
nite epileptic  attacks,  but  the  cases  of  petit  mal  may  be  puzzling. 

The  onset  of  exophthalmic  goitre  may  be  mistaken  for  neurasthenia,  espe- 
cially if  there  be  no  exophthalmos  at  the  beginning.  The  emotional  disturb- 
ances and  the  irritability  of  the  heart  may  mislead  the  physician.  In  pro- 
nounced cases  of  nervous  prostration  the  differential  diagnosis  from  the  various 
psychoses  may  be  extremely  difficult. 

The  two  forms  of  organic  disease  of  the  nervous  system  with  which  neuras- 
thenia is  most  likely  to  be  confounded  are  tabes  and  general  paresis.  The 
s}Tnptoms  of  the  spinal  form  of  neurasthenia  may  resemble  those  of  the  former 
disease,  while  the  s}Tnptoms  of  the  psychic  or  cerebral  form  of  neurasthenia 
may  be  very  similar  to  those  of  general  paresis.  The  diagnosis,  as  a  rule, 
presents  no  difficulty  if  the  physician  be  careful  to  make  a  thorough  routine 
examination.  It  is  only  the  superficial  study  of  a  case  that  is  likely  to  lead 
one  astray.  In  tabes  especially  a  consideration  of  the  sensory  disturbances, 
of  the  deep  reflexes,  and  of  the  pupillary  findings  will  always  establish  the 
presence  or  absence  of  the  disease.  In  general  paresis  there  is  sometimes  more 
difficult}^  The  onset  of  general  paresis  is  often  characterized  by  the  appear- 
ance of  symptoms  quite  like  those  of  ordinary  neurasthenia,  and  the  family 
physician  may  entirely  overlook  the  grave  nature  of  the  malady.  The  mistake 
in  the  other  direction  is,  however,  perhaps  just  as  common.  A  physician  who 
once  or  twice  has  seen  a  case  of  general  paresis  arise  out  of  what  appeared  to 
be  one  of  pronounced  neurasthenia  is  too  prone  afterward  to  suspect  every 
neurasthenic  to  be  developing  the  malign  affection.  The  most  marked  symp- 
toms, however,  of  psychic  exhaustion  do  not  jilstify  a  diagnosis  of  general 
paresis  even  when  the  history  is  suspicious,  unless  along  with  it  there  is  a 
definite  paresis  of  the  pupils,  of  the  facial  muscles,  or  of  the  muscles  of  articu- 
lation. A  history  of  syphilis  or  of  chronic  alcoholism  or  morphinism  asso- 
cated  with  severe  psychic  exhaustion  should,  of  course,  put  one  always  on  his 
guard,  and  the  physician  should  be  sharply  on  the  lookout  for  the  appearance 
of  intellectual  defects,  paraphasia,  facial  paresis,  and  sluggishness  of  the  pupils. 

Treatment. — Prophylaxis. — Many  patients  come  under  our  care  a  gen- 
eration too  late  for  satisfactory  treatment,  and  it  may  be  impossible  to  restore 


GENERAL  AND  FUNCTIONAL  DISEASES.  1093 

the  exhausted  capital.  The  greatest  care  should  be  taken  in  the  rearing  of 
children  of  neuropathic  predisposition.  From  a  very  early  age  they  should 
be  submitted  to  a  process  of  "  psychic  hardening,"  every  effort  being  made  to 
strengthen  the  bodily  and  mental  condition.  Even  in  infancy  the  child  should 
not  be  pampered.  Later  on  the  greatest  care  should  be  exercised  with  regard 
to  food,  sleep,  and  school  v^^ork.  Complaints  of  children  should  not  be  too 
seriously  considered. 

Much  depends  upon  the  example  set  by  the  parents.  A  restless,  emotional, 
constantly  complaining  mother  will  rack  the  nervous  system  of  a  delicate  child. 
In  some  instances,  for  the  welfare  of  a  developing  boy  or  girl,  the  physician 
may  find  it  necessary  to  advise  its  removal  from  home. 

Neurotic  children  are  especially  liable  during  development  to  fits  of  temper 
and  of  emotional  disturbance.  These  should  not  be  too  lightly  considered. 
Above  all,  violent  chastisement  in  such  cases  is  to  be  avoided,  and  loss  of 
temper  on  the  part  of  the  parent  or  teacher  is  particularly  pernicious  for  the 
nervous  system  of  the  child.  Where  possible,  in  such  instances,  the  best  treat- 
ment is  to  put  the  obstreperous  child  immediately  to  bed,  and  if  the  excite- 
ment and  temper  continue  a  warm  bath  followed  by  a  cool  douche  may  be 
effective.    If  he  be  put  to  bed  after  the  bath  sleep  soon  follows. 

Special  attention  is  necessary  at  puberty  in  both  boys  and  girls.  If  there 
be  at  this  period  any  marked  tendency  to  emotional  disturbance  or  to  intel- 
lectual weakness  the  child  should  be  removed  from  school  and  every  care  taken 
to  avoid  unfavorable  influences. 

Peesonal  Hygiene. — Throughout  life  individuals  of  neuropathic  predis- 
position should  obey  scrupulously  certain  hygienic  and  prophylactic  rules.  In- 
tellectual work  especially  should  be  judiciously  limited  and  should  alternate 
frequently  with  periods  of  repose.  Excitement  of  all  kinds  should  of  course 
be  avoided,  and  such  individuals  will  do  well  to  be  abstemious  in  the  use  of 
tobacco,  tea,  coffee,  and  alcohol,  if,  indeed,  they  be  permitted  to  use  these 
substances  at  all.  The  habit,  happily  becoming  very  common,  of  taking  at 
least  once  a  year  a  prolonged  holiday  away  from  the  ordinary  environment, 
in  the  woods,  in  the  mountains,  or  at  the  seashore,  should  be  urgently  en- 
joined upon  every  neuropathic  individual.  In  many  instances  it  is  found  to 
be  the  greatest  relief  and  rest  if  the  patient  can  take  his  holiday  away  from 
his  relatives. 

During  ordinary  life  nervous  people  should,  during  some  portion  of  each 
day,  pay  rational  attention  to  the  body.  Cold  baths,  swimming,  exercises  in 
the  gymnasium,  gardening,  golf,  lawn  tennis,  cricket,  hunting,  shooting,  row- 
ing, sailing,  and  bicycling  are  of  value  in  maintaining  the  general  nutrition. 
Such  exercises  are,  of  course,  to  be  recommended  only  to  individuals  physically 
equal  to  them.  If  neurasthenia  be  once  well  established  the  greatest  care  must 
be  observed  in  the  ordering  of  exercise.  Many  nervous  girls  have  been  com- 
pletely broken  down  by  following  injudicious  advice  with  regard  to  long  walks. 

Treatment  of  the  Condition. — The  treatment  of  neurasthenia  when 
once  established  presents  a  varied  problem  to  the  thoughtful  physician.  Every 
case  must  be  handled  upon  its  own  merits,  no  two,  as  a  rule,  requiring  exactly 
the  same  methods.  In  general  it  will  be  the  aim  of  the  medical  adviser  to 
remove  the  patient  as  far  as  possible  from  the  influences  which  have  led  to 
his  downfall,  and  to  restore  to  normal  the  nervous  mechanisms  which  have 


1094  DISEASES  OF  THE  NERVOUS  SYSTEM. 

been  weakened  by  injurious  influences.  The  general  character  of  the  indi- 
vidual, his  physical  and  social  status  must  of  course  be  considered,  and  the 
therapeutic  measures  carefully  adjusted  to  these. 

The  diagnosis  having  been  settled,  the  physician  may  assure  the  patient 
that  with  jDrolonged  treatment,  during  which  his  cooperation  with  the  physi- 
cian is  absolutely  essential,  he  may  expect  to  get  well.  He  must  be  told  that 
much  depends  upon  himself  and  that  he  must  make  a  vigorous  efEort  to  over- 
come certain  of  his  tendencies,  and  that  all  his  strength  of  will  will  be  needed 
to  further  the  progress  of  the  cure.  In  the  case  of  business  or  professional 
men,  in  whom  the  condition  develops  as  a  result  of  overwork  or  overstudy,  it 
may  be  sufficient  to  enjoin  absolute  rest  with  change  of  scene  and  diet.  A  trip 
abroad,  with  a  residence  for  a  month  or  two  in  Switzerland,  or,  if  there  are 
sjanptoms  of  nervous  dyspepsia,  a  residence  at  one  of  the  Spas  will  usually 
prove  sufficient.  The  excitement  of  the  large  cities  abroad  should  be  avoided. 
The  longer  the  disease  has  lasted  and  the  more  intense  the  symptoms  have 
been,  the  longer  the  time  necessary  for  the  restoration  of  health.  In  cases  of 
any  severity  the  patient  must  be  told  that  at  least  six  months'  complete  ab- 
sence from  business,  under  strict  medical  guidance,  will  be  necessary.  Shorter 
periods  may  of  course  be  of  benefit,  which,  however,  as  a  rule,  will  be  only 
temporary. 

It  will  often  be  found  advisable  to  make  out  a  daily  programme,  which 
shall  occupy  almost  the  whole  time  of  the  patient.  At  first  he  need  Iniow 
nothing  about  this,  the  case  being  given  over  entirely  to  the  nurse.  As  im- 
provement advances,  moderate  physical  and  intellectual  exercises,  alternating 
frequently  with  rest  and  the  administration  of  food,  may  be  undertaken.  Some 
one  hour  of  the  day  may  be  left  free  for  reading,  correspondence,  conver- 
sation, and  games.  In  some  instances  the  writing  of  letters  is  particularly 
harmful  to  the  patient  and  must  be  prohibited  or  limited.  Cultured  indi- 
viduals may  find  benefit  from  attention  to  drawing,  painting,  modelling, 
translating  from  a  foreign  language,  the  making  of  abstracts,  etc.,  for  short 
periods  in  the  day. 

In  not  a  few  cases,  including  a  large  proportion  of  neurasthenic  women, 
a  S3^stematic  "Weir  Mitchell  treatment  rigidly  carried  out  should  be  tried  (see 
H3^steria).  For  obstinate  and  protracted  cases,  particularly  if  combined  with 
the  chloral  or  morphia  habit,  no  other  plan  is  so  satisfactory.  The  patient 
must  be  isolated  from  his  friends,  and  any  regulations  undertaken  must  be 
strictly  adhered  to,  the  consent  of  the  patient  and  his  family  having  first  been 
gained.  If  the  case  responds  well  to  the  treatment  there  should  be  a  gain  of 
from  2  to  4  pounds  per  week.  The  benefit  is  often  extraordinary,  individuals 
increasing  in  weight  as  much  as  from  50  to  80  pounds  in  the  course  of  twelve 
weeks.  The  treatment  of  the  gastric  and  intestinal  symptoms  so  important 
in  this  condition  has  already  been  considered.  For  the  irregular  pains,  par- 
ticularly in  the  back  and  neck,  the  thermo-cautery  is  invaluable. 

Hydrotherapy  is  indicated  in  nearly  every  case  if  it  can  be  properly  applied. 
Much  can  be  done  at  home  or  in  an  ordinary  hospital,  but  for  systematic 
hydrotherapeutic  treatment  residence  in  a  suitable  sanitarium  is  necessary. 
I  have  found  the  wet  pack  of  especial  value.  Particularly  at  night,  in  cases  of 
sleeplessness,  it  is  perhaps  the  best  remedy  against  insomnia  we  have.  Some 
patients  gain  rapidly  in  weight  through  the  systematic  use  of  the  wet  pack. 


GENERAL  AND  FUNCTIONAL  DISEASES.  1095 

Salt  baths  are  more  helpful  to  some  patients.  The  various  forms  of  douches, 
partial  packs,  foot  baths,  etc.,  may  be  valuable  in  individual  cases.  The  Scotch 
douche  is  often  invigorating  in  the  milder  cases. 

Electrotherapy  is  of  some  value,  though  only  in  combination  with  psychic 
treatment  and  hydrotherapy.  General  and  local  faradization,  galvanic  elec- 
tricity, and  Franklinization  may  be  used;  in  every  case,  however,  with  great 
caution  and  only  by  skilled  operators.  The  care  of  the  eyes  is  most  important, 
and  refractive  errors  should  be  corrected. 

Treatment  by  drugs  should  be  avoided  as  much  as  possible.  They  are  of 
benefit  chiefly  in  the  combating  of  single  symptoms.  A  placebo  is  sometimes 
necessary  for  its  psychic  effect.  Alcohol,  morphia,  chloral,  or  cocaine  should 
never  be  given.  The  family  physician  is  often  responsible  for  the  develop- 
ment of  a  drug  habit.  I  have  been  repeatedly  shocked  by  the  loose,  careless 
way  in  which  physicians  inject,  morphia  for  a  simple  headache  or  a  mild 
neuralgia. 

General  tonics  may  be  helpful,  especially  if  the  individual  be  anaemic. 
Arsenic  and  more  often  iron  are  then  indicated.  The  value  of  phosphorus  has 
been  exaggerated.  For  the  severer  pains  and  nervous  attacks  some  sedative 
may  occasionally  be  necessary,  esj)ecially  at  the  beginning  of  the  treatment. 
The  bromides,  especially  a  mixture  of  the  salts  of  ammonium,  potassium,  and 
sodium  may  here  be  given  with  advantage.  An  occasional  dose  of  phenacetin, 
antipyrin,  or  salipyrin  may  be  required,  but  the  less  of  these  substances  we  can 
get  along  with  the  better.  For  the  relief  of  sleeplessness  all  possible  measures 
should  be  resorted  to  before  the  employment  of  drugs.  The  wet  pack  will 
usually  suffice.  If  absolutely  necessary  to  give  a  drug,  sulphonal,  trional,  or 
amylene  hydrate  may  be  employed. 

In  cases  in  which  the  anxiety  conditions  are  disturbing,  the  cautious  use 
of  opium  in  pill  form  may  be  necessary,  since,  as  in  the  psychoses,  opium  here 
will  sometimes  yield  permanent  relief.  A  prolonged  treatment  with  opium  is, 
however,  never  necessary  in  neurasthenia. 

Faith  Healing. — In  all  ages,  and  in  all  lands,  the  prayer  of  faith,  to 
use  the  words  of  St.  James,  has  healed  the  sick ;  and  we  must  remember  that 
amid  the  iEsculapian  cult,  the  most  elaborate  and  beautiful  system  of  faith 
healing  the  world  has  seen,  scientific  medicine  took  its  rise.  As  a  profession, 
consciously  or  unconsciously,  more  often  the  latter,  faith  has  been  one  of  our 
most  valuable  assets,  and  Galen  expressed  a  great  truth  when  he  said,  "  He 
cures  most  successfully  in  whom  the  people  have  the  greatest  confidence." 
It  is  in  these  cases  of  neurasthenia  and  psychasthenia,  the  weak  brothers  and 
the  weak  sisters,  that  the  personal  character  of  the  physician  comes  into  play, 
and  once  let  him  gain  the  confidence  of  the  patient,  he  can  work  just  the 
same  sort  of  miracles  as  Our  Lady  of  Lourdes  or  Ste.  Anne  de  Beaupre.  Three 
elements  are  necessary:  first,  a  strong  personality  in  whom  the  individual 
has  faith — Christ,  Buddha,  iEsculapius  (in  the  days  of  Greece),  one  of  the 
saints,  or,  what  has  served  the  turn  of  common  humanity  very  well,  a  physi- 
cian. Secondly,  certain  accessories — a  shrine,  a  sanctuary,  the  service  of  a 
temple,  or  for  us  a  hospital  or  its  equivalent,  with  a  skilful  nurse.  Thirdly, 
suggestion,  either  of  the  "  only  believe,"  "  feel  it,"  "  will  it "  attitude  of  mind, 
which  is  the  essence  of  every  cult  and  creed,  or  of  the  active  belief  in  the 
assurance  of  the  physician  that  the  precious  boon  of  health  is  within  reach. 


1096  DISEASES  OF  THE  NERVOUS  SYSTEM. 

XIII.     THE    TRAUMATIC    NEUROSES. 

(Railway  Brain  and  Railway  Spine ;  Traumatic  Hysteria.) 

Definition. — A  morbid  condition  following  shock  which  presents  the  symp- 
toms of  neurasthenia  or  hysteria  or  of  both.  The  condition  is  kno^vn  as 
"  railway  brain  "  and  "  railway  spine.^' 

Erichsen  regarded  the  condition  as  the  result  of  inflammation  of  the  men- 
inges and  cord,  and  gave  it  the  name  railway  spine.  Walton  and  J.  J.  Putnam, 
of  Boston,  were  the  first  to  recognize  the  hysterical  nature  of  many  of  the  cases, 
and  to  Westphal's  pupils  we  owe  the  name  traumatic  neurosis.  For  an  ex- 
cellent discussion  of  the  whole  question  the  reader  is  referred  to  Pearce  Baily's 
work,  On  Accident  and  Injury;  their  Eelation  to  Diseases  of  the  Nervous 
System. 

Etiology. — The  condition  follows  an  accident,  often  in  a  railway  train,  in 
which  injury  has  been  sustained,  or  succeeds  a  shock  or  concussion,  from  which 
the  patient  may  apparently  not  have  suffered  in  his  body.  A  man  may  appear 
perfectly  well  for  several  days,  or  even  a  week  or  more,  and  then  develop  the 
symptoms  of  the  neurosis.  Bodily  shock  or  concussion  is  not  necessary.  The 
affection  may  follow  a  profound  mental  impression;  thus,  an  engine-driver 
ran  over  a  child,  and  received  thereby  a  very  severe  shock,  subsequent  to  which 
the  most  pronounced  symptoms  of  neurasthenia  developed.  Severe  mental 
strain  combined  with  bodily  exposure  may  cause  it,  as  in  a  case  of  a  naval 
officer  who  was  wrecked  in  a  violent  storm  and  exposed  for  more  than  a  day 
in  the  rigging  before  he  was  rescued.  A  slight  blow,  a  fall  from  a  carriage 
or  on  the  stairs  may  suffice. 

Symptoms. — The  cases  may  be  divided  into  three  groups :  simple  neuras- 
thenia, cases  Avith  marked  hysterical  manifestations,  and  cases  with  severe 
symptoms  indicating  or  simulating  organic  disease. 

(a)  Simple  Traumatic  Neurasthenia. — The  first  symptoms  usually  de- 
velop a  few  weeks  after  the  accident,  which  may  or  may  not  have  been  asso- 
ciated with  an  actual  trauma.  The  patient  complains  of  headache  and  tired 
feelings.  He  is  sleepless  and  finds  himself  unable  to  concentrate  his  attention 
properly  upon  his  work.  A  condition  of  nervous  irritability  develops,  which 
may  have  a  host  of  trivial  manifestations,  and  the  entire  mental  attitude  of 
the  person  may  for  a  time  be  changed.  He  dwells  constantly  upon  his  condi- 
tion, gets  very  despondent  and  low-spirited,  and  in  extreme  cases  melancholia 
may  develop.  He  may  complain  of  numbness  and  tingling  in  the  extremities, 
and  in  some  cases  of  much  pain  in  the  back.  The  bodily  functions  may  be  well 
performed,  though  such  patients  usually  have,  for  a  time  at  least,  disturbed 
digestion  and  loss  in  weight.  The  physical  examination  may  be  entirely  nega- 
tive. The  reflexes  are  slightly  increased,  as  in  ordinary  neurasthenia.  The 
pupils  may  be  unequal ;  the  cardio-vascular  changes  already  described  in  neu- 
rasthenia may  be  present  in  a  marked  degree.  According  as  the  symptoms  are 
more  spinal  or  more  cerebral,  the  condition  is  known  as  railway  brain  or  rail- 
way spine. 

(2)  Cases  with  Marked  Hysterical  Features. — Following  an  injury 
of  any  sort,  neurasthenic  symptoms,  like  those  described  above,  may  develop. 


GENERAL  AND  FUNCTIONAL  DISEASES.  1097 

and  in  addition  symptoms  regarded  as  characteristic  of  hysteria.  The  emo- 
tional element  is  prominent,  and  there  is  but  slight  control  over  the  feelings. 
The  patients  have  headache,  backache,  and  vertigo.  A  violent  tremor  may  be 
present,  and  indeed  constitutes  the  most  striking  feature  of  the  case.  In  the 
case  of  an  engineer  who  developed  subsequent  to  an  accident  a  series  of 
nervous  phenomenon,  the  most  marked  feature  was  an  excessive  tremor  of 
the  entire  body,  which  was  specially  manifest  during  emotional  excitement. 
The  most  pronounced  hysterical  symptoms  are  the  sensory  disturbances.  As 
first  noted  by  Putnam  and  Walton,  hemianaesthesia  may  occur  as  a  sequence 
of  traumatism.  This  is  a  common  symptom  in  France,  but  rare  in  England 
and  in  the  United  States.  Achromatopsia  may  exist  on  the  anaesthetic  side. 
A  second,  more  common,  manifestation  is  limitation  of  the  field  of  vision, 
similar  to  that  which  occurs  in  hysteria. 

Eemarkable  disturbances  may  develop  in  some  of  these  cases.  I  once  saw 
a  man  who  had  been  struck  by  an  electric  car,  whose  chief  symptom  was  an 
extraordinary  increase  in  the  number  of  respirations.  He  was  a  stout,  power- 
fully built  man,  and  presented  practically  no  other  symptom  than  dyspnoea 
of  the  most  extreme  grade.  At  the  time  of  observation  his  respirations  were 
over  130  per  minute,  and  he  stated  that  they  had  been  counted  at  over  150. 

(3)  Cases  in  which  the  Symptoms  suggest  Organic  Disease  of  the 
Brain  and  Cord. — As  a  result  of  spinal  concussion,  without  fracture  or  ex- 
ternal injury,  there  may  subsequently  develop  symptoms  suggestive  of  organic 
disease,  which  may  come  on  rapidly  or  at  a  late  date.  In  a  case  reported  by 
Leyden  the  symptoms  following  the  concussion  were  at  first  slight  and  the 
patient  was  regarded  as  a  simulator,  but  finally  the  condition  became  aggra- 
vated and  death  resulted.  The  post  mortem  showed  a  chronic  pachymenin- 
gitis, which  had  doubtless  resulted  from  the  accident.  The  cases  in  this  group 
about  which  there  is  so  much  discussion  are  those  which  display  marked  sen- 
sory and  motor  changes.  Following  an  accident  in  which  the  patient  has  not 
received  external  injury  a  condition  of  excitement  may  develop  within  a  week 
or  ten  days;  he  complains  of  headache  and  backache,  and  on  examination 
sensory  disturbances  are  found,  either  hemianaesthesia  or  areas  on  the  skin  in 
which  the  sensation  is  much  benumbed ;  or  painful  and  tactile  impressions  may 
be  distinctly  felt  in  certain  regions,  and  the  temperature  sense  is  absent.  The 
distribution  may  be  bilateral  and  symmetrical  in  limited  regions  or  hemiplegic 
in  type.  Limitation  of  the  field  of  vision  is  usually  marked  in  these  cases, 
and  there  may  be  disturbance  of  the  senses  of  taste  and  smell.  The  superficial 
refiexes  may  be  diminished;  usually  the  deep  reflexes  are  exaggerated.  The 
pupils  may  be  unequal;  the  motor  disturbances  are  variable.  The  French 
writers  describe  cases  of  monoplegia  with  or  without  contracture,  symptoms 
upon  which  Charcot  lays  great  stress  as  a  manifestation  of  profound  hysteria. 
The  combination  of  sensory  disturbances — anaesthesia  or  hyperaesthesia — with 
paralysis,  particularly  if  monoplegic,  and  the  occurrence  of  contractures  with- 
out atrophy  and  with  normal  electrical  reactions,  may  be  regarded  as  distinct- 
ive of  hysteria. 

In  rare  cases  following  trauma  and  succeeding  to  symptoms  which  may 

have  been  regarded  as  neurasthenic  or  hysterical,  there  are  organic  changes 

which  may  prove  fatal.     That  this  sequence  occurs  is  demonstrated  clearly 

by  recent  post-mortem  examinations.     The  features  upon  which  the  greatest 

71 


1098  DISEASES  OF  THE  NERVOUS  SYSTEAi. 

reliance  can  be  placed  as  indicating  organic  change  are  optic  atrophy,  bladder 
sjonptoms,  particularly  in  combination  with  tremor^  paresis,  and  exaggerated 
reflexes. 

The  anatomical  changes  in  this  condition  have  not  been  very  definite. 
When  death  follows  spinal  concussion  within  a  few  days  there  may  be  no 
apparent  lesion,  but  in  some  instances  the  brain  or  cord  has  shown  puncti- 
form  liEemorrhages.  Edes  has  reported  4  cases  in  which  a  gradual  degeneration 
in  the  pyramidal  tracts  followed  concussion  or  injury  of  the  spine ;  but  in  all 
these  cases  there  was  marked  tremor  and  the  spinal  symptoms  developed  early, 
or  followed  immediately  upon  the  accident.  Autopsies  upon  cases  in  which 
organic  lesions  have  supervened  upon  a  traumatic  neurosis  are  extremely  rare. 

Diagnosis. — A  condition  of  fright  and  excitement  following  an  accident 
may  persist  for  days  or  even  weeks,  and  then  gradually  pass  away.  The  symp- 
toms of  neurasthenia  or  of  hysteria  which  subsequently  develop  present  nothing 
peculiar  and  are  identical  with  those  which  occur  under  other  circumstances. 
Care  must  be  taken  to  recognize  simulation,  and,  as  in  these  cases  the  condition 
is  largely  subjective,  this  is  sometimes  extremely  difficult.  In  a  careful  exam- 
ination a  simulator  will  often  reveal  himself  by  exaggeration  of  certain  symp- 
toms, particularly  sensitiveness  of  the  spine,  and  by  increasing  voluntarily  the 
reflexes.  Maunkopif  suggests  as  a  good  test  to  take  the  pulse-rate  before,  dur- 
ing, and  after  pressure  upon  an  area  said  to  be  painful.  If  the  rate  is  quick- 
ened, it  is  held  to  be  proof  that  the  pain  is  real.  This  is  not,  however,  always 
the  case.  It  may  require  a  careful  study  of  the  case  to  determine  whether  the 
individual  is  honestly  suffering  from  the  symptoms  of  which  he  complains. 
A  still  more  important  question  in  these  cases  is.  Has  the  patient  organic  dis- 
ease? The  symptoms  given  under  the  first  two  groups  of  cases  may  exist  in 
a  marked  degree  and  may  persist  for  several  years  without  the  slightest  evidence 
of  organic  change.  Hemiansesthesia,  limitation  of  the  field  of  vision,  mono- 
plegia with  contracture,  may  all  be  present  as  hysterical  manifestations,  from 
which  recovery  may  be  complete.  In  our  present  knowledge  the  diagnosis  of 
an  organic  lesion  should  be  limited  to  those  cases  in  which  optic  atrophy,  blad- 
der troubles,  and  signs  of  sclerosis  of  the  cord  are  well  marked — indications 
either  of  degeneration  of  the  lateral  columns  or  of  multiple  sclerosis. 

Prognosis. — A  majority  of  patients  with  traumatic  hysteria  recover.  In 
railway  cases,  so  long  as  litigation  is  pending  and  the  patient  is  in  the  hands 
of  lawyers  the  symptoms  usually  persist.  Settlement  is  often  the  starting-point 
of  a  speedy  and  perfect  recovery.  I  have  known  return  to  health  after  the 
persistence  of  the  most  aggravated  symptoms  with  complete  disability  of  from 
three  to  five  years'  duration.  On  the  other  hand,  there  are  a  few  eases  in  which 
the  symptoms  persist  even  after  the  litigation  has  been  closed ;  the  patient  goes 
from  bad  to  worse  and  psychoses  develop,  such  as  melancholia,  dementia,  or 
occasionally  progressive  paresis.  And,  lastly,  in  extremely  rare  cases,  organic 
lesions  may  occur  as  a  sequence  of  the  traumatic  neurosis. 

The  function  of  the  physician  acting  as  medical  expert  in  these  cases  con- 
sists in  determining  (a)  the  existence  of  actual  disease,  and  (h)  its  character, 
whether  simple  neurasthenia,  severe  hysteria,  or  an  organic  lesion.  The  out- 
look for  ultimate  recovery  is  good  except  in  cases  which  present  the  more  seri- 
ous symptoms  above  mentioned.  Nevertheless,  it  must  be  borne  in  mind  that 
traumatic  hysteria  is  one  of  the  most  intractable  affections  which  we  are  called 


GENERAL  AND  FUNCTIONAL  DISEASES.  1099 

upon  to  treat.  In  the  treatment  of  the  traumatic  neuroses  the  practitioner 
may  be  guided  by  the  principles  laid  down  in  the  preceding  chapter,  in  which 
the  treatment  of  neurasthenia  in  general  has  been  described. 

XIV.  OTHER  FORMS  OF  FUNCTIONAL  PARALYSIS. 

I.  Periodical  Paralysis. 

The  periodical  paralysis  of  the  ocular  muscles,  which  may  recur  for  years, 
has  already  been  referred  to.  A  periodical  paralysis  involving  the  general 
muscles,  also  a  "  family  "  aflEection,  may  return  with  great  regularity.  Gold- 
flam  described  twelve  cases  in  one  family,  the  heredity  being  through  the 
mother.  In  the  United  States  E.  W.  Taylor  described  eleven  cases  in  one 
family  in  five  generations.  Holtzapple,  of  York,  Pa.,  reports  16  cases  in  one 
family.     Six  of  the  number  died  in  an  attack. 

The  clinical  picture  is  similar  in  all  recorded  cases.  The  paralysis  involves, 
as  a  rule,  the  arms  and  legs,  but  may  be  general  below  the  neck.  It  comes  on 
in  healthy  persons  without  apparent  cause,  and  often  during  sleep.  At  first 
there  may  be  weakness  of  the  limbs,  a  feeling  of  weariness  and  sleepiness,  but 
rarely  sensory  symptoms.  The  paralysis,  beginning  in  the  legs,  to  which  it 
may  be  confined,  is  usually  complete  within  the  first  twenty-four  hours.  The 
neck  muscles  are  sometimes  involved,  and  occasionally  those  of  the  tongue  and 
pharynx.  The  cerebral  nerves  and  the  special  senses  are,  as  a  rule,  unaffected. 
The  temperature  is  normal  or  subnormal  and  the  pulse  slow.  The  deep  re- 
flexes are  diminished,  sometimes  abolished,  and  the  skin  reflexes  may  be 
enfeebled.  A  most  remarkable  feature  is  the  extraordinary  reduction  or  com- 
plete abolition  of  the'faradic  excitability  of  both  muscles  and  nerves. 

Improvement  begins  within  a  few  hours  or  a  day  or  two,  the  paralysis 
disappearing  completely  and  the  patient  becoming  perfectly  well.  The  attacks 
usually  recur  at  intervals  of  one  to  two  weeks,  but  they  may  return  daily. 
They  generally  cease  after  the  fiftieth  year.  There  may  be  signs  of  acute 
dilatation  of  the  heart  during  the  attack.  In  the  three  cases  reported  by 
J.  K.  Mitchell,  Flexner,  and  Edsall,  a  diminished  kreatinin  excretion  for 
several  days  before  and  at  the  beginning  of  a  seizure  was  repeatedly  found. 
There  was  a  rise  to  normal  after  the  attacks.  Potassium  citrate  in  full  doses 
either  shortened  or  aborted  the  paralyses, 

II.  Astasia;  Abasia. 

These  terms,  indicating  respectively  inability  to  stand  and  inability  to 
walk,  have  been  applied  by  Charcot  and  Blocq  to  diseased  conditions  charac- 
terized by  loss  of  the  power  of  standing  or  of  walking,  with  retention  of 
muscular  power,  coordination,  and  sensation.  Blocq's  definition  is  as  follows: 
"  A  morbid  state  in  which  the  impossibility  of  standing  erect  and  walking 
normally  is  in  contrast  with  the  integrity  of  sensation,  of  muscular  strength, 
and  of  the  coordination  of  the  other  movements  of  the  lower  extremities."  The 
condition  forms  a  symptom  group,  not  a  morbid  entity,  and  is  probably  a  func- 
tional neurosis.  Knapp  in  his  monograph  analyzes  the  50  cases  reported  in 
the  literature.  Twenty-five  of  these  were  in  men,  25  in  women.  In  21  cases 
hysteria  was  present ;  in  3,  chorea ;  in  2,  epilepsy ;  and  in  4,  intention  psychoses. 


1100  DISEASES  OF  THE  NERVOUS  SYSTEM. 

As  a  rule,  the  patients,  though  able  to  move  the  feet  and  legs  perfectly  when 
in  bed,  are  either  unable  to  walk  properly  or  can  not  stand  at  all.  The  dis- 
turbances have  been  very  varied,  and  different  forms  have  been  recognized. 
The  commonest,  according  to  Knapp's  analysis  of  the  recorded  cases,  is  the 
paralytic,  in  which  the  legs  give  out  as  the  patient  attempts  to  walk  and  "  bend 
under  him  as  if  made  of  cotton."  "  There  is  no  rigidity,  no  spasm,  no  inco- 
ordination. In  bed,  sitting,  or  even  while  suspended,  the  muscular  strength 
is  found  to  be  good."  Other  cases  are  associated  with  spasm  or  ataxia;  thus 
there  may  be  movements  which  stiffen  the  legs  and  give  to  the  gait  a  somewhat 
spastic  character.  In  other  instances  there  are  sudden  flexions  of  the  legs,  or 
even  of  the  arms,  or  a  saltatory,  spring-like  spasm.  In  a  majority  of  the  cases 
it  is  a  manifestation  of  a  neurosis  allied  to  hysteria. 

The  cases,  as  a  rule,  recover,  particularly  in  young  persons.    Kelapses  are 
not  uncommon.    The  rest  treatment  and  static  electricity  should  be  employed. 


H.    YASO-MOTOR  AND  TROPHIO  DISORDERS. 
I.     RAYNAUD'S    DISEASE. 

Definition. — A  vascular  disorder,  probably  dependent  upon  vaso-motor  in- 
fluences, characterized  by  three  grades  of  intensity:  (a)  Local  syncope,  (&) 
local  asphyxia,  and  (c)  local  or  symmetrical  gangrene. 

Local  Syncope. — This  condition  is  seen  most  frequently  in  the  extremi- 
ties, producing  the  condition  knovm  as  dead  fingers  or  dead  toes.  It  is  analo- 
gous to  that  produced  by  great  cold.  The  entire  hand  may  be  affected  with 
the  fingers;  more  commonly  only  one  or  more  of  the  fingers.  This  feature  of 
the  disease  rarely  occurs  alone,  but  is  generally  associated  with  local  asphyxia. 
The  common  sequence  is  as  follows :  On  exposure  to  slight  cold  or  in  conse- 
quence of  some  emotional  disturbance  the  fingers  become  white  and  cold,  or 
both  fingers  and  toes  are  affected.  The  pallor  may  continue  for  an  indefinite 
time,  though  usually  not  more  than  an  hour  or  so;  then  gradually  a  reaction 
follows  and  the  fingers  get  burning  hot  and  red.  This  does  not  necessarily 
occur  in  all  the  fingers  together;  one  finger  may  be  as  white  as  marble,  while 
the  adjacent  ones  are  of  a  deep  red  or  plum  color. 

Local  Asphyxia. — Chilblains  form  the  mildest  grade  of  this  condition. 
It  usually  follows  the  local  syncope,  but  it  may  come  on  independently.  The 
fingers  and  toes  are  of tenest  affected,  next  in  order  the  ears ;  more  rarely  por- 
tions of  the  skin  on  the  arms  and  legs.  During  an  attack  the  fingers  alone, 
sometimes  the  hands,  also  swell  and  become  intensely  congested.  In  the  most 
extreme  grade  the  fingers  are  perfectly  livid,  and  the  capillary  circulation  is 
almost  stagnant.  The  swelling  causes  stiffness  and  usually  pain,  not  acute, 
but  due  to  the  distention  of  the  skin.  Sometimes  there  is  marked  ansesthesia. 
Pain  of  a  most  excruciating  kind  may  be  present.  Attacks  of  this  sort  may 
recur  for  years,  and  be  brought  on  by  the  slightest  exposure  to  cold  or  in 
consequence  of  disturbances,  either  mental  or,  in  some  instances,  gastric. 
Apart  from  this  unpleasant  symptom  the  general  health  may  be  very  good. 
The  condition  is  always  worse  during  the  winter,  and  may  be  present  only 
when  the  external  temperature  is  low. 


VASO-AIOTOR  AND   TROPHIC  DISORDERS.  1101 

Local  or  Symmetrical  Gangrene. — The  mildest  grade  of  this  condition 
follows  the  local  asphyxia,  in  the  chronic  cases  of  which  small  necrotic  areas 
are  sometimes  seen  at  the  tips  of  the  fingers.  Sometimes  the  pads  of  the 
fingers  and  of  the  toes  are  quite  cicatricial  from  repeated  slight  losses  of  this 
kind.  So  also  when  the  ears  are  affected  there  may  be  superficial  loss  of  sub- 
stance at  the  edge.  The  severer  cases,  which  terminate  in  extensive  gangrene, 
are  fortunately  rare. 

In  an  attack  the  local  asphyxia  persists  in  the  fingers.  The  terminal  pha- 
langes, or  perhaps  the  end  of  only  one  finger,  become  black,  cold,  and  insen- 
sible. The  skin  begins  to  necrose  and  superficial  gangrenous  blebs  appear. 
Gradually  a  line  of  demarkation  shows  itself  and  a  portion  of  one  or  more  of 
the  fingers  sloughs  away.  The  resulting  loss  of  substance  is  much  less  than  the 
appearance  of  the  hand  or  foot  would  indicate,  and  a  condition  which  looks 
as  if  the  patient  would  lose  all  the  fingers  or  half  of  a  foot  may  result  perhaps 
in  only  a  slight  superficial  loss  in  the  phalanges.  In  severer  cases  the  greater 
portion  of  a  finger  or  the  tip  of  the  nose  may  be  lost.  Occasionally  the  disease 
is  not  confined  to  the  extremities,  but  affects  symmetrical  patches  on  the  limbs 
or  trunk,  and  may  pass  on  to  rapid  gangrene.  These  severe  types  of  cases 
occur  particularly  in  young  children,  and  death  may  result  within  three 
or  four  days.  The  attacks  are  usually  very  painful,  and  the  motion  of  the 
part  is  much  impaired.  In  some  cases  numbness  and  tingling  persist  for  a 
long  time. 

The  climax  of  this  series  of  neuro-vascular  changes  is  seen  in  the  remark- 
able instances  of  extensive  multiple  gangrene.  They  are  most  common  in 
children,  and  may  progress  with  frightful  rapidity.  In  the  Medico-Chirurgical 
Society^s  Transactions,  vol.  xxii,  there  is  an  extraordinary  case  reported,  in 
which  the  child,  aged  three,  lost  in  this  way  both  arms  above  the  elbow,  and 
the  left  leg  below  the  knee.  There  also  had  been  a  spot  of  local  gangrene  on 
the  nose.  Spontaneous  amputation  occurred,  and  the  child  made  a  complete 
recovery.  The  cases  are  more  frequent  than  has  been  supposed,  and  an  illus- 
tration is  given  by  Weeks,  of  Marion,  Ohio,  in  which  the  boy  had  rheumatic 
pains  in  the  legs,  and  purpuric  blotches  developed  before  the  gangrene  began 
(Medico- Surgical  Bulletin,  July  1,  1894). 

There  are  remarkable  concomitant  symptoms  in  Eaynaud's  disease  to  which 
a  good  deal  of  attention  has  been  paid  of  late  years.  Hasmoglobinuria  may 
occur  during  an  attack,  or  may  take  the  place  of  it.  In  such  instances  the 
affection  is  usually  brought  on  by  cold  weather.  In  a  case  reported  by  H.  M. 
Thomas  from  my  clinic,  Eaynaud's  disease  occurred  for  three  successive  win- 
ters and  always  in  association  with  hsemoglobinuria.  The  attacks  were  some- 
times preceded  by  a  chill.  Several  cases  of  the  kind  are  found  in  Barlow's 
appendix  to  his  translation  of  Eaynaud's  paper  for  the  New  Sydenham  Society. 
The  onset  with  a  chill,  as  in  the  case  just  mentioned,  has  doubtless  given  rise 
to  the  idea  that  the  disease  is  in  some  way  associated  with  ague.  Cerebral 
symptoms,  particularly  mental  torpor  and  transient  loss  of  consciousness, 
have  also  been  noticed  in  some  cases.  The  case  just  mentioned  with  hsemo- 
globinuria had  epilepsy  with  the  attacks.  Exposure  on  a  cold  day  would  bring 
on  an  epileptic  seizure  with  the  local  asphyxia  and  bloody  urine.  Another 
patient,  the  subject  for  years  of  Eaynaud's  disease,  had  many  attacks  of  tran- 
sient hemiplegia  on  one  side  or  the  other,  when  on  the  right  side  with 


1102  DISEASES  OF  THE  NERVOUS  SYSTEM. 

aphasia.  She  finally  died  in  an  attack.  Occasionally  joint  affections  develop, 
particularly  anchylosis  and  thickening  of  the  phalangeal  articulations. 
Southey  has  reported  a  case  in  which  mania  developed,  and  Barlow  an  in- 
stance in  which  the  woman  had  delusions.  Peripheral  neuritis  has  been  found 
in  several  cases. 

Pathology. — The  patholog}^  of  this  remarkable  disease  is  still  obscure.  Eay- 
naud  suggested  that  the  local  s3^ncope  was  produced  by  a  vascular  spasm,  which 
seems  likely.  The  aspliyxia  is  dependent  upon  dilatation  of  the  capillaries  and 
small  veins,  probably  with  the  persistence  of  some  degree  of  spasm  of  the 
smaller  arteries.  There  are  two  totally  different  forms  of  congestion,  which 
ma}"  be  shown  in  adjacent  fingers;  one  may  be  swollen,  of  a  vivid  red  color, 
extremely  hot,  the  capillaries  and  all  the  vessels  fully  distended,  and  the  antemia 
produced  by  pressure  may  be  instantaneously  obliterated;  the  adjacent  finger 
may  be  equally  swollen,  absolutely  cyanotic,  stone  cold,  and  the  anaemia  pro- 
duced by  pressure  takes  a  long  time  to  disappear.  In  the  latter  case  the 
arterioles  are  probably  still  in  a  condition  of  spasm.  Monro's  monograph  may 
be  consulted  for  additional  details. 

Treatment. — In  many  cases  the  attacks  recur  for  years  uninfluenced  by 
treatment.  Mild  attacks  require  no  treatment.  In  the  severer  forms  of  local 
asph3':s:ia,  if  in  the  feet,  the  patient  should  be  kept  in  bed  with  the  legs  elevated. 
The  toes  should  be  wrapped  in  cotton-wool.  The  pain  is  often  very  intense 
and  may  require  morphia.  Carefully  applied,  systematic  massage  of  the  ex- 
tremities is  sometimes  of  benefit.  Galvanism  may  be  tried.  Barlow  advises 
immersing  the  afEected  limb  in  salt  water  and  placing  one  electrode  over  the 
spine  and  the  other  in  the  water.  Xitroglycerin  has  been  warmly  recommended 
by  Gates.  Gushing  has  introduced  a  plan  of  treatment  with  the  tourniquet 
which  has  proved  very  successful  in  several  cases  in  my  wards.  The  elastic 
bandage,  or,  better,  one  of  his  pneumatic  tourniquets,  is  applied  to  an  extrem- 
itj  tight  enough  to  shut  off  the  arterial  circulation  and  left  for  some  minutes. 
On  releasing  the  constriction  the  member  flushes  brightly,  owing  to  the  vaso- 
motor relaxation.  The  application  in  cases  of  severe  spasm  may  have  to  be 
repeated  at  frequent  intervals  before  the  vascular  constriction  in  the  affected 
parts  will  be  overcome,  and  the  normal  temperature  and  color  return  in  them. 

II.     ERYTHROMELALGIA  (Red  Neuralgia). 

Definition. — "  A  chronic  disease  in  which  a  part  or  parts — usually  one  or 
more  extremities — suffer  with  pain,  flushing,  and  local  fever,  made  far  worse 
if  the  parts  hang  down"  (Weir  Mitchell).  The  name  signifies  a  painful,  red 
extremity. 

Symptoms. — In  1872  (Phila.  Med.  Times,  Xovember  23d),  in  a  lecture  on 
certain  painful  affections  of  the  feet.  Weir  Mitchell  described  the  case  of  a 
sailor,  aged  forty,  who  after  an  African  fever  began  to  have  "  dull,  heavy  pains, 
at  first  in  the  left  and  soon  after  in  the  right  foot.  There  was  no  swelling  at 
first.  When  at  rest  he  was  comfortable  and  the  feet  were  not  painful.  After 
walking  the  feet  were  swollen.  They  scarcely  pitted  on  pressure,  but  were 
purple  with  congestion;  the  veins  were  ever}^where  singularly  enlarged,  and 
the  arteries  were  throbbing  visibly.  The  whole  foot  was  said  to  be  aching  and 
burning,  but  above  the  ankle  there  was  neither  swelling,  pain,  nor  flushing." 


VASO-MOTOR  AND   TROPHIC  DISORDERS.  1103 

As  the  weather  grew  cool  he  got  relief.  Nothing  seemed  to  benefit  him.  This 
brief  summary  of  Mitchell's  first  case  gives  an  accurate  clinical  picture  of  the 
disease.  Plis  second  communication,  On  a  Eare  Vaso-motor  Neurosis  of  the 
Extremities,  appeared  in  the  Am.  Jour,  of  the  Medical  Sciences  for  July,  1878, 
while  in  his  Clinical  Lessons  on  Nervous  Diseases,  1897,  will  be  found  addi- 
tional observations. 

The  disease  is  rare.  Eost  states  that  there  are  only  about  40  instances  in 
the  literature.  The  feet  are  much  more  often  affected  than  the  hands.  The 
pain  may  be  of  the  most  atrocious  character.  It  is  usually,  but  not  always, 
relieved  by  cool  weather ;  in  one  of  my  cases  the  winter  aggravates  the  trouble. 
In  a  few  cases  (Eisner,  Dehio,  Eolleston)  the  affection  has  been  complicated 
with  Eaynaud's  disease. 

Mitchell  speaks  of  it  as  a  "  painful  nerve-end  neuritis."  Dehio  suggests 
that  there  may  be  irritation  in  the  cells  of  the  ventral  horns  of  the  cord  at 
certain  levels.  Excision  of  the  nerves  passing  to  the  parts  has  been  followed, 
by  relief.  In  one  of  Mitchell's  cases  gangrene  of  the  foot  followed  excision 
of  four  inches  of  the  musculo-cutaneous  nerve  and  stretching  of  the  posterior 
tibial.  Sclerosis  of  the  arteries  was  found.  Of  the  9  cases  in  which  the  local 
conditions  were  studied  anatomically,  the  only  constant  change  was  a  chronic 
endarteritis  (Batty  Shaw). 

III.    ANGIO-NEUROTIC    (EDEMA     (auincke's  Disease). 

Definition. — An  affection  characterized  by  the  occurrence  of  local  ocdema- 
tous  swellings,  more  or  less  limited  in  extent,  and  of  transient  duration. 
Severe  colic  is  sometimes  associated  with  the  outbreak.  There  is  a  marked 
hereditary  disposition  in  the  disease. 

Symptoms. — The  oedema  appears  suddenly  and  is  usually  circumscribed. 
It  may  appear  in  the  face ;  the  eyelid  is  a  common  situation ;  or  it  may  involve 
the  lips  or  cheek.  The  backs  of  the  hands,  the  legs,  or  the  throat  may  be 
attacked.  Usually  the  condition  is  transient,  associated  perhaps  with  slight 
gastro-intestinal  distress,  and  the  affection  is  of  little  moment.  There  may  be 
a  remarkable  periodicity  in  the  outbreak  of  the  oedema.  In  Matas'  case  this 
periodicity  was  very  striking ;  the  attack  came  on  every  day  at  eleven  or  twelve 
o'clock.  The  disease  may  be  hereditary  through  many  generations.  In  the 
family  whose  history  I  reported,  five  generations  had  been  affected,  including 
twenty-two  members.  The  swellings  appear  in  various  parts;  only  rarely  are 
they  constant  in  one  locality.  The  hands,  face,  and  genitalia  are  the  parts 
most  frequently  affected.  Itching,  heat,  redness,  or  in  some  instances  urti- 
caria, may  precede  the  outbreak.  Sudden  oedema  of  the  lar3aix  may  prove 
fatal.  Two  members  of  the  family  just  referred  to  died  of  this  complication. 
In  one  member  of  this  family,  whom  I  saw  repeatedly  in  attacks,  the  swellings 
came  on  in  different  parts.;  for  example,  the  under  lip  would  be  swollen  to  such 
a  degree  that  the  mouth  could  not  be  opened.  The  hands  enlarge  suddenly, 
so  that  the  fingers  can  not  be  bent.  The  attacks  recur  every  three  or  four 
weeks.  Accompanying  them  are  usually  gastro-intestinal  attacks,  severe  colic, 
pain,  nausea,  and  sometimes  vomiting.  It  is  quite  possible  that  some  of  the 
cases  of  Leyden's  intermittent  vomiting  may  belong  to  this  group.  The  colic 
is  of  great  intensity  and  usually  requires  morphia.    Arthritis  apparently  does 


1104  DISEASES  OF  THE  NERVOUS  SYSTEM. 

not  occur.  Periodic  attacks  of  cardialgia  have  also  been  met  with  during  the 
outbreak  of  the  oedema.    Hemoglobinuria  has  occurred  in  several  cases. 

The  disease  has  affinities  with  urticaria,  the  giant  form  of  which  is  prob- 
ably the  same  disease.  There  is  a  form  of  severe  purpura,  often  with  urticarial 
manifestations,  which  is  also  associated  with  marked  gastro-intestinal  crises, 
and  it  is  interesting  to  note  that  Schlesinger  has  reported  a  case  in  which  a 
combination  of  erythromelalgia,  Eajmaud's  disease,  and  acute  oedema  occurred. 
Quincke  regards  the  condition  as  a  vaso-motor  neurosis,  under  the  influence 
of  which  the  permeability  of  the  vessels  is  suddenly  increased.  Milroy,  of 
Omaha,  has  described  cases  of  hereditary  oedema,  twenty-two  individuals  in 
six  generations,  in  which  there  existed  from  birth  a  solid  oedema  of  one  or  of 
both  legs,  without  any  special  inconvenience  or  any  progressive  increase  of  the 
disease. 

Some  years  ago  I  described  a  remarkable  vaso-motor  neurosis  characterized 
by  sweUing  and  tumefaction  of  the  whole  arm  on  exertion.  My  patient  was  a 
man,  healthy  in  every  other  respect.  A  similar  case  has  been  observed  in 
Philadelphia ;  on  the  supposition  that  it  might  be  due  to  pressure,  the  axillary 
vessels  were  exposed,  but  nothing  was  found. 

The  treatment  is  very  unsatisfactory.  In  the  cases  associated  with  anasmia 
and  general  nervousness,  tonics,  particularly  large  doses  of  strychnia,  do  good. 
I  have  seen  great  improvement  follow  the  prolonged  use  of  nitroglycerin;  and 
calcium  lactate  may  be  tried,  in  doses  of  15  grains  thrice  daily. 

IV.     FACIAL    HEMIATROPHY. 

A  rare  affection  characterized  by  progressive  wasting  of  the  bones  and  soft 
tissues  of  one  side  of  the  face.  The  atrophy  starts  in  childhood,  but  in  a  few 
cases  has  not  come  on  until  adult  life.  Perhaps  after  a  trifling  injury  or  disease 
the  process  begins,  either  diffusel}^  or  more  commonly  at  one  spot  on  the  skin. 
It  gradually  spreads,  involving  the  fat,  then  the  bones,  more  particularly  the 
upper  jaw,  and  last  and  least  the  muscles.  The  wasting  is  sharply  limited  at 
the  middle  line,  and  the  appearance  of  the  patient  is  very  remarkable,  the  face 
looking  as  if  made  up  of  two  halves  from  different  persons.  There  is  usually 
change  in  the  color  of  the  skin  and  the  hair  falls.  Owing  to  the  wasting  of 
the  alveolar  processes  the  teeth  become  loose  and  ultimately  drop  out.  The 
eye  on  the  affected  side  is  sunken,  owing  to  loss  of  orbital  fat.  There  is  usually 
hemiatrophy  of  the  tongue  on  the  same  side.  Disturbance  of  sensation  and 
muscle  twitching  may  precede  or  accompany  the  atrophy.  In  a  majority  of 
the  cases  the  atrophy  has  been  confined  to  one  side  of  the  face,  but  there  are 
instances  on  record  in  which  the  disease  was  bilateral,  and  a  few  cases  in  which 
there  were  areas  of  atrophy  on  the  back  and  on  the  arm  of  the  same  side. 

Of  the  autopsies,  Mendel's  alone  is  satisfactory.  There  was  the  terminal 
stage  of  an  interstitial  neuritis  in  all  the  branches  of  the  trigeminus,  from 
its  origin  to  the  periphery,  most  marked  in  the  superior  maxillary  branch. 

The  disease  is  recognized  at  a  glance.  The  facial  asymmetry  associated 
with  congenital  wrjmeck  must  not  be  confounded  with  progressive  facial  hemi- 
atrophy. Other  conditions  to  be  distinguished  are :  Facial  atrophy  in  anterior 
polio-myelitis,  and  more  rare!}'  in  the  hemiplegia  of  infants  and  adults;  the 
atrophy  following  nuclear  lesions  and  sympathetic  nerve  paralysis;  acquired 


VASO-MOTOR  AND   TROPHIC  DISORDERS.  1105 

facial  hemihypertrophy,  such  as  in  the  case  recorded  by  D,  W.  Montgomery, 
which  may  by  contrast  give  to  the  other  side  an  atrophic  appearance;  and, 
lastly,  scleroderma  (a  closely  related  affection),  if  confined  to  one  side  of  the 
face.  The  precise  nature  of  the  disease  is  still  doubtful,  but  it  is  a  suggestive 
fact  that  in  many  of  the  cases  the  atrophy  has  followed  the  acute  infections. 
It  is  incurable. 

V.     ACROMEGALY. 

Definition. — A  dystrophy  characterized  by  abnormal  processes  of  growth, 
chiefly  in  the  bones  of  the  face  and  extremities. 

The  term  was  introduced  by  Marie,  and  signifies  large  extremities. 

Etiology. — It  occurs  rather  more  frequently  in  women.  The  affection  usu- 
ally begins  about  the  twenty-fifth  year,  though  in  some  instances  as  late  as  the 
fortieth.  Eheumatism,  syphilis,  and  the  specific  fevers  have  preceded  the  de- 
velopment of  the  disease,  but  probably  have  no  special  connection  with  it.  In 
America  many  cases  have  now  been  reported. 

Symptoms. — In  a  well-marked  case  the  disease  presents  most  characteristic 
features.  The  hands  and  feet  are  greatly  enlarged,  but  are  not  deformed,  and 
can  be  used  freely.  The  hypertrophy  is  general,  involving  all  the  tissues,  and 
gives  a  curious  spade-like  character  to  the  hands.  The  lines  on  the  palms  are 
much  deepened.  The  wrists  may  be  enlarged,  but  the  arms  are  rarely  affected. 
The  feet  are  involved  like  the  hands  and  are  uniformly  enlarged.  The  big 
toe,  however,  may  be  much  larger  in  proportion.  The  nails  are  usually  broad 
and  large,  but  there  is  no  curving,  and  the  terminal  phalanges  are  not  bulbous. 
The  head  increases  in  volume,  but  not  as  much  in  proportion  as  the  face,  which 
becomes  much  elongated  and  enlarged  in  consequence  of  the  increase  in  the 
size  of  the  superior  and  inferior  maxillary  bones.  The  latter  in  particular 
increases  greatly  in  size,  and  often  projects  below  the  upper  jaw.  The  alveolar 
processes  are  widened  and  the  teeth  separated.  W.  W.  Graves  has  called  atten- 
tion to  the  value  of  this  separation  of  the  teeth  as  an  important  early  sign. 
The  soft  parts  also  increase  in  size,  and  the  nostrils  are  large  and  broad. 
The  eyelids  are  sometimes  greatly  thickened,  and  the  ears  enormously  hyper- 
trophied.  The  tongue  in  some  instances  becomes  greatly  enlarged.  Late  in 
the  disease  the  spine  may  be  affected  and  the  back  bowed — kyphosis.  The  bones 
of  the  thorax  may  slowly  and  progressively  enlarge.  With  this  gradual  increase 
in  size  the  skin  of  the  hands  and  face  may  appear  normal.  Sometimes  it  is 
slightly  altered  in  color,  coarse,  or  flabby,  but  it  has  not  the  dry,  harsh  appear- 
ance of  the  skin  in  myxoedema.  The  muscles  are  sometimes  wasted.  Changes 
in  the  thyroid  have  been  found,  but  are  not  constant.  The  gland  has  been 
normal  in  some,  atrophied  in  others,  and  in  a  third  group  of  cases  enlarged. 
Erb,  who  has  made  an  elaborate  study  of  the  disease,  has  noticed  an  area  of 
dulness  over  the  manubrium  sterni,  which  he  thought  possibly  due  to  the  per- 
sistence or  enlargement  of  the  thymus.  Headache  is  not  uncommon.  Somno- 
lence has  been  noted  in  many  cases.  Menstrual  disturbance  may  occur  early, 
and  there  may  be  suppression.  Ocular  symptoms  are  common.  Hertel  has 
analyzed  175  recorded  cases,  92  of  which  presented  eye  complications.  In 
three-fourths  of  these  the  optic  nerves  were  affected — usually  atrophy,  rarely 
neuritis.  Bitemporal  hemianopia  is  often  an  early  sign.  The  disease  may 
persist  for  fifteen,  twenty,  or  more  years. 


1106  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Pathological  Anatomy. — To  April,  1902,  there  were  262  cases  on  record 
with  77  autopsies,  in  only  4  of  which  the  pituitary  gland  was  not  involved 
(Woods-Hutchinson).  In  24  cases  in  which  it  was  examined  the  thyroid  was 
normal  in  5,  hypertrophied  in  12;  the  thymus  in  17  examined  was  absent  in 
7,  hypertrophied  in  3,  and  persistent  in  7  (Furnival).  In  Osborne's  case  the 
heart  was  enormous^  weighing  2  pounds  9  ounces. 

Owing  to  the  remarkable  changes  in  the  pituitary  gland  in  acromegaly,  it 
has  been  suggested  that  the  disease  is  a  nutritional  disturbance  analogous  to 
myxcedema,  and  caused  directly  by  disturbance  in  the  function  of  this  organ. 
The  evidence  from  comparative  anatomy  and  embryolog}^  shows  that  the  pitui- 
tary body  is  a  very  "  complex  organ,  consisting  of  an  anterior  secreting  glandu- 
lar organ;  a  water-vascular  duct;  a  posterior,  sensitive,  nervous  lobe,  of  which 
the  last  two — nameh',  the  duct  and  the  nervous  lobe — were  morphologically 
well  developed  and  functioned  in  ancestral  vertebrates,  but  have  become  oblit- 
erated and  atrophied  in  structure  and  function  forever  above  larval  acraniates  " 
(Andriezen,  British  Medical  Journal,  1894,  i).  The  pituitary  body  continues 
active,  but  the  duct  is  obliterated  "  and  the  gland  changed  into  a  ductless 
gland ;  the  secretion  becomes  an  '  internal  secretion,^  "  which  is  absorbed  by  the 
lymphatics.  The  extraordinary  frequency  with  which  the  pituitary  is  involved 
in  this  disease  lends  weight  to  the  view  that  it  is,  in  the  words  of  Woods 
Hutchinson,  the  growth  centre,  or  at  any  rate  the  proportion  regulator  of 
the  skeleton. 

It  has  been,  suggested  by  Massalongo  and  others  that  gigantism  and  acro- 
megaly are  one  and  the  same  disease,  both  due  to  the  superfunction  of  the 
pituitary  gland.  Certain  persons  exhibited  as  giants,  or  who  have  been  "  strong 
men  "  and  wrestlers,  have  become  acromegalic,  and  the  skulls  of  some  notable 
giants  show  enormous  enlargement  of  the  sella  turcica. 

There  is  a  congenital  progressive  hypertrophy  of  one  extremity  or  of  a 
part  of  it,  or  of  one  side  of  the  body, — the  so-called  giant  growth^  which  does 
not  appear  to  have  any  connection  with  acromegaly. 

Treatment. — The  treatment  does  not  appear  to  have  any  influence  upon 
the  progress  of  the  disease.  The  th}Toid  extract  has  been  tried  in  many  cases, 
without,  so  far  as  my  personal  experience  goes,  any  benefit.  Extract  of  the 
pituitary  gland  has  also  been  used.  The  lung  extract  has  been  employed  in 
some  cases  of  pulmonary  osteo-arthropathy.  In  a  case  of  Caton's,  of  Liverpool, 
an  unsuccessful  attempt  was  made  to  extirpate  the  pituitary  body. 

Osteitis  Deformaxs   {Paget' s  Disease). 

Definition. — A  disease  characterized  by  "  enlargement  and  forward  pro- 
jection of  the  head,  dorso-cervical  kyphosis,  prominence  of  the  clavicles,  spread- 
ing of  the  base  of  the  thorax,  a  diamond-shaped  abdomen,  crossed  by  a  deep 
sulcus,  a  relative  increase  in  the  width  of  the  hips,  and  an  outward  and  forward 
bowing  of  the  legs." 

It  is  a  rare  disease.  I  have  seen  only  4  cases — 1  in  Philadelphia,  which 
is  figured  in  Ashhurst's  Surgery,  and  3  in  Baltimore.  Of  these,  one  is  un- 
reported; the  others  I  saw  with  Watson  (who  has  recorded  the  case,  Johns 
Hopkins  Hospital  Bulletin,  1898)  and  vdth  A.  D.  xA.tkinson.  Careful  studies 
have  been  made  by  J.  C.  Wilson,  by  Elting,  and  by  Packard,  Steele,  and 


»  VASO'MOTOR  AND  TROPHIC  DISORDERS.  1107 

Kirkbride,  from  whose  exhaiistive  paper  I  have  taken  the  definition.  About 
67  typical  cases  are  on  record:  41  males,  24  females,  and  in  2  the  sex  was 
not  given.  In  49  cases  the  bones  of  the  skull  were  involved,  in  47  both  tibiae, 
in  40  the  femur,  and  in  31  the  spine.  These  figures  from  Packard's  paper 
give  the  relative  frequency  with  which  the  bones  are  attacked.  The  shorten- 
ing of  the  stature  is  remarkable;  in  Watson's  patient  the  height  at  forty-two 
was  5  feet  llf  inches,  and  at  sixty-two  it  was  5  feet  2^  inches.  The  head 
had  increased  3^  inches. 

Etiology. — The  etiology  of  the  disease  is  unknown;  it  is  possibly  allied  to 
but  not  identical  with  osteo-malacia,  fragilitas  ossium,  and  acromegaly.  There 
is  a  curious  relationship  between  osteitis  deformans  and  malignant  tumors, 
of  which  a  certain  number  of  the  patients  have  died. 

The  bone  structure  shows  a  mixture  of  rarefying  osteitis,  with  large  and 
irregular  Haversian  canals,  and  of  a  formative  osteitis,  with  certain  Haversian 
canals  narrowed  and  lamellge  of  recent  formation. 

Diagnosis. — The  diagnosis  is  readily  made.  The  features  given  in  the  defi- 
nition make  up  a  most  typical  picture.  As  Marie  states,  in  Paget's  disease  the 
face  is  triangular  with  the  base  upward ;  in  acromegaly  it  is  ovoid  or  egg-shaped 
with  the  large  end  downward ;  while  in  myxoedema  it  is  round  and  full -moon- 
shaped.    Treatment  seems  to  be  of  no  avail. 

Hypertrophic  Pulmonary  Arthropathy. 

Marie  has  given  the  name  hypertrophic  pulmonary  osteo-arthropathy  to  a 
remarkable  disorder,  first  recognized  by  Bamberger,  characterized  by  enlarge- 
ment of  the  hands  and  feet,  and  of  the  ends  of  the  long  bones,  chiefly  of  the 
lower  three-fourths  of  the  forearm  and  legs.  Unlike  acromegaly,  the  bones  of 
the  skull  and  of  the  face  are  not  involved.  The  terminal  phalanges  are  much 
enlarged  and  show  both  transverse  and  longitudinal  curves ;  the  nails,  too,  are 
large  and  much  curved  over  the  ends  of  the  phalanges.  Scoliosis  and  kyphosis 
are  rarely  seen.  The  disease  is  very  chronic,  and  in  nearly  all  cases  has  been 
associated  with  some  long-standing  affection  of  the  bronchi,  lungs,  or  pleura 
(hence  the  name  pulmonary  osteo-arthropathy) ,  of  which  sarcoma,  chronic 
bronchitis,  chronic  tuberculosis,  and  empyema  have  been  the  most  frequent. 
There  are  several  instances  in  which  the  affection  has  developed  in  the  subjects 
of  syphilis.  It  occurs  usually  in  adults  and  in  the  male  sex.  Thayer  has  re- 
ported 4  cases  from  my  clinic  and  has  collected  55  typical  eases  from  the 
literature.  Forty-three  showed  preceding  pulmonary  affection;  of  the  remain- 
in,  3  followed  syphilis,  3  heart-disease,  2  chronic  diarrhoea,  1  spinal  caries, 
and  3  unknown  causes. 

The  essential  pathology  of  the  disease  is  very  obscure.  Marie  suggests  that 
the  toxines  of  the  pulmonary  disease  are  absorbed  into  the  circulation  and 
exercise  an  irritant  action  on  the  bony  and  articular  structures,  causing  an 
ossifying  periostitis.  Thorburn  thinks  that  it  is  a  chronic  tuberculous  affec- 
tion of  a  large  number  of  bones  and  joints  of  a  benign  type. 

Leontiasis  Ossea, 

In  a  remarkable  condition  known  as  leontiasis  ossea,  there  is  hyperos- 
tosis of  the  bones  of  the  cranium,  and  sometimes  those  of  the  face.     The 


1108  DISEASES  OF  THE  NERVOUS  SYSTEM. 

description  is  largely  based  upon  the  skulls  in  museums,  but  Allen  Starr  has 
recently  reported  an  instance  in  a  woman,  who  presented  a  slowly  progressing 
increase  in  the  size  of  the  head,  face,  and  neck,  the  hard  and  soft  tissues  both 
being  affected.  He  has  applied  to  the  condition  the  term  megalo-cephaly. 
Putnam  states  that  the  disease  begins  in  early  life,  often  as  a  result  of  injury. 
There  may  be  osteophytic  growths  from  the  outer  or  inner  tables,  which  in  the 
latter  situation  may  give  the  symptoms  of  tumor. 

Osteogenesis  Imperfecta   {Fragilitas  Ossium). 

This  is  a  systemic  disease  of  the  foetus  in  which  the  normal  osseous  develop- 
ment does  not  occur.  At  birth  there  is  marked  fragility  of  all  the  bones.  There 
may  have  been  intra-uterine  fractures  which  have  united  and  show  large  cal- 
luses. The  extremities  are  often  bent  and  deformed.  The  main  features  are 
defective  development  of  the  cranium  and  fragility  of  all  the  bones.  It  was 
thought  that  death  always  occurred,  but  Nathan  has  shown  that  some  of  the 
patients  survive  and  that  the  bones  become  firmer  as  the  child  grows  older. 
Treatment  consists  in  using  every  protection  against  injury.  Fractures  usually 
unite  readily. 

Achondroplasia  (Chondrodystropliia  FcetaJis). 

Achondroplasic  dwarfs  are  easily  recognized.  They  are  well  nourished  and 
strong,  and  of  average  intelligence.  Their  height  varies  from  3  to  4  feet;  the 
head  and  trunk  are  of  about  normal  size,  but  the  extremities  are  very  short,  the 
fingers,  when  the  arms  are  at  the  sides,  reaching  little  below  the  crest  of 
the  ilium.  The  important  point  in  diagnosis  is  that  in  the  shortness  of  the 
limbs  it  is  the  proximal  segments  which  are  specially  involved,  the  humerus 
and  femur  being  even  shorter  than  the  ulna  and  tibia  (rhizomelia) .  The  limbs 
are  considerably  bent,  but  this  is  more  an  exaggeration  of  normal  curves  and 
abnormalities  in  the  joints  than  pathological  curves,  as  in  rickets.  The  features 
of  rickets  are  absent.  The  hand  is  short,  and  has  a  trident  shape,  since  the 
fingers,  which  are  of  almost  equal  length,  often  diverge  somewhat.  The  root 
of  the  nose  is  depressed,  the  back  flat,  and  the  lumbar  lordosis  abnormally  deep, 
owing  to  a  tilting  forward  of  the  sacrum.  The  scapulge  are  short,  the  fibulae 
longer  than  the  tibise,  and  the  pelvis  is  contracted ;  hence  the  number  of  these 
cases  reported  by  obstetricians.  Heredity  plays  little  part  (Marie,  Presse 
Med.,  1900). 

Pathologically  it  is  a  dystrophy  of  the  epiphysical  cartilages.  The  cartilage 
cells  are  irregularly  scattered,  and  the  ground  substance  is  invaded  by  con- 
nective tissue  from  the  periosteum,  which  seems  to  send  in  a  band  of  tissue 
across  the  end  of  the  diaphysis,  thus  preventing  its  increase  in  length,  and 
causing  premature  union  of  epiphysis  and  diaphysis.  The  development  of  the 
bones  with  a  membranous  matrix  seems  normal.  The  etiology  of  the  disease 
is  unknown.  Virchow  described  it  as  foetal  cretinism,  others  as  foetal  rickets 
which  has  run  its. course  before  birth.  But  it  is  certainly  not  always  a  purely 
foetal  disease,  for  it  can  continue  its  development  during  infancy,  and  we  have 
had  one  case  under  observation  which  would  tend  to  show  that  it  could  even 
begin  after  birth.  Most  of  the  cases,  however,  die  either  before  birth  or  in 
early  infancy. 


VASO-MOTOR  AND  TROPHIC  DISORDERS.  U09 


VI.     SCLERODERMA. 

Definition. — A  condition  of  localized  or  diffuse  induration  of  the  skin. 

Lewin  and  Heller  (Die  Sclerodermic^  Berlin,  1895)  have  recently  collected 
from  the  literature  508  cases. 

Two  forms  are  recognized :  the  circumscribed,  which  corresponds  to  the 
keloid  of  Addison,  and  to  morphoea ;  and  the  diffuse,  in  which  large  areas  are 
involved. 

The  disease  affects  females  more  frequently  than  males.  The  cases  occur 
most  commonly  at  the  middle  period  of  life.  The  sclerema  neonatorum  is  a 
different  affection,  not  to  be  confounded  with  it.  The  disease  is  more  common 
in  the  United  States  than  statistics  indicate.  I  have  had  20  cases  under  obser- 
vation in  the  past  fifteen  years. 

In  the  circumscribed  form  there  are  patches,  ranging  from  a  few  centime- 
tres in  diameter  to  the  size  of  the  hand  or  larger,  in  which  the  skin  has  a 
waxy  or  dead-white  appearance,  and  to  the  touch  is  brawny,  hard,  and  inelastic. 
Sometimes  there  is  a  preliminary  hypersemia  of  the  skin,  and  subsequently 
there  are  changes  in  color,  either  areas  of  pigmentation  or  of  complete  atrophy 
of  the  pigment — leucoderma.  The  sensory  changes  are  rarely  marked.  The 
secretion  of  sweat  is  diminished  or  entirely  abolished.  The  disease  is  more 
common  in  women  than  in  men,  and  is  situated  most  frequently  about  the 
breasts  and  neck,  sometimes  in  the  course  of  the  nerves.  The  patches  may 
develop  with  great  rapidity,  and  may  persist  for  months  or  years;  sometimes 
they  disappear  in  a  few  weeks. 

The  diffuse  form,  though  less  common,  is  more  serious.  It  develops  first 
in  the  extremities  or  in  the  face,  and  the  patient  notices  that  the  skin  is 
unusually  hard  and  firm,  or  that  there  is  a  sense  of  stiffness  or  tension  in 
making  accustomed  movements.  Gradually  a  diffuse,  brawny  induration  de- 
velops and  the  skin  becomes  firm  and  hard,  and  so  united  to  the  subcutaneous 
tissues  that  it  can  not  be  picked  up  or  pinched.  The  skin  may  look  natural, 
but  more  commonly  is  glossy,  drier  than  normal,  and  unusually  smooth.  With 
reference  to  the  localization,  in  66  observations  the  disease  was  universal;  in 
203,  regions  of  the  trunk  were  affected;  in  193,  parts  of  the  head  or  face; 
in  287,  portions  of  one  or  other  of  the  upper  extremities;  and  in  122,  portions 
of  the  lower  extremities.  In  80  cases  there  were  disturbances  of  sensation. 
The  disease  may  gradually  extend  and  involve  the  skin  of  an  entire  limb. 
When  universal,  the  face  is  expressionless,  the  lips  can  not  be  moved,  mastica- 
tion is  hindered,  and  it  may  become  extremely  difiicult  to  feed  the  patient. 
The  hands  become  fixed  and  the  fingers  immobile,  on  account  of  the  extreme 
induration  of  the  skin  over  the  joints.  Eemarkable  vaso-motor  disturbances 
are  common,  as  extreme  cyanosis  of  the  hands  and  legs.  In  one  of  my  cases 
tachycardia  was  present.  The  disease  is  chronic,  lasting  for  months  or  years. 
There  are  instances  on  record  of  its  persistence  for  more  than  twenty  years. 
Recovery  may  occur,  or  the  disease  may  be  arrested.  One  of  my  patients, 
with  extensive  involvement  of  the  face,  ears,  and  hands,  is  now,  ten  years 
after  the  onset,  very  much  better ;  the  skin  of  the  face  is  supple  and  the  hands 
are  much  less  indurated.  The  patients  are  apt  to  succumb  to  pulmonary 
pomplaints  or  to  nephritis.     Rheumatic  troubles  have  been  noticed  in  some 


1110  DISEASES  OF  THE  NERVOUS  SYSTEM. 

instances;  in  others,  endocarditis.  Eaynaud's  disease  may  be  associated  with 
it,  as  in  2  cases  described  by  Stephen  Mackenzie.  I  have  seen  an  instance  of 
the  diffuse  form  in  "which  the  primary  symptoms  were  those  of  local  asphyxia 
of  the  fingers,  and  in  which,  with  extensive  scleroderma  of  the  arms  and 
hands  and  face,  there  were  cyanosis  and  swelling  of  the  skin  of  the  feet 
without  any  brawny  induration.  The  pigmentation  of  the  skin  may  be  as 
deep  as  in  Addison's  disease,  for  which  cases  have  been  mistaken ;  scleroderma 
may  occur  as  a  complication  of  exophthalmic  goitre. 

The  remarkable  dystrophy  known  as  sderodactylie  belongs  to  this-disorder. 
There  are  symmetrical  involvements  of  the  fingers,  which  become  deformed, 
shortened,  and  atrophied;  the  skin  becomes  thickened,  of  a  waxy  color,  and  is 
sometimes  pigmented.  Bulls  and  ulcerations  have  been  met  with  in  some  in- 
stances, and  a  great  deformity  of  the  nails.  The  disease  has  usually  followed 
exposure,  and  the  patients  are  much  worse  during  the  winter,  and  are  curiously 
sensitive  to  cold.  There  may  be  changes  in  the  skin  of  the  feet,  but  the  de- 
formity similar  to  that  which  occurs  in  the  hand  has  not  been  noted.  Some 
of  the  cases  present  in  addition  diffuse  sclerodermatous  changes  of  the  skin 
of  other  parts.  In  Lewin  and  Heller's  monograph  there  are  35  cases  of  isolated 
sclerodactylism.  and  106  cases  in  which  it  was  combined  with  scleroderma. 

The  patholog}'  of  the  disease  is  unknown.  It  is  usually  regarded  as  a 
tropho-neurosis,  probably  dependent  upon  changes  in  the  arteries  of  the  skin 
leading  to  connective-tissue  overgrowth.  The  thyroid  has  been  found  atro- 
phied. 

Treatment. — The  patients  require  to  be  warmly  clad  and  to  be  guarded 
against  exposure,  as  they  are  particularly  sensitive  to  changes  in  the  weather. 
"Warm  baths  followed  by  frictions  with  oil  should  be  systematically  used.  I  have 
tried  the  th}Toid  feeding  thoroughly  in  the  diffuse  form.  In  one  case  the  disease 
appears  to  be  arrested ;  the  patient  has  taken  the  extract  for  nearly  seven  years. 
In  a  second  case,  after  a  year  the  face  became  softer,  and  there  has  been  per- 
manent improvement.  In  a  case  of  quite  extensive  localized  scleroderma,  the 
patches  became  softer  and  the  pigmentation  much  less  intense.  Salol  in  15- 
grain  doses  three  times  a  day  is  stated  to  have  been  successful  in  several  cases. 

Here  a  brief  reference  may  be  made  to  the  remarkable  trophic  lesion  de- 
scribed by  Da  Silva  Lima,  which  is  met  with  in  negroes  in  Brazil,  Africa,  India, 
and  occasionally  in  the  Southern  States.  It  is  confined  to  the  toes,  usually  the 
little  toe,  and  begins  as  a  furrow  on  the  line  of  the  digito-plantar  fold.  This 
gradually  deepens,  the  end  of  the  toe  enlarges,  and,  usually  without  inflam- 
mation or  pain,  the  toe  falls  off.  The  process  may  last  some  years.  Cases  have 
been  reported  in  America  by  Hornaday,  Pittman,  F.  J.  Shepherd,  and  Mor- 
rison. 


SECTION   XL 
DISEASES   OF  THE   MUSCLES. 

I.     MYOSITIS. 

Definition. — Inflammation  of  the  voluntary  muscles. 

A  primary  myositis  occurs  as  an  acute,  subacute,  or  chronic  affection.  It  is 
seen  in  two  forms — the  suppurative  and  non-suppurative.  The  former  variety, 
known  as  infectious  myositis,  is  especially  frequent  in  Japan,  where,  according 
to  Miyake,  some  250  cases  have  been  reported;  but  he  claims  that  some  of  these 
examples  belong  to  other  affections.  Miyake  personally  saw  33  cases  in  Japan 
during  twenty-one  months'  practice,  and  took  cultures  from  all  but  one  of 
them.  In  2  cases  the  results  were  negative,  but  in  27  a  pure  culture  of  the 
staphylococcus  pyogenes  aureus  was  obtained,  while  in  another  the  streptococ- 
cus and  in  2  more  the  albus  with  the  aureus  was  grown.  The  malady  may 
involve  one  or  many  muscles,  and  is  usually  sudden  in  its  onset.  There  is  also 
high  fever  and  marked  prostration.  Subsequently  abscesses  occur  in  the  in- 
durated muscles,  and  pysemia  may  ensue  if  the  implicated  muscles  are  not 
thoroughly  evacuated.  Of  the  second  form  a  number  of  characteristic  cases 
have  been  described  of  late  years  under  the  term  dermato-myositis.  There  have 
been  two  examples  of  this  disease  at  the  Johns  Hopkins  Hospital,  The  muscle 
inflammation  is  here  multiple,  and  is  associated  with  oedema  and  a  dermatitis. 
The  case  of  E.  Wagner  may  be  taken  as  a  typical  example,  A  tuberculous  but 
well-built  woman  entered  the  hospital,  complaining  of  stiffness  in  the  shoul- 
ders and  a  slight  oedema  of  the  back  of  the  hands  and  forearms.  There  was 
paresthesia,  the  arms  became  swollen,  the  skin  tense,  and  the  muscles  felt 
doughy.  Gradually  the  thighs  became  affected.  The  disease  lasted  about  three 
months.  The  post  mortem  showed  slight  pulmonary  tuberculosis;  all  the 
muscles  except  the  glutei,  the  calf,  and  abdominal  muscles  were  stiff  and  firm, 
but  fragile,  and  there  were  serous  infiltration,  great  proliferation  of  the  inter- 
stitial tissue,  and  fatty  degeneration.  Similar  cases  have  been  reported  by 
Unverricht,  Hepp,  Jacoby,  of  New  York,  and  others.  In  the  case  reported 
by  Jacoby  the  muscles  were  firm,  hard,  and  tender,  and  there  was  slight  oedema 
of  the  skin.  The  cases  usually  last  from  one  to  three  months,  though  there 
are  instances  in  which  it  has  been  longer.  The  swelling  and  tenderness  of  the 
muscles,  the  oedema,  and  the  pain  naturally  suggest  trichinosis,  and  indeed 
Hepp  speaks  of  it  as  a  pseudo-trichinosis.  The  nature  of  the  disease  is  un- 
known. One  of  Senator's  cases  presented  marked  disorders  of  sensation  and 
has  been  named  neuro-myositis.  Wagner  suggests  that  some  of  these  cases 
were  examples  of  acute  progressive  muscular  atrophy.     The  differentiation 

1111 


1112  DISEASES  OF  THE  MUSCLES. 

from  trichinosis  is  possible  only  by  removing  a  portion  of  the  mnscle.  It 
has  not  yet  been  determined  whether  the  eosinophilia  descril^ed  by  Brown  is 
peculiar  to  the  trichinosis  myositis.  Still  another  variety  has  been  described 
which  differs  from  dermato-myositis  chiefly  in  the  presence  of  a  greater  or  less 
amount  of  interstitial  hsemorrhages  between  the  muscle  fibres  and  in  the  pres- 
ence of  circulatory  s}Tnptoms  caused  by  the  implication  of  the  cardiac  muscle. 
It  is  known  as  pol3Tiiyositis  hsemorrhagica.    About  12  cases  have  been  reported. 

Myositis  Ossificans  Progeessiva. 

In  this  rare  and  remarkable  affection  the  process  begins  in  the  neck  or 
back,  usually  with  swelling  of  the  affected  muscles,  redness  of  the  skin,  and 
slight  fever,  or  with  small  nodules  in  the  muscles  which  appear  and  disap- 
pear. After  subsiding  an  induration  remains,  which  becomes  progressively 
harder  as  the  transformation  into  bone  takes  place.  The  disease  may  ulti- 
mately involve  a  majority  of  the  skeletal  muscles.  ISTothing  is  known  of  the 
etiology.    Malformations,  particularly  of  the  thumbs  and  big  toes,  are  common. 

II.     MYOTONIA    (Thomsen's  Disease). 

Definition. — An  infection  characterized  by  tonic  cramp  of  the  muscles  on 
attempting  voluntary  movements.  The  disease  received  its  name  from  the 
physician  who  first  described  it,  in  whose  family  it  has  existed  for  five  gen- 
erations. 

While  the  disease  is  in  a  majority  of  cases  hereditar}^,  hence  the  name  myo- 
tonia congenita,  there  are  other  forms  of  spasm  very  similar  which  may  be 
acquired,  and  others  still  which  are  quite  transitory. 

Etiology. — All  the  tyiDical  cases  have  occurred  in  family  groups;  a  few 
isolated  instances  have  been  described  in  which  similar  symptoms  have  been 
present.  Males  are  much  more  frequently  affected  than  females.  In  102  re- 
corded cases,  91  were  males  and  only  11  females  (Hans  Koch).  The  disease 
is  rare  in  America  and  in  England;  it  seems  more  common  in  Germany  and 
in  Scandinavia. 

Symptoms. — The  disease  comes  on  in  childhood.  It  is  noticed  that  on 
account  of  the  stiffness  the  children  are  not  able  to  take  part  in  ordinary 
games.  The  peculiarity  is  noticed  only  during  voluntary  movements.  The 
contraction  which  the  patient  wills  is  slowl}^  accomplished;  the  relaxation 
which  the  patient  wills  is  also  slow.  The  contraction  often  persists  for  a  little 
time  after  he  has  dropped  an  object  which  he  has  picked  up.  In  walking,  the 
start  is  ditficult;  one  leg  is  put  forward  slowly,  it  halts  from  stiffness  for  a 
second  or  two,  and  then  after  a  few  steps  the  legs  become  limber  and  he  walks 
without  any  difficult}'.  The  muscles  of  the  arms  and  legs  are  those  usually 
implicated;  rarely  the  facial,  ocular,  or  larjmgeal  muscles.  Emotion  and  cold 
aggravate  the  condition.  In  some  instances  there  is  mental  weakness.  The 
sensation  and  the  reflexes  are  normal.  G.  M.  Hammond  has  reported  three 
remarkable  cases  in  one  family,  in  which  the  disease  began  at  the  eighth  year 
and  was  confined  entirely  to  the  arms.  It  was  accompanied  with  some  slight 
mental  feebleness.  The  condition  of  the  muscles  is  interesting.  The  patients 
appear  and  are  muscular,  and  there  is  sometimes  a  definite  hypertrophy  of  the 


PARAMYOCLONUS  MULTIPLEX.  1113 

muscles.  The  force  is  scarcely  proportionate  to  the  size.  Erb  has  described 
a  characteristic  reaction  of  the  nerve  and  muscle  to  the  electrical  currents — ■ 
the  so-called  myotonic  reaction,  the  chief  feature  of  which  is  that  normally 
the  contractions  caused  by  either  current  attain  their  maximum  slowly  and 
relax  slowly,  and  vermicular,  wave-like  contractions  pass  from  the  cathode  to 
the  anode. 

The  disease  is  incurable,  but  it  may  be  arrested  temporarily.  The  nature 
of  the  affection  is  unknown.  In  the  only  autopsy  made  Dejerine  and  Sottas 
have  found  hypertrophy  of  the  primitive  fibres  with  multiplication  of  the 
nuclei  of  all  the  muscles,  including  the  diaphragm,  but  not  the  heart.  The 
spinal  cord  and  the  nerves  were  intact.  From  Jacoby's  latest  studies  it  is 
doubtful  whether  these  changes  in  the  muscles  are  in  any  way  characteristic 
or  peculiar  to  the  disease.  J.  Koch,  however,  has  found,  in  addition  to  the 
muscle  hypertrophy,  degenerative  and  regenerative  changes  present,  which  he 
considers  sufficient  to  account  for  the  myotonic  disorder.  Karpinsky  and  von 
Bechterew,  from  careful  urinary  examinations,  regard  the  affection  as  due  to 
an  auto-intoxication  of  the  muscle  tissue,  caused  by  some  faulty  metabolism. 
No  treatment  for  the  condition  is  known. 

III.    PARAMYOCLONUS    MULTIPLEX    (Myoclonia). 

An  affection,  described  by  Friedreich,  characterized  by  clonic  contractions, 
chiefly  of  the  muscles  of  the  extremities,  occurring  either  constantly  or  in 
paroxysms. 

The  cases  have  been  chiefly  in  males,  and  the  disease  has  followed  emo- 
tional disturbance,  fright,  or  straining.  The  contractions  are  usually  bilateral 
and  may  vary  from  fifty  to  one  hundred  and  fifty  in  the  minute.  Occasionally 
tonic  spasms  occur.  They  are  not  accompanied  by  any  sensory  disturbances. 
In  the  intervals  between  the  attacks  there  may  be  tremors  of  the  muscles.  In 
the  severe  spasms  the  movements  may  be  very  violent ;  the  body  is  tossed  about, 
and  it  is  sometimes  difficult  to  keep  the  patient  in  bed.  Gucci  has  described 
a  family  in  which  the  affection  has  occurred  in  three  generations. 

Weiss  has  also  noted  heredity  in  four  generations.  According  to  this 
author  the  essential  symptoms  are  continuous  or  paroxysmal  contractions, 
usually  symmetrical  and  rhythmical,  of  muscles  otherwise  normal,  which  cease 
during  sleep.  There  are  neither  psychical  nor  sensory  disturbances.  The  con- 
dition is  most  common  in  young  males,  and  is  unaffected  by  treatment.  Ray- 
mond groups  this  disease  with  fibrillary  tremors,  electric  chorea  (Henoch),  tic 
non  douloureux  of  the  face,  and  the  convulsive  tic,  under  the  name  of  myo- 
clonies, believing  that  it  is  only  one  link  in  a  chain  of  pathological  manifesta- 
tions in  the  degenerate.  Dana,  in  1903,  divided  the  myoclonias  into  five 
groups.  In  the  first  he  placed  paramyoclonus  multiplex,  and  considered  the 
names  of  four  somewhat  similar  affections  as  synonyms  of  the  same. 

IV.     MYASTHENIA    GRAVIS. 

(Asthenic  Bulbar  Paralysis;  Erb-G-oldflam's  Symptom-Complex.) 

Some  sixty  cases  have  been  analyzed  by  Harry  Campbell  and  Edwin  Bram- 
well   (Brain,  1900).     The  etiology  is  unknown.     Young  persons  are  chiefly 


1114  DISEASES  OF  THE  MUSCLES. 

affected.  The  muscles  iuneryated  by  the  bulb  are  first  affected — those  of  the 
ej'es,  the  face,  of  mastication,  and  of  the  neck.  All  the  voluntary  muscles 
may  become  involved.  After  rest  the  power  is  recovered.  In  severe  cases 
paralysis  may  persist.  The  myasthenic  reaction  of  Jolly  is  the  rapid  exhaus- 
tion of  the  muscles,  by  faradism,  not  by  galvanism.  There  are  marked  remis- 
sions and  fluctuations  in  the  severity  of  the  symptoms. 

Examination  of  the  nervous  system  has  revealed  no  abnormality.  Weigert 
found  a  thymus  tumor  with  metastatic  growths  in  the  muscles.  Hun,  Bloomer, 
and  Streeter  have  described  an  infiltration  of  the  muscles  and  of  the  th}Tnus 
gland  with  h-mphoid  cells  and  a  proliferation  of  the  glandular  elements  of  the 
th}Tnus.     More  recently  E.  Link  has  recorded  similar  findings. 

The  diagnosis  is  easy — from  the  ptosis,  the  facial  expression,  the  nasal 
speech,  the  rapid  fatigue  of  the  muscles,  the  myasthenic  reaction,  the  absence 
of  atrophy,  tremors,  etc.,  and  the  remarkable  variations  in  the  intensity  of 
the  symptoms.  Of  the  60  cases,  23  ended  fatally.  The  patient  may  live  many 
years;  recovery  may  take  place.  Eest,  strychnia  in  full  doses,  massage  alter- 
nate courses  of  iodide  of  potassium  and  mercury  may  be  tried. 

V.    AMYOTONIA    CONGENITA. 

( Oppenlieimfs  ^Disease. ) 

A  congenital  affection  characterized  by  general  or  local  hypotonus  of  the 
voluntary  muscles  Oppenheim  called  the  disease  myotonia,  but  this  is  pho- 
netically so  similar  to  myotonia  (Thomsen's  disease)  that  the  name  amyotonia 
of  English  writers  is  preferable. 

Collier  and  Wilson  (Brain,  1908),  who  have  analyzed  the  recorded  cases, 
give  the  following  definition :  "  A  condition  of  extreme  flaccidity  of  the  mus- 
cles, associated  with  an  entire  loss  of  the  deep  reflexes,  most  marked  at  the 
time  of  birth  and  always  showing  a  tendency  to  slow  and  progressive  amelio- 
ration. There  is  great  weakness  but  no  absolute  paralysis  of  any  of  the  mus- 
cles. The  limbs  are  most  affected;  the  face  is  almost  always  exempt.  The 
muscles  are  small  and  soft,  but  there  is  no  local  wasting.  Contractures  are 
prone  to  occur  in  the  course  of  time.  The  faradic  excitability  in  the  muscles 
is  lowered  and  strong  faradic  stimuli  are  borne  without  complaint.  ISTo  other 
s}Tnptoms  indicative  of  lesions  of  the  nervous  system  occur." 

In  Spiller's  case  no  lesions  were  found,  but  in  an  autopsy  by  Baudouin 
the  cells  of  the  anterior  horns  were  found  to  be  small,  and  there  were  extensive 
changes  in  the  muscle  fibres,  similar  to  those  in  the  myopathies. 


INDEX 


Abasia,  1090,  1099. 

Abdominal  typhus,  57. 

Abducens  nerve  (see  Sixth  Nerve),  1015. 

Aberrant  thyroid  glands,  764. 

Abortion,  in  relapsing  fever.  111;  in  smallpox,  120; 
in  syphilis,  278. 

Abscess,  atheromatous,  849;  of  brain,  993;  in 
appendicitis,  516;  in  glanders,  264;  of  kidney 
(pyonephrosis),  703;  hepato-pulmonary,  in 
amoebic  dysentery,  5;  of  liver,  4,  563;  of  lung, 
640;  of  mediastinum,  662;  of  parotid  gland,  441; 
of  tonsils,  446;  perinephric,  717;  cerebral,  993; 
pyseraic,  216;  retro-pharyngeal,  444;  tropical,  4, 
563. 

Acanthocephala,  51. 

Acardia,  843. 

Acarus  scabiei,  A.  folliculorum,  52. 

Accentuated    aortic    second    sound,    in    chronic 
Bright's  disease,  698;  in  arterio-sclerosis,  852. 

Accessory  spasm,  1030. 

Acephalocysts  (see  Hydatid  Cysts). 

Acetonsemia,  418. 

Acetone,  416;  tests  for,  416. 

Acetonuria,  682. 

Achondroplasia,  769,  1108. 

Achromotopsia  in  hysteria,  1081. 

Achylia  gastrica,  493. 

Acne,  from  bromide  of  potassium,  1065;rosacea,  371. 

Acromegaly,  1105;  and  gigantism,  1106. 

Actinomycosis,  263;  pulmonary,  264;  cutaneous, 
265;  cerebral,  265;  digestive,  264. 

Acute  bulbar  paralysis,  905. 

Acute  yellow  atrophy,  538. 

Addison's  disease,  756;  asthenia  in,  758;  pigmenta- 
tion of  skin  in,  757. 

Addison's  pill,  281;  keloid,  1109. 

Adenie,  739. 

Adenitis,  in  scarlet  fever,  136 ;  tuberculous,  306. 

Adenoid  growths  in  pharynx,  447. 

Adherent  pericardium,  782. 

Adhesive  pylephlebitis,  542. 

Adiposis  dolorosa,  432. 

Adrenalitis,  acute  heemorrhagic,  760. 

Adrenal  insufficiency,  760. 

Adrenals,  in  Addison's  disease,  757. 

Aegophony,  177,  647. 

Aerophagia,  490. 

Aestivo-autumnal  fever,  20. 

Afferent  system,  diseases  of,  886. 

Ageusia,  1026. 

Agoraphobia,  1089. 

Agraphia,  959. 

Ague,  10;  cake  (see  Enlakged  Spleen),  23. 

Ainhum,  1110. 


"Air-hunger"  in  diabetes,  417. 

Akinesia  algera,  1090. 

Akoria,  495. 

Albini,  nodules  of,  844. 

Albinism,  in  leprosy  (lepra  alba),  362;  of  the  lung, 
635. 

Albumin,  tests  for,  673. 

Albuminous  expectoration  in  pleurisy,  654. 

Albuminuria,  672;  of  adolescence,  672;  in  ap- 
pendicitis, 515;  and  Ufe  assurance,  675;  cyclic, 
672;  dietetic,  673;  febrile,  673;  functional,  672; 
in  acute  Bright's  disease,  688;  in  chronic  Bright's 
disease,  693,  698;  in  diabetes,  416;  in  diphtheria, 
204;  in  epilepsy,  1062;  in  erysipelas,  212;  in 
gout,  405;  intermittent,  673;  in  malarial  fever, 
16;  in  pneumonia,  179;  in  scarlet  fever,  134;  in 
typhoid  fever,  88;  in  variola,  119;  neurotic,  673; 
orthostatic,  672;  paroxysmal,  673;  physiological, 
672;  prognosis  in,  675;  in  yellow  fever,  237. 

Albuminuric  retinitis,  1007. 

Albuminuric  ulceration  of  the  bowels,  502. 

Albumosuria,  674;   myelopathic,  674. 

Alkaptonuria,  681;  and  ochronosis,  681. 

Alcohol,  effects  of,  on  the  digestive  system,  370; 
on  the  kidneys,  371;  on  the  nervous  system,  370; 
poisonous  effects  of,  370. 

Alcoholic  neuritis,  1001. 

Alcohohsm,  369;  acute,  369;  and  tuberculosis,  371; 
chronic,  369. 

Aleppo  button,  9. 

Alexia,  959. 

Algid  form  of  malaria,  22. 

Allantiasis,  381. 

AUocheiria,  891. 

Alopecia,  in  syphilis,  268. 

Alternating  paralysis  (see  Crossed  Paralysis). 

Altitude,  effects  of  high,  366. 

Altitude  in  tuberculosis,  285,  355. 

Amaurosis,  hysterical,  1008,  1081;  toxic,  1008; 
uraemic,  684,  699;  in  haematemesis,  489. 

Amblyopia,  1008;  tobacco,  1008;  crossed,  1011. 

Ambulatory  typhoid  fever.  71,  91. 

Amoeba,  dysenteriae,  2;  in  Uver  abscess,  2,  563;  in 
sputa,  6. 

Amoebic  dysentery,  2. 

AmmoniEemia,  706. 

Amnesia  verbalis,  959. 

Amphistome,  27. 

Amphoric,  breathing,  331,  659;  echo,  331. 

Amyloid  disease,  in  phthisis,  321;  in  syphilis,  269; 
of  kidney,  702;  of  liver,  571. 

Amyosthenia,  1089. 

Amyotonia,  1114. 

Amyotrophic  lateral  sclerosis,  901. 

1115 


1116 


INDEX. 


Anaemia,  718;  aialastic,  726;  bothriocephalus,  30; 
in  ankj'lostomiasis,  46;  from  Bilharzia,  27 ;  of  the 
brain,  964;  in  chlorosis,  722;  from  gastric  atrophy, 
462;  from  hsemorrhage,  719;  miner's,  44;  brick- 
maker's,  44;  tunnel,  44;  from  inanition,  721; 
from  lead,  376;  idiopathic,  724;  in  gastric  cancer, 
482;  in  gastric  iilcer,  475;  general,  719;  local, 
718;  in  Hodgkin's  disease,  741 ;  Ij-mphatica,  739; 
mountain,  366;  in  malarial  fever,  23;  in  rheuma- 
tism, 222;  in  sj-philis,  268;  in  tj'phoid  fever,  76; 
primary  or  essential,  721 ;  progressive  pernicious, 
724;  pseudo,  718;  secondary'  or  sj-mptomatic, 
719;  of  spinal  cord,  934;  splenic,  762;  toxic,  721. 

Angemic  murmurs  (see  H.EM1C  Murmurs). 

Anaemic  necrosis,  823. 

Anaesthesia,  dolorosa,  939;  in  haematomyelia,  936; 
in  hemiplegia,  973;  in  hysteria,  1080;  in  leprosy, 
362;  in  locomotor  ataxia,  891;  in  Mor\-an's  disease, 
944;  paralj'sis,  1003;  pneumonia,  185;  inrailway 
spine,  1097;  in  unilateral  lesions  of  the  cord,  933. 

Analgesia  in  hysteria,  1080;  in  Mor%-an's  disease, 
944;  in  sjTingo-myelia,  943. 

Anarthria,  956. 

Anasarca  (see  Dropsy). 

Anchmeromj-ia  luteola,  56. 

Aneurism,  853;  arterio-venous,  854,  865;  cirsoid, 
853;  cylindrical,  853;  dissecting,  854;  embolic, 
854;  false,  854;  fusiform,  853;  mycotic,  854;  of 
the  abdominal  aorta,  863;  of  the  branches  of  the 
abdominal  aorta,  865;  of  the  cerebral  arteries, 
982;  of  thecoeliacaxis,  865;  of  heart,  830;  of  the 
hepatic  artery,  865;  of  the  renal  artery,  865;  of 
the  splenic  artery,  865 ;  of  the  superior  mesenteric 
artery,  865;  traction,  855;  true,  853;  varicose, 
865. 

Aneurism,  of  thoracic  aorta,  855;  haemorrhage  in, 
859;  pain  in,  858;  TufneU's  treatment  of,  861; 
unilateral  sweating  in,  860. 

Aneurism,  verminous,  in  the  horse,  45,  855. 

Aneurismal  varix,  865. 

Angina,  crural,  853;  Ludovici.  444;  simplex,  442; 
suffocativa,  193;  Vincent's,  201. 

Angina  pectoris,  839;  functional,  841;  toxic,  842; 
vaso-motor,  842. 

Angiocholitis,  chronic  catarrhal,  544;  suppurative 
and  ulcerative,  544 

Angio-neurotic  cedema,  1103 

Angio-sclerosis,  851. 

Anguillula  aceti,  51;  A.  stercoraUs,  A.  intestinalis, 
51. 

Animal  lymph,  127. 

Anisocoria,  1014. 

Ankle  clonus,  in  hysterical  paraplegia,  914,  1079; 
in  spastic  paraplegia,  909;  spurious,  1079. 

Ankylostoma  duodenale,  45. 

Ankylostomiasis,  44. 

Anorexia  ner^-osa,  495,  1082. 

Anosmia,  1006. 

Anterior  cerebral  artery  embolism  of,  980. 

Anterior  crural  nerve,  paralysis  of,  1038. 

Anthomjda  canicularis,  55. 

Anthracosis,  of  lungs,  631;  of  liver,  556;  and 
tuberculosis,  632. 

Anthrax,  252;  bacillus,  252;  in  animals,  252;  ex- 
ternal, 253;  internal,  254;  in  man,  253. 

Anthropophobia,  1089. 

Antipneumococcic  serum,  191. 


Antitoxin  of  diphtheria,  195,  209;  of  pneumonia, 
191;  of  tetanus,  261. 

Antityphoid  serum,  102. 

Anuria,  668;  complete,  from  stone,  668;  hysterical, 
668. 

Anus,  imperforate,  521. 

Aorta,  aneurism,  of,  855;  double,  854;  dynamic 
pulsation  of,  860;  throbbing,  864,  1090;  tuber- 
culosis of,  349. 

Aortic  incompetency,  796;  sudden  death  in,  800. 

Aortic  orifice,  congenital  lesions  of,  845. 

Aortic  stenosis,  802. 

Aortic  valves,  bicuspid  condition  of,  844;  in- 
sufficiency of.  796. 

Apex  pneumonia,  182. 

Aphasia,  955;  auditorj'  958;  hereditary,  960;  in 
infantile  hemiplegia,  986;  medico-legal  aspects 
of,  960;  motor,  960;  in  phthisis.  334;  prognosis 
of,  961;  sensory,  958;  subcortical-motor,  960 
subcortical  sensory,  959;  in  tj^phoid  fever,  86 
tests  for,  960;  transient,  in  migraine,  1067 
visual,  959. 

Aphemia.  956. 

Aphonia,  hysterical,  1081;  in  acute  larjmgitis,  597; 
in  adductor  paralysis,  1028;  in  pericardial 
effusion,  779. 

Aphthae  (see  Stomatitis,  Aphthous)  ,  434. 

Aphthous  fever,  367. 

Apoplectic  habitus,  966;  stroke,  969. 

Apoplexj-,  capillary,  978;  cerebral,  966;  ingraves- 
cent, 970;  meningeal,  935;  spinal,  936;  pul- 
monarj',  618. 

Appendicitis,  512;  acute  catarrhal,  513;  chronic, 
513;  obliterative,  513;  gangrenous,  513;  puru- 
lent, 513;  relapsing,  516. 

Appendicular  coUc,  514. 

Appendix  vermiformis,  perforation  of,  in  tji^hoid 
fever,  67;  faecal  concretions  in,  513;  foreign 
bodies  in,  513. 

Apraxia,  959. 

Aprosexia,  447,  450. 

Arachnida,  parasitic,  52. 

Arachnitis  (see  Meningitis),  925. 

Aran-Duchenne  type  of  muscular  atrophy,  901, 
914;  in  lead-poisoning,  377. 

Arch  of  aorta,  aneurism  of,  855. 

Arcus  senilis,  827. 

Argas  moubata,  53. 

Argyll  Robertson  pupU,  1014;  in  ataxia,  889;  in 
general  paralj-sis,  897. 

Arithmomania,  1054. 

Arm,  peripheral  paralysis  of  (see  Paralysis  of 
Brachial  Plexus). 

Arrhythmia.  833. 

Arsenical  neuritis,  380,  1002. 

Arsenical  pigmentation,  380;  in  chorea,  1050. 

Arsenical  poisoning,  379;  paralysis  in,  380. 

Arteries,  diseases  of,  847;  calcification  of,  847; 
degeneration  of,  847;  tuberculosis  of,  349. 

Arterio-capiUary  fibrosis,  847. 

Arterio-sclerosis,  847;  diffuse,  850;  in  lead-poison- 
ing, 378;  in  migraine,  1067;  nodular  form,  849; 
in  phthisis,  337;  senile  form,  850. 

Arterio-venous  aneurism,  865. 

Arteritis  in  tjiahoid  fever,  69,  78;  syphilitic,  277. 

Arthralgia  from  lead,  378. 

Arthri tides,  post-febrile,  217;  in  gout,  404. 


INDEX. 


1117 


Arthritis,  acute,  in  infants,  226;  gonorrhcEal,  282; 
in  acute  myelitis,  945;  in  cerebro-spinal  meningitis, 
162;  in  chorea,  1045;  in  dengue,  156;  in  dysentery, 
245;  in  haemophilia,  749;  in  Malta  fever,  248;  in 
small -pox,  120;  in  tabes  dorsalis,  892;  multiple  sec- 
ondary, 225;  in  purpura,  744;  rheumatoid,  389;  in 
scarlet  fever,  135;  septic,  225;  in  typhoid  fever,  89. 

Arthritis  deformans,  389;  acute,  226;  as  a  chronic 
infection,  390;  in  children,  393;  general  progres- 
sive form,  391;  Heherden's  nodes  in,  391;  relation 
of,  to  diseases  of  nervous  system,  389;  partial  or 
mono-articular  form,  392;  vertebral  form,  392. 

Arthropathies  in  tabes,  892. 

Arthropathy,  hypertrophic  pulmonary,  1107. 

Ascariasis,  38. 

Ascaris  lumbricoides,  38. 

Ascites,  589,  592;  from  cancerous  peritonitis,  588; 
from  cirrhosis  of  the  liver,  559;  from  syphiHs  of 
the  liver,  275;  in  cancer  of  the  liver,  569;  in 
tuberculous  peritonitis,  311;  physical  signs  of, 
589;  treatment  of,  592. 

Ascitic  fluid,  chylous,  590;  serous,  590;  heem- 
orrhagic,  590. 

Aspergillus,  in  lung,  324;  fumigatus,  614. 

Asphyxia,  local,  1100;  death  by,  in  phthisis,  338; 
traumatic,  662. 

Aspiration,  Bowditch's  conclusions  on,  653;  in 
empyema,  654;  in  pericardial  eiiusion,  782;  in 
pleuritic  effusion,  653. 

Aspiration  pneumonia,  621. 

Astasia-abasia,  1090,  1099. 

Asthenic  bulbar  paralysis,  1113. 

Asthenopia,  nervous,  1089. 

Asthma,  bronchial,  609;  nasal  affections  in,  610; 
sputum  in,  611;  cardiac,  609;  hay,  594;  Leyden's 
crystals  in,  611,  613;  renal,  609,  684;  thymic, 
599,  772. 

Astrophobia,  1089. 

Atavism,  in  haemophilia,  748;  in  gout,  397. 

Ataxia,  cerebellar,  954;  cerebellar-heredo,  922; 
in  diabetes,  418;  hereditary,  921;  in  progressive 
paresis,  898;  locomotor,  886;  after  small-pox,  120. 

Ataxic  gait,  890;  paraplegia,  920. 

Ataxie  variolique,  120. 

Atelectasis,  pulmonary,  622. 

Ateliosis,  774. 

Atheroma   (see  Arterio-sclerosis  and  Phlbbo- 

SCLEROSIS). 

Atheromatous  abscess,  849. 

Athetosis,  987;  bilateral  or  double,  911;  hysterical, 
1080. 

Athlete's  heart,  797. 

Athyrea,  765,  768. 

Atmospheric  pressure,  effects  of,  937. 

Atremia,  1090. 

Atrophy,  acute  yellow,  of  liver,  538;  of  brain,  dif- 
fuse in  general  paresis,  896;  of  brain,  unilateral, 
986;  of  muscles,  various  forms  of,  907;  progressive 
muscular,  of  central  origin,  901;  unilateral,  of 
face,  1104;  progressive  neural,  905. 

Attitude, inpseudo-hypertrophic  muscular  paralysis, 
906;  in  paralysis  agitans,  1043. 

Auditory  centre,  affections  of,  1023 ;  nerve,  diseases 
of,  1023;  vertigo,  1024. 

Aura,  forms  of,  in  epilepsy,  1060. 

Auto-infection  in  tuberculosis,  297. 

Automatism,  in  -petit  mal,  1062. 


Autumnal,  catarrh,  594;  fever,  59. 

Avian  tuberculosis,  284. 

Axones  (axis-cylinder  processes),  867. 

Babinski  syndrome,  860. 

Baccelli's  sign,  647,  649. 

Bacillary  dysentery,  242. 

Bacilluria  in  typhoid  fever,  88. 

Bacillus  of  Achalme,  221;  B.  anthracis,  252;  B. 
botulinus,  381 ;  of  cholera,  228;  B.  coli  communis 
— distinction  from  typhoid  bacillus,  60;  in  bile- 
passages,  545;  in  faeces  of  sucklings,  505;  in  fat 
necrosis  with  colitis,  576;  in  peritonitis,  581;  B. 
diphtheriae,  194,  445;  B.  dysenteriae,  243;  B.  ente- 
ritidis,  381;  B.  Flexner-Harris,  243;  B.  gas  (B. 
aerogenes  capsulatus) ,  in  peritonitis,  581 ;  in  pneu- 
mothorax, 658;  in  pneumaturia,  682 ;  in  pneumo- 
pericardium, 785;  B.  Klebs-Loeffler,  194;  toxin  of 
195;  B.  of  glanders,  261 ;  B.  of  influenza,  153,  216; 
B.  in  whooping-cough,  149;  B.  of  leprosy,  360;  B. 
of  plague,  239;  B.  of  tetanus,  259;  B.  pyocyaneus 
215,  216;  B.  leprae,  360;  B.  mallei,  261;  B.  pestis, 
239;  pneumoniae,  168,  623;  B.  Shiga,  243;  B. 
tuberculosis,  285,  644;  diagnostic  value  of,  335; 
distribution  of,  286;  in  sputum,  323;  methods  of 
detection,  323;  outside  the  body,  286;  modes  of 
growth  of,  286;  B.  typhosus,  59;  B.  xerosis,  196; 
B.  "Y,"  244. 

"Back-stroke"  of  heart,  795. 

Bacteraemia,  214. 

Bacteria,  proteus  group  in  diarrhoea,  505. 

Bacterium,  coli  commune  (see  Bacillus  Con 
Communis)  ;  B.  solaniferum,  384. 

Balanitis  in  diabetes,  417. 

Balantidium  coli,  26. 

Ball-thrombus  in  left  auricle,  809. 

Ball-valve  stone  in  common  duct,  553. 

Balne's  cough,  449. 

Balz's  disease,  440. 

Banting's  method  in  obesity,  432. 

Banti's  disease,  762. 

"Barben  cholera,"  383. 

Barking  cough  of  puberty,  1081. 

Barlow's  disease,  753. 

Barrel-shaped  chest  in  emphysema,  636;  in  en- 
larged tonsils,  449. 

Basedow's  disease,  765. 

Basilar  artery,  embolism  and  thrombosis  of,  979. 

Baths,  cold,  in  typhoid  fever,  100;  in  hyperpyrexia 
of  rheumatism,  227 ;  in  scarlet  fever,  139. 

Batophobia,  1089. 

Beaded  ribs  in  rickets,  428. 

Beaumfe's  law,  266. 

Bed-bug,  54. 

Bednar's  aphthae,  436. 

Bed-sores,  acute,  in  myelitis,  945,  946;  in  typhoid 
fever,  75. 

Bell's  mania,  1041;  palsy,  1019. 

Bence-Jones  body  in  albumosuria,  674. 

Beri-beri,  249;  forms  of,  251. 

Besoin  de  respirer,  367. 

Bicuspid  condition  of  heart  valves,  844. 

"Big-jaw"  in  cattle,  263. 

Bile  coloring  matter,  tests  for,  535. 

Bile-ducts,  acute  catarrh  of,  542;  ascarides  in,  547; 
cancer  of,  546;  congenital  obliteration  of,  548; 
stenosis  of,  547. 


1118 


INDEX. 


Bile-passages,  diseases  of,  542. 

Bilharziosis,  27. 

Biliary,  cirrhosis  of  liver,  556;  colic,  550;  fistnlse, 
554. 

Bilious  remittent  fever,  20. 

Birth  palsies,  910. 

Black   death,    239. 

Black  spit  of  miners,  633. 

Black  vomit,  237;  in  dengue,  157. 

Black-water  fever,  22. 

Bladder,  paralysis  of,  in  locomotor  ataxia,  S89; 
care  of,  in  myelitis,  947;  hjT>ertrophy  of,  in 
diabetes  insipidus,  424;  tuberculosis  of,  347. 

Blastomycosis,  systemic,  2. 

"Bleeders,"  747. 

Blepharospasm,  1022. 

Blindness  (see  Amaurosis). 

Blood  and  ductless  glands,  diseases  of,  718. 

Blood,  characters  of,  in  anEemia,  719;  in  cancer  of 
the  stomach,  482;  in  chlorosis,  722;  in  cholera,  230; 
in  diabetes,  412, 416;  in  gout,  400;  in  hcemophiUa, 
748;  in  lead-poisoning,  376;  in  leuksemia,  735;  in 
pernicious  anaemia,  727;  in  pneumonia,  177;  in 
pseudo-leuksemia,  Hodgkin's  disease,  741;  in  pur- 
pura, 743;  in  secondary  anaemia,  719;  in  syphilis, 
268;  in  trichiniasis,  42;  in  tjijhoid  fever,  76. 

Blood  crises,  728. 

Blood-letting,  in  arterio-sclerosis,  853;  in  cerebral 
hsemorrhage,  980;  in  emphysema,  638;  in  heart- 
disease,  817;  in  pneumonia,  190;  in  sun-stroke, 
388;  in  yellow  fever,  239. 

Blood  pressure,  in  arterio-sclerosis,  851;  in  pneu- 
monia, 177;  in  typhoid  fever,  77. 

Blood-serum  therapy  in  diphtheria,  209;  in  pneu- 
monia, 191,  in  tetanus,  261;  in  typhoid  fever,  102. 

Blood-vessels  of  Uver,  affections  of,  540. 

"  Blue  disease,"  845. 

Blue  line  on  gums  in  lead-poisoning,  376- 

Boils,  in  diabetes,  417;  after  typhoid  fever,  7G; 
after  small-pox,  120. 

Bones,  lesions  of,  in  acromegaly,  1105;  in  congenital 
syphilis,  271;  fragUity  of,  in  osteogenesis  imper- 
fecta, 1108;  fragihty  of,  in  rickets,  427;  in  typhoid 
fever  88. 

Borborygmi,  490,  499. 

Bothriocephalus  latus,  29;  anaemia,  30. 

BotuUsm,  381. 

BotjToid  hver  in  sj-philis,  275. 

Bovine  tuberculosis,  284. 

Bowel,  affections  of  (see  Intestines);  acute  ob- 
struction of,  519;  infarction  of,  533. 

^-oxy-butyric  acid,  418,  682. 

Brachial  plexus,  affections  of,  1035. 

Bradycardia  (Brachycardia),  836;  paroxysmal,  834; 
in  tjTDhoid  fever,  76. 

Brad>T3ncea,  1081. 

Brain,  diffuse  and  focal  diseases  of,  947;  abscess  of, 
993;  abscess  of.  in  congenital  heart-disease,  846; 
affections  of  blood-vessels  of,  961;  anaemia  of, 
964;  atrophy  and  scleroses  of,  928;  congestion  of, 
964;  cysts  in,  989;  echinococcus  of,  37;  haemor- 
rhage into,  966;  syphilis  of,  271,  988;  glioma  of 
988;  hj-peraemia  of,  964;  inflammation  of,  992; 
oedema  of   965;  porencephalus  of,  986. 

Brain-murmur  in  rickets,  429. 

Brain,  sclerosis  of,  928;  diffuse,  929;  insular,  930; 
miliary,  929;  tuberous,  930, 


Brain,  softening  of,  red,  yellow,  and  white,  978. 

Brain,  tubercle  of,  342,  988. 

Brain,  tumors  of,  988;  medical  treatment  of,  992; 

surgical   treatment  of,   992;   symptoms,  general 

and  locahzing,  989. 
Brand's  method  in  typhoid  fever,  100. 
Breakbone  fever  (see  Dengue),  156. 
Breast,  funnel,  449;  pigeon  or  chicken,  449. 
Breast-pang,  839. 
Breath,  odor   of,  in   diabetic   coma,  418;    foul,  in 

scurvy,  751;  in  fetor  oris,  439;  foetid,  in  enlarged 

tonsils,  450. 
Breathing  (see  Respiration);  mouth,  447. 
Bremer's  blood  test  in  diabetes,  419. 
Brick-dust  deposit  in  urine,  677. 
Brick-maker's  anaemia,  44. 

Bright's  disease,  acute.  686;  interstitial  form  of,  688. 
Bright's  disease,  chronic,  692;  interstitial  form  of, 

694;  causes  of,  694;  cardio-vascular  changes  in, 

698;    hereditary    influences    in,    694;    Edebohls's 

operation  in,  702;  parenchymatous  form  of,  692. 
Briquet,  syndrome  of,  1081. 
Broadbent's  sign,  783. 
Broca's  convolution,  lesions  of,  960. 
"Broken-winded,"  821. 
Bromism,  1065. 
Bronchi,  casts  of,  613;  diseases  of,  602;  syphilis  of, 

273. 
Bronchial  asthma,  609. 
Bronchial  catarrh  (bronchitis),  602. 
Bronchial  glands,  tuberculosis  of,  307;  enlargement 

in  whooping-cough,  150,  660;  suppuration  in,  660. 
Bronchiectasis,    606;    abscess    of    brain    in,    608; 

congenital,    607;    cylindrical,    607;    rheumatoid 

aS'ections  in,  608;  saccular,  607;  sputum  in,  608; 

universahs,  607. 
Bronchiolectasis;  607. 
Bronchiolitis  exudativa,  609, 
Bronchitis,  602;  acute,  602;  capUlary,  620;  chronic, 

604;  croupous,  613;  fibrinous,  613;  in  measles,  143; 

in  smaU-pox,  119;  in  typhoid  fever,  84;  plastic, 

613;  putrid,  605. 
Bronchocele  (see  Goitre)    763. 
Bronchophony,  in  pneumonia,  177, 
Broncho-pneumonia,  620;  acute,  621;  chronic,  828; 

secondary,  621;  acute  tuberculous,  315. 
Bronchorrhagia,  617. 
Bronchorrhoea,  605;  serous,  605. 
Bronze-sldn  in  phthiriasis,  54;  in  Addison's  disease, 

757;  in  Basedow's  disease,  767;  in  diabetes,  417; 

in  Hodgkin's  disease,  741. 
Brauer's  operation,  784. 
Brown  atrophy  of  heart,  826. 
Brown  induration  of  lung,  615. 
Brown-Siquard's  paralysis,  933. 
Bruit,  d'airain,  659;  de  cuir  neuf,  777;  de  diable, 

724,767;  de  drapeaii,  613;  de  moulin,  785;  depot 

fele  (see  Cracked-pot  Sound),  330;  de  souffle,  789; 

oesophageal,  454. 
Bubo  parotid  (see  also  Parotitis),  441. 
Bubonic  plague,  240. 

Buccal,  psoriasis,  439;  spots  in  measles,  142. 
Buhl's  disease,  747. 
Bulbar  paralysis,  904;  acute,  905;  asthenic  form, 

1113;  of  cerebral  origin,  905;  progressive,  901; 

pseudo,  905. 
Bulimia,  414,  494. 


INDEX. 


1119 


Cachexia,  in  cancer  of  the  stomach,  482;  in  Hodg- 
kin's  disease,  741;  malarial,  15,  23;  periosteal, 
753;  saturnine,  376;  strumipriva,  770;  syphilitic, 
268;  tropical,  9. 

Caisson  disease,  937. 

Calcareous  concretions,  in  phthisis,  319;  in  the 
tonsils,  450. 

Calcareous  degeneration,  of  arteries,  847;  of  heart, 
827. 

Calcification,  annular,  of  arteries,  847. 

Calcification  in  tubercle,  296. 

Calculi,  biliary,  548;  "coral,"  709;  pancreatic,  580; 
renal,  709;  tonsillar,  450;  urinary,  709. 

Calculous  pyelitis,  704. 

Camp  fever,  105. 

Cancer,  of  bile-passages,  546,  568;  of  bowel,  521 ;  of 
brain,  988;  of  gall-bladder,  546;  green,  738; 
of  kidney,  714;  of  liver,  567;  of  lung,  641;  of 
oesophagus,  454;  of  pancreas,  579;  of  perito- 
naeum, miliary,  588;  of  stomach,  479;  acute, 
485. 

Cancrum  oris,  437;  in  measles,  143. 

Canities,  the  result  of  neiu-algia,  1069. 

Canned  goods,  poisoning  by,  382. 

Capillary  pulse,  in  aortic  insufficiency,  801 ;  in 
neurasthenia,  1090;  in  phthisis,  333. 

Capsule,  internal,  949;  lesions  of,  949. 

Caput  Medusae,  589. 

Caput  quadratum,  in  rickets,  429. 

Carboluria,  681. 

Carbuncle  in  diabetes,  417. 

Carcinoma  (see  Cancer). 

Cardia,  spasm  of,  491;  insufficiency  of,  492. 

Cardiac  disease  (see  Disease  op  Heart). 

Cardiac  murmurs,  haemic,  in  chlorosis,  724;  in 
chorea,  1049;  in  idiopathic  anaemia,  728. 

Cardiac  murmurs,  organic,  in  aortic  insufficiency, 
800;  in  aortic  stenosis,  803;  in  congenital  heart 
affections,  846;  in  mitral  incompetency,  807;  in 
mitral  stenosis,  810;  in  tricuspid  valve  disease, 
812. 

Cardiac  nerves,  neuralgia  of,  839. 

Cardiac  overstrain,  821. 

Cardiac  septa,  anomalies  of,  843. 

Cardialgia  (see  Gastralgia). 

Cardiocentesis,  832. 

Cardio-hepatic  angle  in  pericarditis  with  effusion, 
780. 

Cardio-lysis,  784. 

Cardio-respiratory  murmur,  331. 

Cardio-sclerosis,  827. 

Cardio-vascular  changes  in  renal  disease,  698. 

Caries,  vertebral,  938. 

Carinated  abdomen,  303. 

Carotid  artery,  ligature  and  compression  of,  in 
cerebral  haemorrhage,  980. 

Carphologia,  85. 

Carpo-pedal  spasm,  1076. 

Carreau,  312. 

Carriers,  typhoid,  62. 

Caseation  in  tubercle,  296. 

Caseous  pneumonia,  297,  323. 

Casts,  blood,  of  bronchial  tubes  in  haemoptysis, 
618;  in  fibrinous  bronchitis,  614;  of  pelvis  of 
kidney  and  ureter,  714. 

Casts  of  urinary  tubules,  689;  epithelial,  688,  689; 
fatty,  693;  granular,  693,  698;  hyaline,  698. 


Casts,  tube,  in  acute  Bright's  disease,  688;  in  chronic 
Bright's  disease,  693,  698. 

Catalepsy  in  hysteria,  1084. 

Cataract,   diabetic,   419;  after   typhoid   fever,   87. 

Catarrh,  acute  gastric,  456;  autumnal,  594;  bron- 
chial, 602 ;  chronic  gastric,  459 ;  dry,  605;  suffoca- 
tive, 625. 

Catarrhal  bronchitis,  influence  of,  in  tuberculosis, 
294. 

Catarrhe  sec,  605. 

Catarrhus  sestivus,  594. 

Caterpillar  rash,  56. 

Cauda  equina,  lesions  of,  940. 

Cavernous  breathing,  331. 

Cavities,  pulmonary,  319;  physical  signs  of,  331; 
quiescent,   320. 

Cayor  fly,  56. 

Cellulitis  of  the  neck,  444. 

Centrum  semiovale,  lesions  of,  949. 

Cephalalgia  (see  Headache). 

Cephalic  tetanus,  260. 

Cephalodynia,  397. 

Cercomonas  intestinalis,  25;  C.  hominis,  25. 

Cerebellar  ataxia,  922,  954;  heredo-ataxia,  922; 
vertigo,  954. 

Cerebellum,  tumors,  of,  953;  affections  of,  953. 

Cerebral  arteries,  aneurism  of,  982 ;  arterio-sclerosis 
of,  983;  embohsm  of,  977;  endarteritis  of,  983; 
syphilitic  endarteritis  of,  272,  983;  thrombosis  of, 
977. 

Cerebral  cortex,  lesions  of,  947. 

Cerebral  haemorrhage,  966;  aneurisms,  miliary  in, 
967;  convulsions  in,  976;  forms  of,  968. 

"  Cerebral  pneumonia, "  179. 

"Cerebral  rheumatism,"  224. 

Cerebral  sinuses,  thrombosis  of,  983. 

Cerebral  softening,  977. 

Cerebritis  (see  Encephalitis),  992. 

Cerebro-spinal  fever,  epidemic,  157;  anomalous 
forms  of,  161;  complications  of,  162;  malignant 
form,  160;  ordinary  form,  160. 

Cervical  pachymeningitis,  924. 

Cervical  plexus,  lesions  of,  1033. 

Cervical  ribs,  1034. 

Cervico-brachial  neuralgia,  1070. 

Cervico-occipital  neuralgia,  1033,  1070. 

Cestodes,  disease  due  to,  28;  visceral,  31. 

Chalicosis,  631,  632. 

Chancre,  267. 

Charbon,  252. 

Charcot's  joint,  892. 

Charcot-Leyden  crystals,  499,  611,  732. 

Chattering  teeth,  1018. 

Cheek,  gangrene  of,  437. 

Cheese,  poisoning  by,  382. 

Chest  expansion,  diminution  of,  in  Graves'  disease, 
767. 

Cheyne-Stokes  breathing,  Cheyne's  original  de- 
scription of,  827 ;  in  apoplexy,  970 ;  in  mj'ocardial 
disease,  827;  in  sun-stroke,  386;  in  acute  miliary 
tuberculosis,  299;  in  uraemia,  684. 

Chiasma  and  tract,  affections  of,  1009. 

Chicken-breast,  428,  449. 

Chicken-pox,  128. 

Child-crowing,  599,  1056. 

Children,  constipation  in,  527;  diabetes  in,  417; 
diarrhoeal  diseases  in,  504;  tuberculous  broncho- 


1120 


INDEX. 


pneumonia  in,  315;  pneumonia  in,  183;  tubercu- 
losis of  mesenteric  glands  in,  308,  312;  mortality 
from  small-pox  in,  120;  rheumatism  in,  219;  ty- 
phoid fever  in,  91. 

Chills  (see  Rigors),  in  tjT)hoid  fever,  74. 

Chloasma  phthisicorum,  335. 

Chloro-ansemia  in  phthisis,  333. 

Chloroma,  732,  738. 

CUorosis,  721 ;  and  anaemia,  sinus  thrombosis  in, 
983;  dilatation  of  stomach  in,  723;  Egj-ptian,  44; 
fever  in,  724;  heart  sjinptoms  in,  724;  menstrual 
disturbance  in,  724;  rubia,  722;  thrombosis  in, 
724. 

Choked  disk,  1008. 

Cholaemia,  536. 

Cholangitis,  infective,  553;  suppurative,  554,  564; 
in  tj-phoid  fever,  83. 

Cholecj'stectomy,  555;  indications  for,  555. 

Cholecystitis  acuta,  551. 

Cholecystitis,  acute  infectious,  545;  in  tj-phoid  fever, 
83. 

Cholecystotomy,  555. 

Cholelitliiasis,  548;  in  tjiihoid  fever,  83. 

Cholera,  asiatica,  228;  bacillus  of,  228;  epidemics 
of,  228;  infantum,  507;  laboratory,  229;  nostras, 
232;  sicca,  231;  tj-phoid,  231. 

Cholera  toxin,  228. 

Cholerine,  232. 

Cholesteraemia,  536. 

Cholesterin  in  biliary  calculi,  550. 

Choluria,  535,  682. 

Chondrodystrophia  foetalis,  769, 1108. 

Chorea,  acute,  1045;  etiologj- of ,  1045;  heart  sjinp- 
toms  of,  1049;  infectious  origin  of,  1048;  in  preg- 
nancy, 1046;  paralysis  in,  1049;  rheumatism  and, 
224,  1045;  school-made,  1046. 

Chorea,  canine,  1046;  chronic,  1055. 

Chorea,  habit  or  spasm,  1047,  1053. 

Chorea,  Huntingdon's  or  hereditary,  1055. 

Chorea  insaniens,  1048,  1050;  paralytic  form  of, 
1049;  major,  1053;  maniacal,  1048;  pandemic, 
1053;  post-hemiplegic,  987;  prehemiplegic,  969. 
rhjiihmic  or  hysterical,  1056;  senile,  1055;  spas- 
tica, 911,  1051;  Sydenham's,  1045. 

Choroid  plexuses,  sclerosis  of,  997. 

Choroid,  tubercles  in,  304. 

Choroiditis  in  sj-philis,  268. 

Chovstek's  sjTnptom  in  tetany,  1076. 

Chylangiomata,   533. 

Chyle  vessels,  disorders  of,  533. 

Chylo-pericardium,  784. 

Chyluria,  non-parasitic,  676;  parasitic,  48. 

Cicatricial  stenosis  of  bowel,  521. 

Ciliary  muscle,  paralj'sis  of,  1014. 

Cimex  leetularius,  54. 

Circulatory  system,  diseases  of,  775. 

Circiimcision,  inoculation  of  tuberculosis  by,  290; 
in  hsemophilia,  748. 

Circumflex  ner\'e,  affections  of,  1036. 

Cirrhosis,  of  kidney,  694;  of  liver,  556;  of  lung,  628; 
tuberculous  of  liver,  342;  ventriculi,  461. 

Clapotage  in  dilated  stomach,  469. 

Claudication,  intermittent,  853. 

Claustrophobia,  1089. 

Cla^-iceps  purpurea,  poisoning  by,  383. 

Claims  hystericus,  1080. 

Claw-hand  (main  en  griff e),  903,  925. 


Climate,  influence  of.  in  asthma,  612;  in  chronic 
Bright 's  disease,  700;  in  tuberculosis,  354. 

Clonus  (see  Axkle  Clonus)  ;  jaw,  903. 

Clownism  in  hysteria,  1078. 

Cnethocampa,  56. 

Coal-miner's  disease,  631. 

Cobalt  miners,  cancer  of  lung  in,  642. 

Coeainization,  spinal,  in  tabes,  895. 

Coccidium  oviforme,  1. 

Coccydj-nia,  1071. 

Cochin-China  diarrhcea,  51. 

Cochlear  ner\-e,  lesions  of,  1023. 

Coeliac  affection  in  children,  499. 

Cog-wheel  respiration,  330. 

Coin-sound,  659. 

Cold  pack,  method  of  giving,  139. 

Colic,  biliary,  550;  in  appendicitis,  514;  in  angio- 
neurotic oedema,  1103;  Devonshire,  375;  in  pur- 
pura, 745;  lead,  377;  mucous,  530;  renal,  711. 

Colica  Pictonum,  375. 

Colitis,  Bilharzial,  28;  diphtheritic,  500;  entero-, 
508;  ileo-,  508;  mucous,  530;  simple  ulcerative, 
501. 

Colles'  law,  266. 

Colloid  cancer,  of  lung,  641;  of  peritonaeum,  588; 
of  stomach,  480. 

Colon,  cancer  of,  521;  dilatation  of,  531;  "giant 
growth  of,"  532;  diverticula,  532. 

Coloptosis,  529. 

Coma,  diabetic,  417;  epileptic,  1061;  from  heat- 
stroke, 386;  from  muscular  exertion,  686;  in  acute 
encephalitis,  993;  in  acute  yellow  atrophy,  539; 
in  alcoholic  poisoning,  369;  in  apoplexy,  969;  in 
cerebral  sj"philis,  272;  in  general  paresis,  898;  in 
miiltiple  sclerosis,  931;  in  pernicious  malaria,  21; 
in  rheumatic  fever,  224;  in  thrombosis  of  cere- 
bral sinuses,  984;  in  tj-phoid  fever,  85;  urEemic, 
684. 

Coma  vigH,  85. 

Comatose  form  of  malaria,  21. 

Comma  bacillus,  228. 

Common  bile-duct,  obstruction  of,  552. 

Compensation  in  valve  lesions,  794;  disturbance  of, 
795;  loss  of,  795. 

Composite  portraiture  in  tuberculosis,  293. 

Compressed  air  disease,  937. 

Compression  and  traction  of  the  bowel,  521. 

Compression  paraplegia,  938. 

Concato's  disease,  587. 

Concretions  (see  Calcareous). 

Concussion  of  spinal  cord,  1097. 

Congenital  heart  affections,  843. 

Congenital  stenosis  of  pylorus,  487. 

Congenital  stricture  of  the  bowel,  521. 

Congenital  sj-philis,  269. 

Conjugate  de^^ation  in  brain  tumor,  991;  in  apo- 
plexy, 971 ;  in  tuberculous  meningitis,  303. 

Conjunctiva,  diphtheria  of,  203. 

Consecutive  nephritis,  703. 

Constipation,  525;  in  adiilts,  525;  in  infants,  527; 
spasmodic,  526;  treatment  of,  527. 

Constitutio  Ij-mphatica,  755. 

Constitutional  diseases,  389. 

Consvunption  (see  Tuberculosis). 

Contracted  kidneys,  694. 

Contracture  hysterical,  1079;  in  hemiplegia,  974; 
of  nursing  women,  1074. 


INDEX. 


1121 


Contusion  pneumonia,  166. 

Conus  arteriosus,  stenosis  of,  845. 

Conus  medullaris,  lesions  oi,  940. 

Convalescence,  fever  of,  72;  from  typhoid  fever, 
management  of,  104. 

Convulsions,  epileptic,  1058;  hysterical,  1077;  in 
acute  yellow  atrophy,  539;  in  alcoholism,  370; 
in  aspiration  of  pleural  effusion,  654;  in  cerebral 
haemorrhage,  970 ;  in  cerebral  syphilis,  272,  1060; 
in  cerebral  tumors,  989;  in  chronic  Bright's 
disea.se,  693 ;  in  general  paralysis,  897;  in  hepatic 
colic,  551;  in  infantile  hemiplegia,  986;  in  lead- 
poisoning,  378;  in  meningitis,  926;  in  rheumatic 
fever,  224;  in  sun-stroke,  386;  in  typhoid  fever, 
86;  in  uriBmia,  684 ;  Jacksonian,  1063. 

Convulsions,  infantile,  1056;  relation  to  rickets,  430. 

Convulsive  tic,  1053. 

Coordination,  disturbance  of,  in  tabes,  890. 

Copaiba  eruption,  144. 

Copper  test  for  sugar,  415. 

Coprismia,  526,  722. 

Coprolalia,  1054. 

Coproliths  as  a  cause  of  appendicitis,  513. 

Cor  adiposum,  826;  biloculare,  843;  bovinum,  696, 
798;  villosum,  776. 

Coral  calculi,  709. 

Coronary  arteries,  in  angina  pectoris,  840,  841; 
blocking  of,  in  myocardial  disease,  823. 

Corpora  quadrigemina,  tumors  in,  991;  lesions  of, 
951. 

Corpulence,  431. 

Corpus  caUosum,  lesions  of,  949. 

Corrigan's  disease,  796. 

Corrigan  pulse,  801. 

Coryza,  acute,  593. 

Costiveness,  525. 

Cough  Balne's,  449;  barking,  of  puberty,  1081; 
goose,  859;  hysterical,  1081;  in  acute  bronchitis, 
602;  in  chronic  bronchitis,  604;  in  pertussis,  149; 
in  phthisis,  323;  during  aspiration  of  pleural  effu- 
sion, 654;  in  pneumonia,  175;  paroxysmal,  in 
bronchiectasis,  608;  paroxysmal,  in  fibroid  phthi- 
sis, 336;  stomach,  462. 

Country  fever,  386. 

Coup  de  soldi,  385. 

Cow-pox,  123. 

Cracked-pot  sound,  330. 

Cramp,  shoemaker's,  1074;  writer's,  1072. 

Cramps  in  muscles,  in  cholera,  232;  in  gout,  405;  in 
chronic  Bright's  disease,  699. 

Cranio-sclerosis,  429. 

Cranio-tabes,  relation  to  congenital  syphilis,  429; 
in  rickets,  429. 

Craniotomy  in  brain  tumors,  992;  in  cerebral  hemor- 
rhage, 980;  in  birth  palsies,  912,  918;  in  lesions  of 
optic  nerve,  1009. 

Craw-craw,  47. 

Creeping  eruption,  56. 

Cretinism,  768;  endemic,  769;  sporadic  768. 

Cretinoid  change,  768. 

Crises,  gastro-intestinal,  in  angio-neurotic  oedema, 
1103;  in  locomotor  ataxia,  891;  in  purpura,  745; 
nasal,  in  tabes,  892. 

Crisis,  in  pneumonia,  174;  in  relapsing  fever,  110; 
in  typhus  fever,  108. 

Crossed  or  alternating  paralysis,  951,  973. 

Crossed  sensory  paralysis,  952. 

72 


Croup,  memliranous,  202;  spasmodic,  .599. 

Croupous  enteritis,  500. 

Croupous  pneumonia,  164. 

Crura  cerebri,  lesions  of,  951,  973. 

Crural  angina  of  Walton,  853. 

Crutch  paralysis,  1036. 

Cruveilhier's  palsy,  901. 

Cry,  epileptic,  1061;  hydrocephalic,  302;  hysterical, 
1081;  in  congenital  syphilis,  270. 

Cryoscopy,  685. 

Cryptogenetio  septictemia,  215. 

Crystalline-pox,  119. 

Cuban  itch,  113. 

Curschmann' s  spirals,  611,  613. 

Cutaneous  nerve,  external,  disease  of,  1038. 

Cyanosis,  in  acute  tuberculosis,  300;  in  congenital 
heart-disease,  845;  in  diabetes,  417;  in  emphy- 
sema, 636;.  and  polycythsemia,  762;  traumatic, 
662. 

Cycloplegia,  1014. 

Cynanche  maligna,  193. 

Cynobex  hebetica,  1081 

Cystic  disease,  of  kidney,  715;  of  liver,  569. 

Cystic  duct,  obstruction  of,  551. 

Cysticercus  cellulosaj,  31;  ocular,  32;  subcutaneous, 
32;  general,  32;  cerebro-spinal,  32. 

Cystin  calculi,  679,  710. 

Cystinuria,  679. 

Cystitis,  in  locomotor  ataxia,  892;  in  transverse 
myelitis,  946;  tuberculous,  347. 

Cysts,  chylous,  of  mesentery,  533;  dermoid,  661; 
in  kidneys,  715;  of  brain,  989;  of  liver,  569;  por- 
encephalic, 986;  pancreatic,  577;  of  brain,  throm- 
botic, 978. 

Cytodiagnosis  in  general  paralysis,  900. 

Cytoryctes  vacciniae,  125;  C.  variolae,  113. 

Cytozoa,  1. 

Dacryoadenitis  (see  Lachrymal,  Glands). 

Dancing  mania,  1053. 

Dandy  fever  (dengue),  156. 

Davainea  Madagascariensis,  29. 

Day-blindness,  1008;  in  scurvy,  752. 

Deaf-mutism  after  cerebro-spinal  fever,  163. 

Deafness,  in  cerebral  tumor,  991;  in  cerebro-spinal 
meningitis,  163;  in  hysteria,  1081;  in  Meniere's 
disease,  1024;  in  scarlet  fever,  136;  in  tabes 
dorsalis,  891;  nervous,  1024. 

Death,  modes  of,  in  tuberculosis,  338. 

Death,  sudden,  after  sera  injections,  205;  in  angina 
pectoris,  840;  in  aortic  insufficiency,  800;  in 
coronary  artery  disease,  824;  in  enlarged  thymus, 
772;  in  myocardial  disease,  828;  in  pleural  effu- 
sion, 648;  in  rheumatic  fever,  225;  in  status 
lymphaticus,  755;  in  typhoid  fever,  96. 

Debility,  nervous  (see  Neurasthenia),  1086. 

Decubitus,  acute,  970;  (bed-sores)  in  transverse 
myelitis,  945. 

Degeneration,  reaction  of,  881;  in  neuritis,  1003; 
in  facial  paralysis,  1021. 

Deglutition,  difficult  (see  Dysphagia). 

Deglutition  pneumonia,  621. 

Delayed  resolution  in  pneumonia,  185. 

Delayed  sensation  in  tabes,  891. 

Delhi  boil,  9. 

Delirium,  acute,  1041 ;  acute,  in  lead-poisoning,  378; 
cordis,  96,  832,  834;  expansive,  897;  in  acute 


1122 


INDEX. 


rheumatism,  224;  in  pneumonia,  179;  in  t}T>hoirl 
fever,  85;  in  typhus  fever,  107;  tremens,  371. 

Deltoid,  paralysis  of,  1036. 

Delusional  insanity  after  pneumonia,  180. 

Delusions  of  grandeur,  897. 

Dementia  paralytica,  895;  syphilis  and,  269,  272, 
896. 

Demodex  folliculorum,  52. 

Dendrites,  (protoplasmic  processes),  867. 

Dengue,  156. 

Dentition,  in  congenital  sjiahilis,  271;  in  mercurial 
stomatitis,  438;  in  rickets,  429. 

Dercum's  disease,  432. 

Dermacentor  americanus,  53. 

Dermamyiasis  linearis  migrans  oestrosa,  56. 

Dermatitis,  exfoliative  form,  136;  protozoic,  2. 

Dermatobia,  56. 

Dermato-myositis,  1111. 

Dermatose  parasitaire,  47. 

Desquamation,  in  measles,  143;  in  rubella,  146;  in 
scarlet  fever,  134;  in  small-pox,  117;  in  typhoid 
fever    74. 

Deviation,  secondary,  1015. 

Devonshire  coUc,  375. 

Dextrocardia,  843. 

Diabetes  insipidus,  424;  heredity  in,  424;  in  ab- 
dominal tumor,  424;  relation  of,  to  brain  sjiihihs, 
424;  in  tuberculous  peritonitis,  424. 

Diabetes  melUtus,  408;  acute  form,  414;  bronzing 
in,  417;  chronic  form,  414;  coma  in,  conjugal, 
417;  diet  in,  420;  dietetic  form,  414;  experimen- 
tal, 410;  gangrene  in,  417;  hereditary  influences 
in,  409;  in  obesity,  410;  in  children,  417;  li- 
pogenic  form,  414;  metabolism,  411;  neiu-otic 
form,  414;  pancreas  in,  413;  pancreatic  form, 
414;  paraplegia  La,  418;  perforating  ulcer  in,  417; 
theories  of,  412;  urine  in,  415. 

Diabetes,  phosphatic,  680. 

Diabetic,  centre  in  medulla,  410;  cirrhosis,  413; 
coma,  417;  phthisis,  412;  tabes,  418. 

Diacetic  acid,  416,  682. 

Diaphragm,  paralysis  of,  1034;  degeneration  of 
muscle  of,  1034. 

Diarrhoea,  497;  acute  dyspeptic,  506;  alba,  500; 
bacteria  in,  505;  chronic,  treatment  of,  503; 
chylosa,  500;  endemic,  of  hot  countries,  51;  in 
children,  treatment  of,  509;  in  cholera,  231;  in 
dysentery,  244;  fermentative,  506;  in  hysteria, 
1082;  inflammatory,  508;  in  phthisis,  334;  in  ty- 
phoid fever,  79;  in  uramia,  685;  nervous  498;  of 
Cochin-China,  51;  tubular,  530;  henteric,  499; 
summer,  505. 

Diathesis,  gouty,  404;  hsemorrhagic,  743;  Uthic 
acid,  677;  tuberculous  or  scrofulous,  293;  uric 
acid,  677. 

Diazo-reaction  in  typhoid  fever,  87. 

Dicrotism  of  pulse  in  typhoid  fever,  70,  76. 

Diet,  in  chronic  dyspepsia,  463;  in  constipation, 
527;  in  convalescence  from  tjTshoid  fever,  104; 
in  diabetes,  420;  in  gout,  406;  in  infantile 
diarrhcEa,  510;  in  obesity,  432;  ia  scurvj%  752; 
in  tuberculosis,  356;  in  typhoid  fever,  99. 

Dietl's  crises,  666. 

Digestive  system,  diseases  of,  434. 

Dioctophyme  gigas,  51. 

Diphtheria,  192;  atypical  forms  of,  200;  of  audi- 
tory   meatus,   203;    of   conjunctiva,    203;    and 


croup,  199;  bacillua  of,  194;  contagiousness  of, 
193;  hemiplegia  in,  204;  immunity  from,  195, 
210;  in  animals,  194;  laryngeal,  202;  latent,  200; 
nephritis  in,  204;  neuritis  in.  204;  nasal.  201; 
pharyngeal,  200;  of  skin,  203;  systemic  infection, 
201;  antitoxin  treatment  of,  209;  of  wounds, 
203. 

Diphtheritic,  coHtis,  500;  membrane,  histology  of, 
199;  processes  in  pneumonia,  172;  processes  in 
typhoid  fever,  90. 

Diphtheritis,  196. 

Diphtheroid  inflammations,  196. 

Diplegia,  facial,  1020;  in  children,  910. 

Diplococcus  intracellularis  meningitidis,  159. 

Diplococcus  pneumonioe  (micrococcus  lanceolatus, 
pneumococcus),  167;  in  empyema,  649;  in  endo- 
carditis, 788;  in  peritonitis,  581. 

Diplopia  (see  Double  Vision),  1016. 

Dipsomania,  369. 

Dipylidium  eaninum,  29. 

Disinfection,  in  diphtheria,  207;  in  typhoid  fever, 
97. 

Dissecting  aneiirism,  854. 

Disseminated  sclerosis,  930. 

Distomes,  varieties  of,  in  man,  26,  27. 

Distomiasis,  26;  hsemic,  27;  hepatic,  26;  intestinal, 
27;  pulmonary,  26. 

Ditfrich's  plugs,  605. 

Diuresis,  424. 

Diver's  paralysis,  937. 

Diverticula  of  oesophagus,  456;  of  colon,  532. 

Diverticulitis,  533. 

Dorsodj-nia,   397. 

Dothienenterite,   57. 

Double  heart,  843. 

Double  vision,  1016;  in  ataxia,  889;  in  chronic 
Bright 's  disease,  699. 

Dracontiasis,  49. 

Dracuneulus  medinensis,  49. 

Drainage  and  diphtheria,  193;  and  tonsillitis,  445. 

Dreamy  state  in  epilepsy,  1062. 

Dropsy,  cardiac,  treatment  of,  818;  in  anaemia 
(oedema),  726;  in  acute  Bright's  disease,  688;  in 
aortic  insufficiency,  799;  in  aortic  stenosis,  803; 
in  cancer  of  stomach.  482;  in  chronic  Bright's 
disease,  699;  in  mitral  insufficiency,  806;  in  mitral 
stenosis,  811;  oily,  431;  in  phthisis,  334;  in 
scarlet  fever,  135. 

Druesetifieber,  365. 

Drug-rashes,  137,  743. 

Drunkenness,  diagnosis  of,  from  apoplexj',  369,  975. 

Dry  mouth,  441. 

Dulness,  movable,  in  pleural  effusion,  647;  in 
pneumothorax,  659. 

Dumb  ague,  24. 

Dum-dum  fever,  9. 

Duodenal  ulcer,  470;  diagnosis  of,  from  gastric, 
476. 

Duodenum,  defect  of,  521;  ulcer  of,  470. 

Dura  mater,  diseases  of,  923;  haematoma  of,  923. 

Durande's  mixture,  555. 

Duroziez's  murmur,  801. 

Dust,  diseases  due  to,  629,  631;  tubercle  bacilli  in, 
287. 

Dwarfs,  tj^pes  of,  774. 

Dysacusis,  1023. 

Dysbasia  angio-sclerotica  of  Erb,  853. 


INDEX. 


1123 


Dysentery,  amoebic  or  tropical,  2;  abscess  of  liver 
in,  4;  amoebaj  in,  2;  bacillary,  242;  acute  catarrh- 
al, 245;  diphtheritic,  245. 

Dyspepsia,  acute,  456;  chronic,  459;  nervous,  490. 

Dysphagia,  hysterical  1082;  in  cancer  of  the 
oesophagus,  455;  in  hydrophobia,  256;  in  oesopha- 
gismus,  453;  in  oesophagitis,  452;  in  pericardial 
effusion,  779;  in  thoracic  aneurism,  859;  in 
tuberculous  laryngitis,  600;  in  tumors  of  the 
mediastinum,  661. 

Dyspnoea,  cardiac,  treatment  of,  818;  from  aneu- 
rism, 859;  in  emphysema,  636;  hysterical,  1081, 
1097;  in  acute  tuberculosis,  299;  in  aortic  in- 
sufficiency. 799;  in  chlorosis,  722;  in  diabetic 
coma,  417;  in  mitral  insufficiency,  806;  in  mitral 
stenosis,  811;  in  myocardial  disease,  827;  in  peri- 
cardial effusion,  779;  in  pneumonia,  174;  in 
phthisis,  326;  in  oedema  of  the  glottis,  598;  in 
spasmodic  laryngitis,  599;  uraemic,  684. 

Dystrophies,  muscular,  906;  clinical  forms  of,  907. 

Ear,  complications  of  scarlet  fever,  136;  affections 

of,   in   syphilis,   268,   271;   symptoms  simulating 

meningitis,  926,  994. 
Ebstein's  method  in  obesity,  432. 
Ecchymoses,  743. 

Echinococcus  cyst,  fluid  of,  34,  37. 
Echinococcus  disease,  32. 
Echinococcus,  endogenous,  33;  exogenous,  33;  mul- 

tilooular,  34,  37. 
Echinorhynchus  gigas,  51;  E.  moniliformis,  52. 
Echokinesis,  1054. 
Echolalia,  1054. 
Eclampsia,  1056. 
Ectopia  cordis,  843. 
Eczema,  of  the  tongue,  438;  in  diabetes,  417;  in  gout, 

404. 
Edebohls'  operation,  702. 
Efferent  tract,  diseases  of,  901. 
Egyptian  chlorosis,  44. 
Ehrlich's  reaction  in  typhoid  fever,  87. 
Eighth  nerve,  lesions  of,  1023. 
Elastic  tissue  in  sputum,  324. 
Electrical  reactions,  in  exophthalmic  goitre,  767: 

in  facial  palsy,  1021;  in  Landry's  paralysis,  919; 

in  multiple  neuritis,  1003;  in  periodical  paralysis, 

1099;  in  poliomyelitis  anterior,  916;  Ln  Thomsen's 

disease,  1113. 
Electrolysis  in  aneurism,  862. 
FJephantiasis,  49;  neuromatosa,  1005. 
Emaciation,  in  anorexia  nervosa,  1082;  in  gastric 

cancer,  481 ;  in  oesophageal  cancer,  455;  in  phthi- 
sis, 329. 
Embolic  abscesses,  216. 
Embolism,  and  aneurism,  854;  in  chorea,  1048;  in 

typhoid  fever,  78;    of  cerebral  arteries,  977;  of 

mesenteric  artery,  533. 
Embryocardia,      in   pneumonia,    177;    in   typhoid 

fever,  78. 
Emphysema,  633;  acute  vesicular,  638;  atrophic, 

638;     compensatory,     633;     hypertrophic,     634; 

idiopathic,    634;    interstitial,    638;    large-lunged, 

634;  substantive,  634. 
Emphysema,  subcutaneous,  after  tracheotomy,  663; 

after  aspiration  of   the  pleura,   654;   in  gastric 

ulcer,  472;  in  phthisis,  335;  of  the  mediastinum, 

663. 


Emprosthotonos  in  tetanu.s,  260. 

Empyema,  648;  bacteriology  of,  649;  necessitatis, 
265,  650,  861;  perforation  of  lung  in,  650;  in 
scarlet  fever,  135. 

Encephalitis,  acute,  992;  meningo-,  fcctal,  911; 
poli-,  of  Strumpell,  986;  suppurative,  993;  syphi- 
litic, 272. 

Encephalopathy,  lead,  377. 

Enohondroma  of  lung,  641 . 

Endarteritis  of  spinal  cord,  935. 

Endocarditis,  acute,  785;  chronic,  792;  chronic 
mural,  793;  in  chorea,  786,  1049;  infective,  786; 
in  the  foetus,  793,  844;  gonorrhoeal,  282;  in  pneu- 
monia, 786;  in  puerperal  fever,  786;  in  rheu- 
matism, 223,  785;  in  scarlet  fever,  135;  in  septi- 
caemia, 786;  in  typhoid  fever,  69,  78;  in  tubercu- 
losis, 321,  786;  malignant,  786;  micro-organisms 
in,  788;  mural,  788;  recurring,  786;  sclerotic,  793; 
simple  or  verrucose,  785;  syphilitic,  276;  ulcera- 
tive, 787. 

Endophlebitis,  851. 

Endothelioma,  mucoid,  716. 

Enteric  fever  (see  Typhoid  Fever),  57. 

Enteritis,  catarrhal,  497;  croupous,  500;  diphther- 
itic, 500;  in  children,  504;  phelgmonous,  501; 
membranous  or  tubular^  530;  ulcerative,  501.     . 

Enteroclysis  in  cholera,  233. 

Enterocolitis,  508. 

Enteroliths,  522;  as  a  cause  of  appendicitis,  513; 
in  sacculi  of  colon,  526. 

Enteroptosis,  528,  665,  1091. 

Entozoa  (see  Animal  Parasites),  1. 

Eosinophilia  in  ankylostomiasis,  46;  in  leukaemia, 
736;  in  trichiniasis,  42. 

Ependymitis,  purulent,  302. 

Ephemeral  fever,  363. 

Epidemic  haemoglobinuria,  270,  671,  747. 

Epidemic  roseola,  145. 

Epidemic  stomatitis,  367. 

Epididymitis  (see  Orchitis),  277,  348. 

Epilepsia,  larvata,  1062;  nutans,  1032. 

Epilepsy,  1058;  and  alcoholism,  1060;  and  syphilis, 
1060,  1063;  heredity  in,  1059;  in  chronic  ergo- 
tism, 383;  in  general  paresis,  898;  in  lead-poison- 
ing, 378;  in  Raynaud's  disease,  1101;  Jacksonian, 
883, 1063;  masked,  1062;  post-epileptic  symptoms 
of,  1062;  procursive,  1061;  reflex,  1060;  rotatory, 
1061;  spinal,  910;  surgical  treatment  of,  1066. 

Epileptic  fits,  stages  of,  1061. 

Epistaxis,  595;  in  Bright's  disease,  699;  family 
form  of,  595,  749;  in  haemophilia,  749;  in  scurvy, 
752;  in  typhoid  fever,  84;  "  renal,"  669;  vicarious, 
596. 

Erb-Gold flam's  symptom-complex,  1113. 

Erb's  syphilitic  spinal  paralysis,  913. 

Ergotism,  383;  convulsive,  383;  gangrenous,  383. 

Erosion  of  teeth,  438. 

Eructations,  nervous,  490. 

Eruptions  (see  Rashes). 

Erysipelas,  210;  abscess  in,  212;  after  vaccination, 
126;  facial,  211;  in  typhoid  fever,  89;  migrans, 
212;  puerperal,  211. 

Erythema,  exudativum,  744;  infectiosum,  146;  in 
pellagra,  384;  in  typhoid  fever,  75;  in  tonsilUtis, 
446. 

Erythrocythaemia,  748,  762. 

Erythromelalgia,  1071,  1102. 


1124 


INDEX. 


Eschar,  sloughing,  in  hemiplegia,  970. 

Eustrongylus  gigas,  51. 

Exaltation  of  ideas  in  general  paresis,  897. 

Exanthematic  tj-phus,  105. 

Exfoliative  dermatitis,  136. 

Exophthalmic  goitre,  765;  acute  form,  766;  diminu- 
tion of  electrical  resistance  in,  767;  flushing  in, 
767;  pigmentation  in,  767;  tachycardia  in,  766; 
tremor  in,  767. 

Exophthalmos,  766. 

Extract  of  Jez,  use  of,  in  tjT)hoid  fever,  102. 

Extra-systole  of  heart,  834. 

Eye,  motor  nerves  of,  paralysis  of,  1013;  spasm  of, 
1014. 

Eye-strain  in  migraine,  1067. 

Eyes,  conjugate  deviation  of,  in  brain  tumor,  991; 
in  apoplexy,  971;  in  tuberculous  meningitis, 
303. 

Facial,  asymmetry,  1030,  1104;  diplegia,  1020; 
hemiatrophy,  1104;  hemihypertrophy,  1105; 
nerve,  paralysis  of,  1019;  paralysis  from  cold, 
1020;  paralysis  from  lesion  of  trunk  of  nerv^e, 
1019;  paralysis  from  lesion  of  cortex,  1019; 
paralysis,  symptoms  of,  1020. 

Facial  spasm,  1022. 

Facies,  Hippocratic,  582;  leontina,  in  leprosy,  362; 
in  mouth-breathers,  449;  Parkinsonian,  1043; 
syphilitic,  270;  in  typhoid  fever,  72. 

Faecal,  accumulation,  521,  526;  concretions,  513, 
526;  vomiting,  522. 

Faeces,  bacteria  in,  505;  in  jaundice,  535. 

Faith  healing,  1095. 

Fallopian  tubes,  tuberculosis  of,  348. 

Famine  fever  (see  Relapsing  Fe-ver),  109. 

Farcy,  261 ;  acute,  262 ;  chronic,  263. 

Farcy-buds,  263. 

Farre's  tubercles,  568. 

Fasciola  hepatica,  26. 

Fat  embolism  in  diabetes,  418. 

Fat  necrosis,  575;  of  pancreas,  in  diabetes,  413. 

Fatty  degeneration,  of  arteries,  847;  of  liver,  570; 
of  the  new-born  {Buhl's  disease),  747. 

Fatty  degeneration  of  heart,  82ai  in  anaemia,  726. 

Fatty  stools,  575. 

Febricula,  363. 

Febris,  carnis,  104;  recurrens,  109. 

Fehling's  test  for  sugar,  415. 

Fermentation,  test  for  sugar,  415. 

Fetid  stomatitis,  435. 

Fetor  oris,  439. 

Fever,  aphthous,  367;  bilious  remittent,  20;  black- 
water,  22;  break-bone,  156;  cachexial,  9;  camp, 
105;  cerebro-spinal,  157;  in  cholera,  231;  country, 
386;  dandy,  156;  dum-dum,  9;  entero-mesenteric, 
57;  ephemeral,  363;  famine,  109;  Florida,  386; 
gastric,  457;  glandular,  365;  hay,  594;  hospital, 
105;  hysterical,  1084;  jail,  105;  pernicious  mala- 
rial, 21;  in  pneumonia,  172;  in  acute  pneumonic 
phthisis,  314,  316;  in  acute  miharj'  tuberculosis, 
299,  300,  302;  in  primary  multiple  neuritis,  1000; 
in  meningi tic  tuberculosis,  302;  petechial.  157;  in 
pulmonary  tuberculosis,  327;  mahgnant  purpuric, 
157;  in  pyaemia,  217;  in  pylephlebitis,  suppura- 
tive, 566;  in  intermittent  fever,  16;  in  relapsing 
fever,  110;  in  remittent  fever,  20;  in  scarlet 
fever,  132;  in  septicaemia,  214;  in  small-pox,  115; 


in  sun-stroke,  386;  in  appendicitis,  514;  in  sec- 
ondary syphilis,  267;  in  typhoid  fever,  72;  in 
typhus  fever,  108;  in  yellow  fever,  236;  lung,  164; 
malarial,  10;  miliary,  367;  Malta,  247;  Mediter- 
ranean, 248;  mountain,  366;  Neapolitan,  248; 
putrid  malignant,  57;  relapsing,  109;  rock,  248; 
seven-day,  109;  ship,  105;  slow  nervous,  57; 
splenic,  252;  spotted,  105,  157;  tick,  53;  trypano- 
some,  8;  typhoid,  57;  tjisho-malarial,  20,  95; 
typhus,  105;  undulant,  247;  yellow,  233. 

Fever,  idiopathic  intermittent,  216. 

Fever,  intermittent,  in  abscess  of  hver,  565;  in  ague, 
16;  in  chronic  obstruction  of  bile-passages  by 
gall-stones,  553;  in  Hodgkin's  disease,  741;  in 
pyaemia,  217;  in  pyeHtis,  705;  in  septicaemia,  216; 
in  secondary  sj'philis,  267;  in  tuberculosis,  322, 
327. 

Fibrinous,  bronchitis,  613;  pneumonia,  164. 

Fibroid  disease  of  heart,  824. 

Fibroma  of  lung,  641. 

Fibrosis,  arterio-capillarj',  847. 

Fievre,  inflammatoire,  386;  typho'ide  a  forme  renale, 
88. 

Fifth  nerve,  paralysis  of,  1017;  gustatory  branch, 
1018;  trophic  changes  in  paralysis  of,  1017. 

FUaria,  forms  of,  47,  49,  50,  51. 

FHariasis,  47. 

Fingers,  Hippocratic,  335. 

Fish  poisoning  by,  383. 

Fisher's  brain  murmur,  429. 

Fistula  in  ano  in  tuberculosis,  337,  341. 

Fistula,  oesophago-pleuro-cutaneous,  456. 

Fistula  of  Eck,  563. 

Flat-foot,  1071. 

Flatulence,  in  hysteria,  1082;  in  nervous  dys- 
pepsia, 492;  treatment  of,  466. 

Flea,  bite  of.  54. 

FHes,  in  tjiahoid  fever,  63;  parasitic,  55. 

Flint's  murmur,  800,  810. 

Floating  kidney,  529,  664. 

Floor  maggot,  56. 

Florida  fever,  386. 

Flukes  (see  Distomes). 

Foetus,  endocarditis  in,  793,  844;  syphilis  in,  269; 
tuberculosis  in,  287;  white  pneumonia  of,  273; 
typhoid  fever  in,  92. 

Folie  Brightique,  684. 

Follicular  tonsOhtis,  445. 

Food  (see  Diet). 

Food  poisoning,  380. 

Foot  and  mouth  disease,  367. 

Foramen  ovale,  patency  of,  843. 

Foreign  bodies  in  appendix,  513;  in  intestines,  521. 

"Fourth  disease,"  146. 

Fourth  nerve,  1014;  paralysis  of,  1015, 

FragUitas  ossium,  1108. 

Fremitus,  tactile,  176,  329,  646;  vocal,  176,  637, 
646;  hydatid,  35. 

Freund's  operation,  638;  theory,  634. 

Friction,  mediastinal,  663;  pericardial,  777;  peri- 
toneal, 587;  pleural,  330,  647;  pleuro-pericardial, 
330,  777. 

Friedreich's  ataxia,  921 ;  disease,  1113. 

Friedreich's  sign  in  adherent  pericardium,  783. 

Frontal  convolutions,  lesions  of,  990. 

Frontal  sinuses,  pentastomes  in,  62. 

Funnel  breast,  329,  449. 


INDEX. 


1125 


Gait,  ataxic,  890;  goose,  681;  in  paralysis  agitans, 
1043;  in  pseudo-hypertrophic  muscular  paralysis, 
906;  in  spastic  paraplegia,  909;  pseudo-tabetic, 
418,  1002;  steppage,  in  peripheral  neuritis,  378, 
380,  1002;  in  diabetic  tabes,  418. 

Gall-bladder,  diseases  of,  542;  atrophy  of,  552; 
calcification  of,  552;  cancer  of,  546;  dilatation  of, 
552;  empyema  of,  552;  forming  abdominal  tumor, 
552;  phlegmonous  inflammation  of,  552. 

Gallop  rhythm,  in  myocardial  disease,  827. 

Galloping  consumption,  315. 

Gall-stone  crepitus,  552. 

Gall-stones,  548. 

Game-birds,  poisoning  by,  382. 

Ganglia,  basal,  tumors  of,  990. 

Ganglia,  dorsal  root,  acute  hsemorrhagic  inflamma- 
tion of,  900. 

Gangrene,  in  diabetes,  417;  in  ergotism,  383;  in 
pneumonia,  187;  in  typhoid  fever,  78;  in  typhus, 
108;  local  or  symmetrical,  1101;  multiple,  1101; 
of  lung,  638;  of  mouth,  437. 

Gangrenous  stomatitis,  437. 

Garrod's  thread  test  for  uric  acid,  400. 

Gas-bacillus   (see   Bacillus  aerogenes  capsdla- 

TUS). 

Gasserian  ganglion,  extirpation  of,  in  tic  douloureux, 

1070. 
Gastralgia,  493. 
Gastrectasis,  467. 
Gastric  catarrh,  acute,  456. 
Gastric,  crises,  476,  494,  891;  fever,  457. 
Gastric  juice,  hyperacidity  of,  476,  492;  subacidity 

of,  493. 
Gastric  spasm,  congenital,  487. 
Gastric  ulfter,  470. 
Gastritis,  acida,  462;  acute,  456;  acute  suppurative, 

458;  anacida,  462;  atroplicans,  462;  chronic,  459; 

diphtheritic,  459;  membranous,  459;   mucipara, 

462;  mycotic,  459;  parasitic,  459;  phlegmonous, 

458;  polyposa,  460;  sclerotic,  460;  simple,  456; 

simple  chronic,  460;  toxic,  458. 
Gastrodiscus  hominis,  27. 
Gastrodynia,  493. 
Gastrophilus  equi,  56. 
Gastrorrhagia,  487. 
Gastrorrhexis,  476,  488. 
Gastrotomy,  455. 
Gastroxynsis,  492. 
General  paralysis  of  the  insane  (general  paresis), 

895;  diagnosis  of,  from  syphilis,  899;   influence 

of  syphilis  in,  269,  272,  896. 
Genito-urinary  system,  tuberculosis  of,  343. 
Gentles,  55. 

Geographical  tongue,  438. 
Gerlier's  disease,  1025. 
German  measles,  145. 
Giant  growth,  1106. 

Gigantism  and  acromegaly,  1106;  and  giants,  1106. 
Gigantorhynchus  gigas,  51. 
Gilles  de  la  Tourette's  disease,  1054. 
Gin-drinker's  liver  (see  Cirrhosis  of  Liver),  556. 
Glanders,  261;  acute,  262;  chronic,  262;  diagnosis 

from  small-pox,  121. 
Glandular  fever,  365. 
Glenard's  disease,  '528. 
Glioma  of  brain,  988. 
GHosis,  943. 


Globulin  in  urine,  675. 

Globus  hystericus,  1077. 

Glomerulo-nephritis,  687. 

Glossitis,  MoUer's,  438. 

Glosso-labio-laryngeal  paralysis,  904. 

Glosso-pharyngeal  nerve,  affections  of,  1026. 

Glossy  skin  in  arthritis  deformans,  392. 

Glottis,  oedema  of,  598;  in  Bright's  disease,  699; 
in  small-pox,  119;  in  typhoid  fever,  69. 

Gluteal  nerve,  affections  of,  1038. 

Glycogen,  formation  of,  412. 

Glycogenic  function  of  liver,  412. 

Glycosuria,  412,  682;  gouty,  402;  lipogenic,  410. 

Gmelin's  test,  535. 

Goitre,  763;  exophthalmic,  765;  sudden  death  in, 
764;  lingual,  764. 

GonorrhcEal  arthritis,  282;  endocarditis,  282;  septi' 
csemia  and  pyaemia,  282. 

Gonorrhoea!  infection,  281;  systemic,  282.' 

Goose  cough  in  aneurism,  859. 

Gout,  397;  acute,  402;  chronic,  403;  Ebstein's  theory 
of,  400;  guanin,  of  hogs,  401;  hereditary  influence 
in,  397;  influence  of  alcohol  in,  397;  influence  of 
food  in,  398;  influence  of  lead  in,  398;  irregular, 
404;  nervous  theory  of,  400;  poor  man's,  398; 
retrocedent  or  suppressed,  403;  rheumatic,  389; 
trauma  and,  398. 

Gouty  kidney,  694. 

Graefe's  sign,  766. 

Grain,  poisoning  by,  383. 

Grandeur,  delusions  of,  897. 

Grand  mal,  1058,  1060. 

Granular  kidney,  694. 

Granulomata,  infectious,  of  brain,  988. 

Gravel,  renal,  709. 

Graves'  disease,  765. 

Green  cancer,  738. 

Green-sickness  (see  Chlorosis),  722. 

Green-stick  fracture  in  rickets,  429. 

GregarinidsB,  parasitic,  1. 

Grinder's  rot,  631. 

Grippe,  la,  152. 

Grocco's  sign,  647. 

Ground  itch,  45. 

Gruebler's  tumor,  377. 

Guinea-worm  disease,  49. 

Gull's  disease,  769. 

Gummata,  267;  in  acquired  syphilis,  269;  in  con- 
genital syphilis,  271 ;  of  brain  and  spinal  cord,  271 ; 
of  heart,  276;  of  kidneys,  277;  of  liver,  275;  of 
lungs,  273;  of  rectum,  276;  of  testis,  277. 

Gummatous  periarteritis,  277. 

Gums,  black  line  on,  in  miners,  377;  blue  line  on,  in 
lead-poisoning,  376;  in  scurvy,  751;  in  stomatitis 
435;  red  Hne  on,  in  pulmonary  tuberculosis,  333. 

Gustatory  paralysis,  1018. 

Habit  spasm,  1053;  in  mouth-breathers,  450. 

Habitus,  apoplectic,  966;  phthisicus,  293. 

Haematemesis,  487;  causes  of,  487;  in  cancer  of 
stomach,  483 ;  in  cirrhosis  of  liver,  558 ;  diagnosis 
from  haemoptysis,  489;  in  enlarged  spleen,  23, 
487;  in  scurvy,  752;  in  typhoid  fever,  79 ;  in  ulcer 
of  stomach,  474. 

Haematochyluria,  non-parasitic,  677;  parasitic,  48. 

Haematoma  of  dura,  of  brain,  923;  of  cord,  924;  of 
mesentery,  532. 


1126 


INDEX. 


Hfpuiatomata,   749. 

Haematomyelia,  936. 

HaematoporphjTin,  682. 

Hsematorrhacliis,  935. 

Haematuria,  669;  angio-neurotie  renal,  347;  endemic 
of  Egj-pt,  27;  essential  renal,  347;  functional,  347; 
in  acute  nephritis,  688;  in  chronic  phthisis,  334; 
in  i^sorospermiasis,  2;  in  renal  calculus,  712;  in 
renal  cancer,  714;  in  tuberculosis  of  kidney,  346; 
malarial,  22;  unilateral,  669. 

Haemochromatosis,  413. 

Hcemocytozoa  of  malaria,  10. 

Hsemoglobin,  reduction  of,  in  chlorosis,  722. 

HsemoglobiniEmia,  671. 

Hsemoglobinuria,  670;  epidemic,  in  infants,  270, 
671,  747;  malarial,  22;in  Raynaud's  disease,  1101; 
paroxysmal,  671;  toxic,  670. 

Hsemoglobinuric  fever,  22. 

Hsemo-pericardium,  784;  -peritonseum,  573. 

Haemophilia,  747. 

Haemoptysis,  causes  of,  617;  hysterical,  1081;  at 
onset  of  phthisis,  322;  in  acute  broncho-pneu- 
monic phthisis,  316;  in  acute  miliary  tuberculosis, 
300;  in  aneurism,  617,  859;  in  aortic  insufficiency, 
799;  in  arthritic  subjects,  617;  in  bronchiectasis, 
608;  in  cirrhosis  of  lung,  630;  in  emphysema, 
637;  in  mitral  insufficiency.  806;  in  mitral  ste- 
nosis, 811;  in  pneumonia,  175;  in  pulmonary 
gangrene,  640;  in  scurvy,  752;  symptoms  of, 
618;  treatment  of,  619;  in  typhoid  fever,  85; 
relation  to  tuberculosis,  325,  617;  parasitic,  26; 
periodic,  617;  vicarious,  617. 

Hemorrhage,  broncho-pulmonary.  617;  cerebral, 
966;  from  mesentery,  532;  from  the  stomach, 
487;  in  acute  yellow  atrophy,  539;  in  anfcmia, 
729;  in  cirrhosis  of  the  liver,  558;  in  contracted 
kidney,  699;  in  gastric  cancer,  483;  in  gastric 
ulcer,  474;  in  hemophilia,  748;  in  hysteria,  1081, 
1083;  in  intussusception,  524;  in  leuka?mia,  734; 
in  malaria.  22;  in  nephrolithiasis,  712;  in  the  new- 
born, 747;  in  purpura  haemorrhagica,  745;  in 
scarlet  fever,  134;  in  scur^•y,  752;  in  small-pox, 
117;  in  splenic  enlargement,  23  762;  into  pan- 
creas, 573;  into  spinal  cord,  936;  into  spinal 
membranes,  935;  in  tuberculous  pyelitis,  347; 
in  tuberculosis  of  bowels,  340;  into  ventricles  of 
brain,  968;  in  typhoid  fever,  68,  80;  in  yellow 
fever,  237;  pulmonary,  325,  617. 

Haemorrhagic  diathesis,  743. 

Haemorrhagic  diseases  of  the  new-bom,  747, 

Hsemorrhagic  typhoid  fever,  91. 

Haemothorax,  651. 

Hair  tumors  in  stomach,  486. 

Hairy  heart,  776. 

Hallucinations  in  hysteria,  1083. 

Harrison's  groove  in  rickets,  428;  in  enlarged 
tonsils,  449. 

Har\'est-bug.  53. 

Hay-asthma  (hay-fever).  594. 

Haygarth's  nodosities,  390. 

Headache,  from  cerebral  tumor,  989;  in  cerebral 
syphilis,  272  ;  in  mouth-breathers,  450 ;  in  ty- 
phoid fever,  70  71,  85;  in  uraemia,  684;  sick, 
1066. 

Head-cheese,  poisoning  by   381. 

Head-shaking  in  infants,  1032. 

Heart-block,  834,  837. 


Heart,  bovine,  798;  diseases  of,  785;  OcrteVs  treat- 
ment of  diseases  of,  829;  amyloid  degeneration 
of.  826;  aneurism  of,  830;  athlete's,  797;  brown 
atrophy  of,  826;  calcareous  degeneration  of, 
827;  congenital  affections  of,  843;  dilatation  of, 
820;  displacement  in  pleuritic  effusion,  645; 
displacement  in  pneumo-thorax,  658;  fatty 
disease  of,  825;  foreign  bodies  in,  831;  fragmenta- 
tion of  fibres  of,  825;  functional  affections  of,  832; 
hairy,  776;  hydatids  of,  831;  hypertrophy  of, 
822;  hypertrophy  of,  in  Bright's  disease,  698; 
in  exophthalmic  goitre,  766;  irritable,  833;  new 
growths  in,  831 ;  palpitation  of,  832;  parenchyma- 
tous degeneration  of,  825;  rapid,  835;  rupture  of, 
S30;  segmentation  of,  825;  syphilis  of,  276,  831; 
tobacco,  842;  tubercle  of,  349,  831;  tumors  of, 
831;  vahiilar  diseases  of,  793;  wounds  of,  831. 

Heart-muscle  in  fevers,  825. 

Heart-sounds,  audible  at  distance,  766,  810;  weak- 
ness of,  827. 

Heart  strain,  821. 

Heart-valves,  congenital  anomalies  and  lesions  of, 
844;  rupture  of.  798. 

Heat,  exhaustion,  385;  stroke,  385, 

Heberden's  nodes.  391. 

Hectic  fever,  327. 

Heel,  painful,  1071. 

Heller's  test,  673 

Helminthiasis  (see  .\nimal  Parasites),  1. 

Hemeralopia,  1008;  in  scurvy,  752. 

Hemialbumose,  674. 

Hemianacsthesia,  in  cerebral  haemorrhage,  973;  in 
hysteria,  1080;  in  railway  spine,  1097;  in  lesions  of 
internal  capsule,  951;  in  unilateral  cord  lesions, 
933. 

Hemianopia,  in  aphasia,  959;  functional,  1012; 
heteronymous,  1009;  homonymous,  1009;  in 
migraine,  1067;  lateral,  1009;  nasal,  1010;  signifi- 
cance of,  1012;  temporal,  1009. 

Hemiatrophy,  facial,  1104. 

Hemicrania,  1066. 

Hemiopic  pupillary  inaction,  1012. 

Hemiplegia,  966.  971;  crossed,  951,  973. 

Hemiplegia,  infantile,  985;  aphasia  in,  986;  cortical, 
948;  in  diphtheria,  204;  epilepsy  in.  987;  in  hys- 
teria, 1079;  in  malaria.  23;  mental  defects  in,  987; 
post-hemiplegic  movements  in,  987;  spastica 
cerebralis,  986;  in  typhoid  fever,  86. 

Hemiplegie  Basque.  974. 

Henoch's  purpura,  745. 

Hepatic  abscess,  563;  artery,  enlargement  of,  542; 
aneurism  of,  865;  colic,  550;  intermittent  fever, 
553;  vein,  affections  of,  542. 

Hepatitis,  interstitial  (see  Cirrhosis),  556;  sup- 
purative, 563. 

Hepatization,  of  lung,  170;  white,  of  foetus,  273. 

Hereditary  form  of  oedema,  1104. 

Heredity,  in  Bright's  disease,  694;  in  diabetes  in- 
sipidus, 409:  'm  Friedreich's  ataxia,  921;  in  gout, 
397;  in  haemophilia,  748;  in  paramyoclonus  multi- 
plex, 1 1 13 ;  in  rheumatic  fever,  220 ;  in  spastic  para- 
plegia, 912;  in  syphilis,  266;  in  tuberculosis,  287. 

Herpes,  in  cerebro-spinal  meningitis,  161;  in  febric- 
ula,  364;  in  malaria,  17;  in  pneumonia,  179;  in 
tj'phoid  fever,  75;  zoster,  900. 

Hiccough,  1034;  causes  of,  1034;  treatment  of,  1035: 
hysterical,  1081. 


INDEX. 


1127 


High-tension  pulse,  characters  of,  698,  851. 
Hippocratic  facies,  82,  582;  fingers,  335;  succussion, 

659. 
Hippus,  1067. 

Hodgkin's  disease,  738;  intermittent  fever  in,  741. 
Homalomyia  scalaris,  55. 
Hook-worm  disease,  44. 
Horn-pox,  119. 
Hospital  fever,  105. 
Hour-glass  stomach,  475. 
Huntingdon's  chorea,  1055. 
Husband  and  wife,  diabetes  in,  409;  tuberculosis 

in,  291. 
Hutchinson' s  teeth,  271. 
Hyaline  casts  in  urine,  688,  693,  698. 
Hybrid  measles,  145. 
Hybrid  scarlet  fever,  145. 
Hydatid  disease  (see  Echinococcus). 
Hydatid  thrill  or  fremitus,  35. 
Hydrarthrosis,  chronic,  283;  intermittent,  1083. 
"  Hydrencephaloid  condition,"  507,  965. 
Hydriatic  treatment  (see  Hydrotherapy). 
Hydrocephalus.  996;  acquired  chronic,  997;  acute, 
301.    996;    angio-neurotic,    996;    chronic,    after 
cerebro-spinal  meningitis,  162;  congenital,  997; 
drainage  in,  998;   externus,  996;  ex  vacuo,  996; 
idiopathic  internal,  996;  spurious,  507. 
Hydrocystoma  in  exophthalmic  goitre,  767. 
Hydromyelus,  924,  943. 
Hydronephrosis,  707;  congenital,  707;  intermittent, 

666,  708. 
Hydropericardium,  784. 
Hydroperitonffium,  589. 
Hydrophobia,  255. 
Hydro-pneumothorax,  657. 
Hydrops  ad  matulam,  409;  vesicae  fellse,  552. 
Hydrothorax,  656. 

Hymenolepsis  diminuta;  H.  nana,  29. 
Hyperacidity  of  gastric  juice,  492. 
Hyperacusis,  1023. 
Hyperadrenalism,  760. 
Hyperaemia  of  the  brain,  964. 

Hyperajsthesia,  in  ataxia,  891;  in   hamatomyelia, 
936;  in  hysteria,  1080;  in  railway  spine,  1097;  in 
rickets,   428;  retinal,    1008;  in   unilateral    cord 
lesions,  933;  of  stomach,  493. 
Hyperalgesia,   1089. 
Hyperchlorhydria,  492. 
Hyperkinesis  of  stomach,  490. 
Hypernephroma,  714. 
Hyperosmia,  1006. 
Hyperpyraemia,  398. 

Hyperpyrexia,  hysterical,  1084;  in  rheumatic  fever, 
223;  in  scarlet  fever,  133;  in  sun-stroke,  386;  in 
tetanus,  260. 
Hyperthyrea,  765. 
Hyperthyroidism,  765. 
Hypertrophic  cirrhosis  of  liver,  560. 
Hypnotism  in  hysteria,  1086. 

Hypodermic  syringe  in  diagnosis  of  pleural  effu- 
sion, 652. 
Hypoglossal  nerve,  diseases  of,  1032;  paralysis  of, 

1032;  spasm  of,  1033. 
Hypoleucocytosis,  in  typhoid  fever,  76. 
Hypophysis,  enlargement  of,  1106. 
Hypostatic  congestion,  of  lungs,  615;  in  typhoid 
fever,  85. 


Hypothermia,  in  typhoid  fever,  74. 

Hypotonia,  891. 

Hysteria,  1076;  and  disseminated  sclerosis.  931; 
contractures  and  spasms  in,  1079;  convulsive 
forms  of,  1077;  cries  in,  1081;  disorders  of  sensa- 
tion in,  1080;  forms  of  fever  in,  1084;  hamoptysis 
in,  1081;  insanity  in,  1083;  joint  affections  in, 
1083;  mental  symptoms  of,  1083;  metabolism  in, 
1084;  metallotherapy  in,  1080;  needle-swallow- 
ing in,  831;  non-convulsive  forms  of.  1078;  paraly- 
sis in,  1078;  special  senses  in,  1081;  stigmata  in, 
744,  1083;  traumatic  1096;  visceral  manifesta- 
tions of,  1081. 

Hysterical  angina  pectoris.  841. 

Hystero-epilepsy,  1063,  1078. 

Hysterogenic  points,  1080. 

Ice-cream,  poisoning  by,  382. 

Ice,  typhoid  bacillus  in,  61. 

Ichthyosis  lingualis,  439. 

Icterus  (see  Jaundice);  gravis,  538;  neonatorum, 

538. 
Idiocy,  in  infantile  hemiplegia,  987;  amaurotic,  912. 
Idiopathic  anaemia  of  Addison,  724. 
Idiopathic  intermittent  fever,  210. 
Ileo-caecal  region,  in  typhoid  fever,  82;  in  appendi- 
citis, 514;  in  primary  tuberculosis  of  bowel,  341. 
Ileo-coHtis,  508. 
Ileus     (see     Strangulation     of     Bowel),     519; 

hysterical,  1082. 
Imbecility  in  infantile  hemiplegia,  987. 
Imitation  in  chorea,  1046. 
Impetigo,    contagious,    and    ulcerative    stomatitis, 

435. 
Impotence,  in  diabetes,  419;  in  locomotor  ataxia, 

892. 
Impulsive  tic,  1054. 
Incarceration  of  bowel,  519. 
Incoordination,  of  arms,  890;  of  legs,  890. 
Indians,  American,  chorea  in,  1045;  consumption 

in,  285;  small-pox  among,  112. 
Indicanuria,  680. 

Indigestion,  456;  acute  intestinal,  506. 
Infantile,  convulsions,  1056;  paralysis,  914;  scurvy 

753. 
Infantilism,   270,   769,   773;   Lorain   type  of,   774; 

myxcedematous,  774;  pancreatic,  774. 
Infarcts,  septic,  of  coronary  arteries,  824. 
Infection,  definition  of,  213. 
Infectious  diseases  57;  of  doubtful  nature,  363. 
Inflation  of  bowel  in  intussusception,  525. 
Influenza,  152;   appendicitis  in,  155;   cholelithiasis 
in,  155;  and  typhoid  fever,  90;  peritonitis  in,  155. 
Infusoria,  parasitic,  25. 

Inhalation    pneumonia    (see    Aspiration    Pneu- 
monia), 621. 
Inoculation,    against    small-pox,    112,    119;    pro- 
tective,  in   cholera,   229;   preventive,  in  hydro- 
phobia,   257;    preventive,    in   plague,    242;    pre- 
ventive, in  pneumonia,  169;  preventive,  in  typhoid 
fever,  98;  tuberculosis  transmitted  by,  289. 
Insane,  general  paralysis  of,  895. 
Insanity,  delusional,  684;  post-febrile,  86;  in  small- 
pox, 119. 
Insanity,   relation    of    drink    to,   370;    relation   of 
chronic  phthisis  to,  334;  relation  of  heart-disease 
to,  800. 


1128 


INDEX. 


Insects,  parasitic,  53. 

Insolation,  385. 

Insular  sclerosis,  930. 

Intention  tremor  (see  Volitioxal  Tremor). 

Intercostal  neuralgia,  1070. 

Intermittency  of  heart  action,  834. 

Intermittent  claudication,  841,  853. 

Intermittent  fever,  16;  forms  of  (see  Fetzb). 

Intermittent  hepatic  fever,  5-53. 

Intermittent  hydrarthrosis,  1083. 

Intermittent  lameness,  853. 

Internal  capsule,  lesions  of,  949. 

Internal  carotid  arterj-,  blocking  of.  979. 

Intestinal  casts,  531;  sand,  532;  coils,  tumor  formed 

by,  311;  obstruction,  519. 
Intestines,  diseases  of,  497;  actinomycosis  of,  264; 

dilatation  of,  531. 
Intestines,    haemorrhage    from,    in    tjTphoid    fever, 

68,  80;  in  dysenterj-,  5,  244;    in  tuberculosis  of 

bowel,  340;  in  intussusception  of,  524;  in  ulcera- 
tion of,  501. 
Intestines,  infarction   of,   533;  intussusception  of, 

519,    524;  invagination    of,    520;  miscellaneous 

afifections  of ,  530 ;  new  growths  in,  521;  ulcers  of, 

501. 
Intestines,  obstruction    of,  519,    584;  acute,    522; 

chronic,    522;  by   enteroliths,    522;    by    foreign 

bodies,  521 ;  by  gall-stones,  522, 555;  by  lipomata, 

521. 
Intestines,  perforation  of,  in  tjTjhoid  fever,  67,  81. 
Intestines,     primarj-    tuberculosis    of,    292,     340; 

strangulation  of,  519,  524;  strictures  and  tumors 

of,  521 ;  twists  and  knots  in,  520. 
Intoxication,  definition  of,  213. 
Intoxications,  369. 
Intussusception,  519,  524. 
Invagination,  520;  post-mortem,  520. 
Inverse  t>T)e  of  temperature  in  acute  tuberculosis, 

299;  in  tj-phoid  fever,  72. 
Iridoplegia,   1014;    accommodative,    1014;    reflex, 

1014. 
Iritis,  s>-philitic,  268,  271. 

Itch,  Cuban,  113;  insect,  52;  Philippine,  113. 
Itching,  of  feet  in  gout,  405;  of  eyeballs  in  gout, 

405;  of  skin  in  Bright 's  disease,  699;  of  skin  in 

jaundice,  .535;  preicteric,  535;  in  diabetes,  417; 

in  exophthalmic  goitre,  767;  in  uraemia,  684;  in 

Hodgkin's  disease,  741. 
Ixodes  ricinus,  53. 
Ixodiasis,  53. 

Jacksonian  epilepsy,  883,  1063. 

Jail  fever,  105. 

Jaundice,  534;  black,  535;  catarrhal,  542;  choluria 
in,  535;  from  cirrhosis  of  liver,  559,  561 ;  congen- 
ital acholuric  form  of,  537  ;  epidemic  form  of, 
364:  infectious,  364;  from  acute  yellow  atrophy, 
538;  from  cancer  of  liver,  569;  in  diphtheria,  204; 
from  gaU-stones,  551,  553;  hereditan.-,  537;  in 
influenza,  154;  in  pneumonia,  181;  and  purpura, 
536,  743;  in  WeH's  disease,  364;  malignant,  538; 
of  the  new-bom,  538;  obstructive,  534;  in  sj-ph- 
ilis,  275;  toxsemic,  536;  in  tj-phoid  fever,  83; 
xanthelasma  in,  535;  in  yellow  fever,  236. 

Jaw  clonus,  903. 

Jigger,  .55. 

Joints  (see  Arthritis). 


Jumpters,  1055. 
"June  cold,"  594. 

Kahler's  disease,  674. 

Kakke,  249. 

Kala-azar,  9. 

Katayama's  disease,  28. 

Keloid  of  Addison,  1109. 

Keratitis,  in  small-pox,  120;  interstitial,  of  in- 
herited syphilis.  271. 

Kernig's  sign,  163. 

Kidney,  diseases  of,  664;  amyloid  or  lardaceous 
disease  of,  702;  cancer  of,  714;  cardiac,  668; 
circulatory  disturbance  in,  667;  cirrhosis  of,  694; 
congenital  cystic,  715;  congestion  of,  667;  con- 
tracted, 694;  cyanotic  induration  of,  668;  cystic 
disease  of,  715;  disk-shaped,  664;  echinococcus  of, 
37;  floating.  664;  fused,  664;  gouty,  694;  granular, 
694;  horseshoe,  664;  large  white,  692;  malforma- 
tions of,  664;  movable,  664;  palpable,  664; 
rhabdo-myoma  of,  714;  sarcoma  of,  714;  scrofu- 
lous, 347,  704;  sigmoid.  664;  small  white  kidney, 
692;  surgical  kidney.  704;  syphilis  of,  277; 
tul>erculosis  of  345;  tumors  of,  713. 

Klebs-lAxfflcr  bacillus,  194. 

Knee-jerk,  loss  of,  in  ataxia  891;  in  diphtheria,  204. 

Koch  treatment  of  tuberculosis,  356. 

Kopftetanus,  of  Rose,  260. 

Koplik's  sign,  142. 

KoesakofTs  syndrome,  370,  1002. 

Kubisagari,  1025. 

Labyrinthine  (Hsea,«e,  1024. 

Lachrymal  gland  in  mumps,  147;  in  Mikulicz's 
disease,  442. 

"  Lacing"  liver,  572. 

LacunEP  of  Marie.  967. 

Lacunar  ton.«illitis,  445. 

La  grippe,  152. 

Lamblia  intestinalis.  25. 

Lameness,  intermittent,  85.3. 

Laminectomy  in  compression  myelitis,  940;  in 
tumors  of  the  cord,  942. 

Lnndry's  paralysis,  918. 

Laparotomy,  in  cirrhosis  of  the  liver,  563;  in  typhoid 
fever,  103. 

I>arva  migrans,  56. 

Larvip  of  flies,  dLseases  caused  by  (myiasis),  55. 

Laryngeal  crises,  892. 

Larj'ngismus  stridulus,  598;  identity  of,  with  en- 
larged thymus,  772. 

Larj'ngitis,  acute,  catarrhal,  596;  chronic,  597; 
CEdematous,  598;  spasmodic,  598;  syphilitic,  601; 
tuberculous,  600. 

Larj-nx,  diseases  of,  596;  adductor  paralysis  of, 
1028;  ansesthesia  of,  1029;  hypersesthesia  of, 
1029;  paralysis  of  abductors  of,  1027;  spasm  of  the 
muscles  of,  1028;  unilateral  abductor  paralysis 
of.  1028. 

Latah,  10,55. 

Lateral  sclerosis,  primary,  909;  amyotrophic,  901. 

Lateritious  deposit,  677. 

Lath>Tism.  384. 

Lead.  coUc,  377;  in  the  urine.  375. 

Lead-palsy,  377;  localized  forms  of.  Zil . 

Lead-poisoning.  375;  acute.  376;  arterio-sclerosis  in, 
378;  cerebral  symptoms  in,  378;   chronic,  376; 


INDEX. 


1129 


convulsions  from,  378;  gouty  deposits  in.  379; 
treatment  of,  379. 

Lead-workers,  prevalence  of  gout  in,  398. 

Leichen-tubercle,  290. 

Leishman  body,  9. 

Leontiasis  ossea,  1107. 

Lepra  alba,  362;  mutilans,  362. 

Leprosy,  359;  anoesthetic,  362;  bacillus  leprae  in, 
360;  contagiousness  of,  361 ;  macular  form  of, 
362;  tubercular,  362. 

Leptomeningitis,  acute  cerebro-spinal,  925;  chronic, 
928;  infantum,  non-tuberculous,  928. 

Leptothrix  in  mouth.  264. 

Leptus  autumnalis,  53. 

Leucin,  539. 

Leucocythaemia,  731. 

Leucocytosis,  in  anaemia,  721 ;  chlorosis,  722;  cere- 
bro-spinal meningitis,  161;  diphtheria,  201;  em- 
pyema, 649;  erysipelas,  212;  Hodgkin's  disease, 
741;  leukaemia,  735;  malaria,  24;  measles,  143; 
pyaemia,  217;  pneun.onia,  177;- pleurisy,  648; 
rheumatic  fever,  222;  scarlet  fever,  133;  stomach 
cancer,  482,  485;  in  trichiniasis,  42;  in  tuber- 
culosis (acute),  300;  in  tuberculosis  (chronic  pul- 
monary), 333;  absence  of,  in  typhoid  fever,  76,  93; 
in  whooping-cough,  151. 

Leucoderma,  1109. 

Leuco-keratosis,  mucosa;  oris,  439. 

Leuconychia,  1002. 

Leucopenia  in  typhoid  fever,  76. 

Leukaemia,  731;  acute,  737;  lymphatic,  736;  blood 
in,  735;  congenital,  732;  heredity  in,  732;  in 
animals,  732;  in  pregnancy,  732;  myelogenous, 
731;  pseudo-,  738;  spleno-meduUary,  734. 

Leukanaemia,  737. 

Leukoplakia  buccalis,  439. 

Leyden's  crystals,  611,  613. 

Lienteric  diarrhcea,  499. 

Life  assurance  and  albuminuria,  675;  and  syphilis, 
281. 

Lightning  pains  in  ataxia,  889. 

Lineae  atrophicae,  75. 

Lingual  corns,  439. 

Linguatula  rhinaria,  52;  L.  .serrata,  52. 

Lipaciduria,  682. 

Lipaemia,  412,  418. 

Lipoma  of  the  spinal  cord,  941. 

Lipothymia,  583. 

Lips,  tuberculosis  of,  339;  chancre  of,  266. 

Lipuria,  416.  682. 

Lithffimia,  677. 

Lithic-acid  diathesis,  677. 

Lithuria,  677. 

Little's  disease,  910. 

Liver,  abscess  of,  4,563;  actinomycosis  of,  264;  acute 
yellow  atrophy  of,  538;  amyloid,  571;  antemia  of, 
540;  angioma  of,  569;  cardiac,  541;  anomalies  in 
form  and  position  of,  572;  cysts  of,  569;  fatty,  570; 
gummata  of,  274;  hepato-phlebotomy  in  con- 
gestion of,  542;  hydatids  of,  35;  hyperaemia  of, 
540;  infarction  of,  542;  melano-sarcoma  of,  568; 
new  growths  in,  567;  nutmeg,  541;  passive  con- 
gestion of,  541;  periodical  enlargement  of,  541; 
primary  cancer  of,  567;  psorospermiasis  of,  1; 
pulsation  of,  541;  sarcoma  of,  568;  secondary 
cancer  of,  568;  syphilis  of,  274;  tuberculosis  of, 
341;  in  typhoid  fever,  68,  83. 


Liver,  cirrhosis  of,  556;  alcoholic  557;  ascites  in, 
559;  atrophic.  557;  capsular  form.  562;  in  diabetes 
413;  fatty.  557;  haemorrhage  from  stomach  in 
558;  hypertrophic  560;  syphilitic,  275,  562;  in 
children,  557;  jaundice  in.  559;  toxic  symptoms 
in.  559;  with  cancer,  570;  tuberculous,  342. 

Liver,  diseases  of,  534. 

Liver  dulness.  obliteration  of,  in  perforative  peri- 
tonitis, 82.  582. 

Liver,  movable.  529,  572. 

Living  skeletons,  903. 

Lobar  pneumonia,  164. 

Lobstein's  cancer,  715. 

Localization,  cerebral,  874;  spinal,  871. 

Localized  peritonitis,  584. 

Lock-jaw,  258,  1018. 

Lock-spasm,  1073. 

Locomotor  ataxia,  886;  ataxic  stage  of,  890;  bladder 
symptoms  in,  889;  gastric  crises  in,  891;  hemi- 
plegia in,  892;  incipient  stage  of,  889;  laryngeal 
crises  in,  892;  nasal  crises  in,  892;  paralytic  stage 
of,  892;  paresis  in,  892;  rectal  crises  in,  891;  re- 
lation of  syphiHs  to,  886. 

I>ong  thoracic  nerve,  affections  of,  1036. 

Loose  shoulders,  907. 

Lucilia  macellaria,  55. 

Ludwig's  angina,  444. 

Lues  venerea  (syphilis),  265. 

Lumbago,  396. 

Lumbar  neuralgia,  1071. 

Lumbar  plexus,  lesions  of,  1038. 

Lumbar  puncture  of  Quincke,  163,  928,  998. 

Lung,  abscess  of,  640;  embolic,  640. 

Lung,  actinomycosis  of,  264;  albinism  of,  635; 
brown  induration  of,  615;  cancer  of,  641;  carni- 
fication  of,  622;  cirrhosis  of,  628. 

Lung,  di.seases  of,  614;  stones,  319. 

Lung  fever,  164. 

Lungs,  congestion  of,  614;'  hypostatic,  615. 

Lungs,  ecldnococcus  of,  36. 

Lungs,  gangrene  of,  638;  abscess  of  brain  in,  639. 

Lungs,  new  growths  in,  641;  in  cobalt-miners,  642. 

Lungs,  hirmorrhagic  infarction  of,  618;  oedema  of, 
616;  splenization  of,  615,  622;  syphilis  of,  273; 
tuberculosis  of,  312. 

Lupinosis,   384. 

Lymph  glands,  tuberculosis  of,  .304. 

Lymphadenitis,  general  tuberculous,  306;  local 
tuberculous,  306;  simple,  660;  suppurative,  660. 

Lymphadenoma,  general,  738. 

Lymphatic  state,  755. 

Lymphatism,  448,  755. 

Lymphocytosis,  in  cerebro-spinal  fluid,  900. 

Lymphoma,  malignant,  739. 

Lympho-sarcoma,  739,  742. 

Lymph-scrotum,  49. 

Lymph,  vaccine,  127. 

Lymph  vessels,  dilatation  of,  49. 

Lyssa,  255. 

I  yssophobia.  258. 

Maculae  ceruleae,  54,  75. 

Macular  syphilides,   268. 

Maidismus,  384. 

Main  en  griffe,  903,  925. 

Maize,  poisoning  by  (pellagra),  284. 

Maladie  de  Hanot,  560;  de  Woillez,  614. 


1130 


INDEX. 


Malarial  cachexia,  15.  23. 

Malarial  fever.  10;  accidental  and  late  lesions  of, 
15;  sestivo-autiimnal,  20;  algid  form  of.  22; 
comatose  form  of.  21;  continued  and  remittent 
form  of.  20;  description  of  the  paroxysm  in.  16; 
geographical  distribution  of,  10;  hEPmorrhagic 
form  of,  22;  intermittent.  16;  nephritis  in.  16; 
pernicious.  15.  21;  pneumonia  in.  16:  quartan.  17; 
quotidian.  17;  season  in.  10;  specific  germ  of,  10; 
tertian.  17. 

Malarial  hsemoglobinuria,  22. 

Malarial  nephritis.  16. 

MaUein.  263. 

Malta  fe%-er.  247. 

Mammarj-  glands.  h>'pertrophy  of,  in  tuberculosis. 
334;  tuberculosis  of.  349. 

Mania  a  potu.  371. 

Mania,  Bell's,  1041. 

Marriage,  question  of,  in  ha?mophilia,  749;  in 
syphilis,  281;  in  tabes  dorsalis,  894;  in  tubercu- 
losis, 351. 

Marrow  of  bones,  in  small-pox.  115;  in  leuksemia, 
732;  in  pernicious  anaemia,  726. 

Masque  des  femmes  en^iente*,  758. 

Massai  disease,  50. 

Mastication,  spasm  of  the  muscles  of,  1018. 

Mastitis  in  enteric  fever,  88;  chronic,  334. 

McBurney's  tender  point.  515. 

Measles.  140;  abortive,  143;  attenuated,  143;  black, 
143;  buccal  spots  in.  142;  contagiousness  of.  141; 
desquamation  in.  143;  eruption  in,  142;  German, 
145;  malignant,  143;  period  of  incubation  in, 
141. 

Measly  meat,  examination  of,  30. 

Meat,  poisoning  by,  381;  tuberculous  infection  by, 
292;  inspection  of,  for  trichinan,  41. 

Mecfcel's  diverticulum.  519. 

Median  nerve,  affections  of,  1037. 

Mediastinal  friction,  663.  . 

Mediastino-pericarditis,  indurative.  663. 

Mediastinum,  affections  of,  GOO;  abscess  of,  662; 
cancer  of,  661;  emphysema  of,  663;  pleural  effu- 
sion in,  662;  sarcoma  of.  661;  tumors  of,  661. 

Mediterranean  fever,  248. 

Medulla  oblongata,  lesions  of,  952;  tumors  of,  991. 

Megalo-cephaly,   1108. 

Megalocytes,  728. 

Megalogastric,  467. 

Mela>na  in  duodenal  »ilcer.  474;  in  t>-phoid  fever,  80; 
in  tuberculosis  of  bowels,  340;  neonatorum,  747. 

Melano-sarcoma  of  liver,  568;  of  lungs,  641. 

Melanuria,  680. 

Melasma  suprarenale,  758. 

Meniere's  disease,  1024. 

Meningeal  ha5morrhage,  968;  in  birth  palsies,  9^0. 

Meninges,  affection  of,  923. 

Meningitis,  acute  cerebro-spinal,  925:  basilar,  301; 
epidemic  cerebro-spinal,  sporadic  cerebro-spinal, 
157,928;   in  erjsipelas,  212;  in  gout.  405;  granu- 
lar, 301;  lepto,  928:    in  tj-photd    fever.  69.   85; 
simple,    of    infants,    928;    posterior  basic.  928; 
serous,  996;  s\-philitic,  272;  tuberculous,  301. 
Meningococcus,  159. 
Meningo-encephalitis,  tuberculous,  302. 
Meralgia  paraesthetica,  1038. 
Mercurial,  tremor,  1045;  stomatitis,  437. 
Merjxismus,  491. 


Mesaortitis,  848. 

Mesenteric  arterj-,  aneurism  of,  533,  865;  embolism 

of,  533;  thrombosis  of.  533. 
Mesenteric  glands,  tuberculosis  of.  308;  tuberculous 

tumors  of,  312;  in  t\-phoid  fever,  68. 
Mesenteric  veins,  diseases  of.  533. 
Mesenteric  vessels,  affections  of.  533. 
Mesentery,  chylous  cysts  of,  533;  affections  of,  532. 
Mesogonimus  heterophyes,  27. 
Metallic  echo,  659;  tinkling,  331,  659. 
Metallotherapy,  1080. 
Metastatic  abscesses.  216 
Metasj-philitic  affections,  269- 
Metatarsalgia,  1071. 

Meteorism  in  t>-phoid  fever,  80;  treatment  of,  102. 
Micrococci,  in  Malta  fever.  248. 
Micrococcus,  catarrhalis,  593;  lanceolatus,  164,  167. 
215,216,623;  melitensis.248;  thecalis,  in I/ondrya 
paralysis,  918. 
Microcytes.  728. 
Micromelia,  in  cretinism,  769. 
Middle  cerebral  arten.-,  embolism  and  thrombosis 

of,  979. 
Migraine.  1066;  treatment  of,  1068. 
Mikulicz's  disease.  442. 
Miliar>-  absce.^ses  in  typhoid  fever,  68. 
Miliary  aneurism,  967. 
Miliar>-  fever,  367;  epidemics  of,  367. 
Miliao'    tubercle,    295;     tuberculosis,   acute,    298; 

tuberculosis,  chronic,  318. 
Milk  and  scarlet  fever.  131;  and  typhoid  fever.  62; 
products,  poisoning  by,  382;  sickness,  365;  tuber- 
culous infection  by,  292. 
Mind-blindness,  959. 
Mind-deafness.  959. 

Miner's  anaemia  or  cachexia,  44;  lung,  631;  nystag- 
mus. 1014;  cancer  of  lung,  642. 
Mitchell.  Weir,  treatment  in  hysteria,  1086. 
Mitral  incompetency,  804. 

Mitral  stenosis,  808;  chorea  and,  808;  paralysis  of 
recurrent  lar>ngeal  in,  811;  presystolic  murmur 
in,  810;  rheumatism  and,  808. 
Mobt  sounds  in  pulmonary  tuberculosis.  330. 
M6ller"s  glossitL*.  438. 
Monophobia.  1089. 
Monoplegia,    cerebral,    883.    947;    facial,    1019;    in 

hysteria,  1079;  in  traumatic  neuroses,  1097. 
Montaigne  on  renal  colic.  71 1 . 

Montreal  General  Hospital,  stati.«tics  of  hsemorrha- 
gic  small-pox,  118;  of  pneumonia.  187;  of  rheuma- 
tic fever.  219. 
Montreal  small-pox  epidemic  1885-'86,   128. 
Morbilli   140;  sine  morbillL«,  143. 
Morbus,  ca'ruleus,  845. 
Morbus,  co-xae  senilis,  392;  erronum,  54. 
Morbus    maculosus,    743;    neonatorum,    747;    of 

Werlhof.  745. 
Morphia  habit,  373;  treatment  of,  374, 
Morphinism,  373. 
Morphinomania,  373. 
Morphtt-a.  1109. 

Mortality,    in    cerebro-spinal    meningitis,    164;    in 
pneumonia,  187;  typhoid  fever.  96;  in  whooping- 
cough.  151;  in  yellow  fever,  238. 
Morton's  painful  foot,  1071. 
Morran's  disease,  944. 
Mosquitoes,  forms  of,  13,  235. 


INDEX. 


1131 


Mosquitoes,  relation  of,  to  filaria  disease,  48;  to 
malaria,  13;  to  yellow  fever,  235. 

Motor  tract,  diseases  of,  901. 

Mountain,  anaemia,  44,  366;  fever,  366;  sickness, 
366. 

Mouth-breathing,  447. 

Mouth,  diseases  of,  434;  dry,  441;  putrid  sore,  435. 

Movable  kidney,  529,  664;  dilatation  of  stomach  in, 
665. 

Movable  liver,  529,  572. 

Mucous  colitis,  530. 

Mucous  glands,  affections  of,  440. 

Mucous  patches,  268. 

Muguet,  436. 

Multiple  gangrene,  1101. 

Multiple  sclerosis,  930. 

Mumps,  146,  441.  _ 

Murmur,  in  aneurism,  858;  btain,  429;  cardio- 
respiratory, 331;  in  chlorosis,  724;  in  congenital 
heart-disease,  846;  Flint's,  800,  810;  in  endo- 
carditis, 789;  humming-top,  724;  in  lung  cavity, 
330;  in  subclavian  artery  in  phthisis,  331;  in 
valvular  disease,  800,  803,  807.  810,  812,  813. 

Musca  domestica,  55;  M.  vomitoria,  55. 

Muscle  callus  in  sterno-mastoid  in  infants,  1031. 

Muscle-sense,  959. 

Muscles,  diseases  of,  1111;  degeneration  of,  in  ty- 
phoid fever,  70,  89. 

Muscular  atrophy,  forms  of,  907;  heredity  in, 
906;  atrophic  and  hypertrophic  varieties,  907; 
infantile  form,  907;  juvenile  tjT)e,  907;  progress- 
ive neural  form,  905;  peroneal  tjije,  905;  progress- 
ive central,  901,  914;  hereditary  influence  in,  902. 

Muscular  contractures  in  hysteria,  1079. 

Muscular  dystrophies,  906. 

Muscular  exertion,  coma  after,  686. 

Muscular  exertion  in  heart-disease,  797,  821, 

Muscular  rheumatism,  396. 

Musculo-spiral  paralysis,  1036. 

Musical  murmurs,  803,  846. 

Mussel  poisoning,  383. 

Myalgia,  396. 

Myasthenia  gravis,  1113. 

Myasthenic  reaction,   1114. 

Mycosis  intestinalis,  254;  pulmonum,  254. 

Mycotic  gastritis,  459. 

Myelajmia,  731. 

Myelitis,  acute,  944;  acute  diffuse,  945;  acute 
transverse,  946;  compression,  938;  in  measles, 
143;  reflexes  in,  946;  transverse,  of  cervical 
region,  947;  syphilitic,  272,  273. 

Myelocytes,  736. 

Myelogenous  leukaemia,  731. 

Myiasis,  55;  of  nostrils  and  of  ears,  55;  of  vagina, 
55;  cutaneous,  .55;  gaatro-intestinal,  55. 

Myatonia,  1114. 

Myiosis,  55. 

Myocarditis,  acute  interstitial,  824;  fibrous,  824; 
in  rheumatism,  223;  segmenting,  825;  in  tjTjhoid 
fever,  69,  78. 

Myocardium,  affections  of,  820;  lesions  of,  due  to 
disease  of  coronary  arteries,  823. 

Myoclonia,  1113. 

Myoclonies,   1113. 

Myoidema,  330. 

Myopathies,  the  primary,  906. 

Myosis,  spinal,  889,  1014. 


Myositis,    1111;    dermato-,  1111;   infectious,  1111; 

ossificans  progressiva,  1112. 
Myotonia,  U12;  congenita,  1112. 
Myotonic  reaction  of  Erb,  1113. 
Myriachit,  1055. 
Mytilotoxin,  383. 
Myxoedema,  768;  acute,  770;  congenital  form,  768; 

operative,  770. 
Myxoma  of  spinal  cord,  941. 
Myxoneurosis  intestinaUs,  530. 

Naevi,  multiple,  of  skin  and  mucous  membranes, 
595,  749. 

Nagana,  7. 

Nails,  in  typhoid  fever,  75;  in  phthisis,  335. 

Naming  centre,  957. 

Nasal  diphtheria,  201. 

Naso-pharyngeal  obstruction,  447. 

Neapohtan  fever,  248. 

Neck,  cellulitis  of,  444;  Derbyshire  neck,  764. 

Necrosis,  acute,  of  bone,  225;  in  typhoid  fever,  88. 

Necrosis  in  tubercle,  296. 

Needle-swallowing  in  hysteria,  831. 

Nematodes,  diseases  caused  by,  38. 

Nephralgia,  1071. 

Nephrectomy,  709. 

Nephritis.  686;  acute,  686;  after  diphtheria,  204; 
chronic,  692;  chronic  ha-morrhagic,  693;  in 
tonsillitis,  446;  surgical  treatment  of,  702. 

Nephritis,  chronic  desquamative,  692;  chronic 
diffuse,  with  exudation,  692;  chronic  interstitial, 
694;  chronic  parenchymatous,  692;  chronic  tubal, 
692;  consecutive,  703;  hirmorrhages  in,  699;  in- 
creased tension  in,  698;  in  erysipelas,  212;  in  ma- 
laria, 16;  lymphomatous,  88;  relation  of  heart 
hypertrophy  to,  696;  in  scarlet  fever,  134;  in 
typhoid  fever,  88;  suppurative,  704;  syphilitic, 
277;   urine  in,  698;  vomiting  in,  699. 

Nephrohthia.sis,  709. 

Nei>hro-phthisis  (see  Kidney,  Tuberculosis  of). 

Nephroptosis,  529,  664. 

Nephrorrhaphy.  666. 

Nephrotomy,  709. 

Nephro-typhus,  88. 

Nerve-fibres,  inflammation  of,  998. 

Nerve-root  symptoms,  9.38. 

"Nerve-storms,"  1068. 

Nerves,  anastomosis  of,  in  facial  paralysis,  1022. 

Nerves,  diseases  of  peripheral,  998;  diseases  of 
cerebral,  1005;  diseases  of  spinal,  1033. 

Nerves,  lesions  of  anterior  crural,  1038;  circumflex, 
1036;  external  popliteal,  1038;  gluteal,  1038;  in- 
ternal popliteal,  1039;  long  thoracic,  1036;  me- 
dian, 1037;  mu8culo-.spiral,  1036;  obturator,  1038; 
sciatic,  1038;  small  sciatic,  10.38;  ulnar,  1037. 

Nervous  diarrhoea,  498,  1082. 

Nervous  dyspepsia,  490. 

Nervous  system,  diseases  of,  867;  diffuse,  923. 

Nettle  rash  (see  Urticaria). 

Neuralgia,  1068;  causes  of,  1069;  cervico-brachial, 
1070;  cervico-occipital,  1033,  1070;  epileptiform, 
1069;  influence  of  malaria  in,  1069;  intercostal, 
1070;  lumbar,  1071;  of  nerves  of  feet,  1071; 
phrenic,  1070;  plantar,  1071;  post-zoster,  1070; 
quinti  major,  1069;  red,  1102;  reflex  irritation  in, 
1069;  treatment  of,  1071;  trigeminal,  1069; 
visceral,  1071. 


1132 


IXDEX. 


Neurasthenia,  1086:  sexual,  1091;  traumatic,  1096. 

Neuritis,  998;  arsenical,  1002 ;  ascending,  1000;  from 
beer,  1002;  fascians,  999;  interstitial,  999;  of  in- 
fants, progressive  interstitial  h>"pertrophic,  922; 
lipomatous,  999;  localized,  998,  999;  parenchy- 
matous, 999;  multiple,  999, 1000;  alcoholic,  1001; 
endemic,  249,  1003;  in  diphtheria,  204;  migra- 
tory, 1000;  in  chronic  phthisis,  334;  in  the  infec- 
tious diseases,  1002 ;  in  tM^hoid  fever, 86 ;  recurring, 
1001;  saturnine,  377,  1002;  sj-mpathetic,  1000; 
traumatic,  998;  optic,  1008;  from  zinc,  1002. 

Neurofibromatosis,  generalized,  1005. 

Neuroglioma,  988. 

Neuromata,  1004;  "amputation,"  1005;  plexiform, 
1004. 

Neurone,  structure  of,  867;  function  of,  868;  degen- 
eration of,  868;  regeneration  of,  868. 

Neuro-retinitis,  in  anaemia,  1007. 

Neuroses,  occupation,  1072;  traumatic,  1096. 

Neutrophiles,  736. 

New-born,  haemorrhagic  diseases  of,  747. 

New  growths  in  the  bowel,  521. 

Night-blindness,    1008;  in   scurvy,   752. 

Night-sweats  in  phthisis,  328;  treatment  of,  358. 

Night-terrors,  449. 

Ninth  nerve,  lesions  of,  1026. 

Nissl  (tigroid)  bodies,  868. 

Nits,  53. 

Nodding  spasm,  1032. 

Nodes,  Haygarlh's,  390;  Hdfcrdcn's,  391. 

Nodes,  symmetrical,  in  congenital  syphilis,  271. 

Nodules,  rheumatic,  224. 

Noma,  437;  in  scarlet  fever,  136;  in  typhoid,  89,91. 

Normoblasts,  722,  728. 

Nose,  bleeding  from  (see  Epibtaxis),  595. 

Nose,  diseases  of,  593. 

Nummular  sputa  in  plithisis,  323. 

Nurse's  contracture  of  Trousseau,  1074. 

Nutmeg  liver,  541. 

Nyctalopia,  1008;  in  scurvy,  752. 

Nylander's  bismuth  test  in  diabetes,  415. 

Nystagmus,  1014;  in  Friedreich's  ataxia,  922;  in 
insular  sclerosis,  931;  of  miners,  1014. 

Obesity,  431;  diabetogenous,  410. 

Obsession,  1054. 

Obstruction  of  bowels,   519;  acute,  522;  chronic, 

522. 
Obturator  nerve,  affections  of,  1038. 
Occipital  lobe,  tumors  of,  990. 
Occipito-cervical  neuralgia,  1033,  1070. 
Occupation  neuroses,  1072. 
Ochronosis,  681. 

Ocular  palsies,  treatment  of,  1017. 
Oculo-motor  paralysis,  recurring,  1013. 
Odor,  in  small-pox,  117;  in  tv-phoid  fever,  75. 
CEdema,  angio-neurotic,  1103;  febrile  purpuric,  744; 

of  glottis,  598;  hereditary,  1104;  of  lungs,  616; 

of  brain,  965;  malignant,  of  anthrax,  253;  of  the 

brain,  in  ursemia,  683,  965. 
Edematous  laryngitis,  598. 
OerteVs  method  in  obesity,  432,  829. 
(Esophageal  bruit,  454;  varices,  452. 
CEsophagismus,  453. 
CEsophagitis,   acute,   451;  clironic,   452;  fibrinous, 

452;  membranous,  452. 
CEsophago-malacia,  453. 


CEsophago-pleuro-cutaneous  fistula,  456. 
CEsophagus,  diseases  of,  451;  cancer  of,  454;  dila- 
tations of,  456;  diverticula  of,  456;  haemorrhage 

from,  in  cirrhosis  of  liver,  559;  paralysis,  of,  453; 

post-mortem  digestion  of,  455;  rupture  of,  455; 

spasm  of,  453;  stricture  of,  453;  s>"philis  of,  276; 

tuberculosis  of,  340;  ulceration  of,  452;  varices  of 

veins,  in  cirrhosis  of  liver,  452,  559. 
Oidium  albicans,  436;  oidiomycosis,  2. 
Olfactory  nerves  and  tracts,  diseases  of,  1005. 
Omentope.xy  in  cirrhosis  of  the  liver,  563. 
Omentum,   tuberculous  tumor  of,  311;  tumor  of, 

in  cancer  of  the  peritonaeum,  588. 
Omod>Tiia,  397. 
Onomatomania,   1054. 
Onycliia,  in  arthritis  deformans,  392;  in  locomotor 

ataxia.  892;  sj-pliilitic,  268,  270. 
Operation  per  se,  effects  of,  in  epilepsy,  1066. 
Operation,  tuberculosis  after,  295. 
Ophthalmia,  gonorrhccal,  with  arthritis,  226. 
Ophthalmoplegia,  914,  1016;  externa,  1016;  inter- 
na,  1016. 
Opisthotonos,  cervical,  in  infants,  928;  in  tetanus, 

260. 
Opium,    poisoning,    diagnosis    from    ursemia,   686; 

habit,  373;  .smoking,  effects  of,  373. 
Opjyenhcim's  disease,  1114. 
Opsonic  index  in  tuberculosis,  356. 
Optic    nerve    atropliy,    1009;      hereditary,    1009; 

primary,  1009;  secondary,  1009;  in  tabes,  889. 
Optic  nerve  and  tract,  diseases  of,  1006. 
Optic  neuritis,   lOOS;  in  abscess  of  brain,  994;  in 

brain-tumor,  989;  in  tuberculous  meningitis,  303; 

in  tj-phoid  fever,  87. 
Oral  sepsis,  440. 
Orchitis,  in  malaria,  23;  in  mumps,  147;  interstitial, 

in  sj-pbilis,  277;  in  t>n)lioid  fever,  88;  in  variola, 

119;  parotidea,  147;  tuberculous,  348;  value  of 

in  diagnosis,  348. 
Ornithodorus   moubata,    53;  0.    Savignyi,    53;  O. 

megnini,  53. 
Orthotonos,  in  tetanus,  260. 
Osteitis  deformans,  1 106. 

Osteo-arthropathy,  hypertrophic  pulmonary,  1107. 
Osteogenesis  imperfecta,  1108. 

Osteo-myelitis  simulating  acute  rheumatism,  225. 
Osteophytes  in  artliritis  deformans,  390. 
Otitis-media,  in  t>-phoid  fever,  87;  in  scarlet  fever, 

136;  in  meningitis,  163;  meningi tic  symptoms  in, 

926. 
Ovaries,  tuberculosis  of,  348. 
Over-exertion,  heart  affections  due  to,  821. 
Oxalate-of-lime  calculus,  710. 
Oxaluria,  678. 
Oxygen,  inhalations  of,  in  diabetic  coma,  423;    in 

pneumonia,  192. 
Oxjniris  vermicularis,  39. 
Oysters,   poisoning   by,   383;    and    typhoid    fever, 

63. 

Pachymeningitis,  923 ;  cervicalis  hj-pertrophica,  924; 

haemorrhagica,  of  cerebral  dura,  923;   of  spinal 

dura,  924. 
Paget' 8  disease,  1 106. 
Pain,  in  appendicitis,  514;  in  cancer  of  stomach, 

483;  in  pleurisy,  645;  in  pneumonia,  174;  in  ulcer 

of  the  stomach,  474. 


INDEX. 


1133 


Palate,  paralysis  of,  in  diphtheria,  204;  in  facial  par- 
alysis, 1020;  perforation  of,  in  scarlet  fever,  136. 
Palate,  tuberculosis  of,  339. 
Palpable  kidney,  664. 
Palpitation  of  heart,  832. 
Palsies,  cerebral,  of  children,  910,  985. 
Palsy,  lead,  377;  obstetrical,  1035;  shaking,  1042. 
Paludism  (see  Malarial  Fever),  10. 
Pancreas,  cancer  of,  579;  in  diabetes,  413;  cysts  of, 

577;  haemorrhage  into,  573;  tumors  of,  579. 
Pancreas,  diseases  of,  573;  insufficiency  of,  573. 
Pancreatic  abscess,  575;  diabetes,  414;  calculi,  580. 
Pancreatitis,  acute,  574;  acute  hsemorrhagic,  574; 
chronic,  577;  fat  necrosis  in,    575;    gangrenous, 
575;  suppurative,  575. 
Panophthalmitis  in  exophthalmic  goitre,  766. 
Pantophobia,  1089. 
Papillitis,  1008. 

Paracentesis,  pericardia,  782;  thoracis,  654;   acci- 
dents in,  654;  abdominis,  592. 
Paraesthesia  (numbness  and  tingling),  in  neuritis, 
1000;  in  locomotor  ataxia,  891;  in  tumor  of  brain, 
990;  in  primary  combined  sclerosis,  921. 
Parageusis,  1026. 

Paralysis,  acute  ascending,  918;  acute  spinal,  of 
adults,  918;  acute,  of  infants,  914;  agitans,  1042; 
alcoholic,  1001;  anffisthesia,  1003;  asthenic  bulbar, 
1113;  atrophic  spinal,  914;  Bell's,  1019;  bulbar, 
acute,  905;  chronic,  904;  of  bladder,  in  myeUtia, 
945;  of  brachial  plexus,  1035;  cerebellar,  954;  in 
chorea,  1049;  of  circumfle.x  nerve,  1036;  crossed  or 
alternate,  951,  973;  "  crutch,"  1036;  Cruveilhier's, 
901;  diver's,  937;  of  diaphragm,  1034;  after 
diphtheria,  204;  following  epilepsy,  1062;  Erb's 
syphilitic  spinal,  913;  of  facial  nerve,  1019;  of 
fifth  nerve,  1017;  of  fourth  nerve,  1014;  general, 
of  the  insane,  895;  of  hypoglossal  nerve,  1032; 
hysterical,  1078;  infantile,  914;  labio-glosso- 
laryngeal,  904;  Landry's,  918;  of  laryngeal  ab- 
ductors, 1027;  of  adductors,  1028;  in  lateral 
sclerosis,  909;  from  lead,  377;  in  locomotor  ataxia, 
892;  of  long  thoracic  nerve,  1030;  in  meningitis, 
303,  927;  of  median  nerve,  1037;  of  musculo- 
spiral  nerve,  1030;  obstetrical,  1035;  of  oculo- 
motor nerves,  1013;  of  olfactory  nerve,  1005; 
periodical,  1099;  in  progressive  muscular  atrophy, 
903;  pseudo-bulbar,  905,  956;  radial,  1036;  of 
rectum,  in  myelitis,  945;  of  recurrent  laryngeal 
nerve,  1027;  secondary  to  visceral  disease,  1000; 
serratus,  1036;  of  sixth  nerve,  1015;  spinal, 
family  form  of,  912;  of  third  nerve,  1013;  of  ulnar 
nerve,  1037;  of  vocal  cords,  1027. 
Paramyoclonus  multiplex,  1113. 
Paraphasia,  959. 
Paraplegia  flasque,  913. 

Paraplegia,  from  alcohol,  1001;  ataxic,  920;  from 
ansemia  of  spinal  cord,  934;  from  compression  of 
cord,  938;  cervical,  947;  diabetic,  418;  dolorosa, 
940;   from   hsemorrhage   into   cord,    934;    hered- 
itary  form    of,    912;    hysterical,    914,    1079;    in 
lathyrism,  384;  from  myelitis,  945;  in  pellagra, 
384;  spastic,  of  adults,  909;  spastica  cerebralis, 
910;   syphilitic  spinal,   913;   from  tumor  of  the 
cord,  942;  in  tabes,  892. 
Parasites,  diseases  due  to  animal,  1. 
Parasitic  gastritis,  459. 
Parasitic  haemoptysis,  26. 


Parasitic  stomatitis,  436. 
Parasyphilitic  affections,  269,  895. 
Para-typhoid  infections,  64. 
"Parchment  crackling  "  in  rickets,  427. 
Parenchymatous  nephritis,  692. 
Paresis,  general,  895. 

Parieto-occipital  region,  brain  tumors  in,  990. 
"  Paris  green,"  poisoning  by,  379. 
Parkinson's  disease,  1042. 
Parosmia,  1006. 
Parotid  bubo,  441. 

Parotitis,    epidemic,    146;    deafness    in,    148;    de- 
lirium  in,    147;    chronic,    442;    orchitis   in,    147 
specific,  441;  symptomatic,  441;  after  abdominal 
section,  441;  in  pneumonia,  182;  post-operative, 
441;  in  typhoid  fever,  79;  in  typhus  fever,  108. 
Paroxj'smal  hsemoglobinuria,  671. 
Parrot's  disease,  754. 
Parrot's  ulcers,  436. 
Parry's  disease,  765. 
Patellar-tendon  reflex  (see  Knee-jerk). 
Pathophobia,  1089. 
Pectoriloquy,  331. 

Pediculi,  53;  relations  of,  to  tache  bleua,tre,  54,  75. 
Pediculosis,  53. 

Pediculus  capitis,  53;  P.  corporis,  54. 
Peliomata,  54,  75. 

Peliosis  rheumatica,  224,  744;  in  chorea,  1051. 
Pellagra,  384. 

Pelvis  of  kidney,  affections  of  (see  Pyelitis), 
Pemphigoid  purpura,  744. 
Pempliigus  neonatorum,  269. 
Pentastomes,  52. 

Peptic  ulcer,  470;  dyspepsia,  in,  474;  hajmorrhage 
in,  474;  jejunal,  473;  pain  in,  474;   tenderness  on 
pressure  in,  475. 
Peptones  in  the  urine,  674. 
Perforating  ulcer  of  foot  in  tabes,  892;  in  diabetes, 

417. 
Perforation    of    bowel,    in    dysentery,    0,    245;    in 

typhoid  fever,  67,  81. 
Periarteritis,  gummatous,  277;  nodosa,  866. 
Pericardial  friction,  777. 
Pericardite  brightique,  775. 

Pericarditis,  775;  acute  fibrinous,  776;  aphonia  in, 
779;  chronic  adhesive,  782;  delirium  in,  779; 
dysphagia  in,  779;  epidemics  of,  776;  epilepsy  in, 
779;  from  extension  of  disease,  775;  from  foreign 
body,  775;  in  chorea,  1050;  in  foetus,  776;  in 
gout,  405;  in  rheumatism,  223;  haemorrhagic, 
778;  hyperpyrexia  in,  777,  779;  idiopathic,  775; 
mental  symptoms  in,  779;  primary,  775;  pulsus 
paradoxus  in,  779;  secondary,  775;  tuberculous, 
309;  with  effusion,  778;  in  typhoid  fever,  69,  78. 
Pericardium,   adherent,   782;    Friedreich's  sign   in, 

783;  calcified,  785. 
Pericardium,  diseases  of,  775;  tuberculosis  of,  309; 

air  in,  785. 
Perichondritis,  laryngeal,  in  typhoid  fever,  68,  84; 

in  tuberculosis,  600. 
Perigastric  adhesions,  473. 
Perihepatitis,  562,  587. 
Perinephric  abscess,  717. 
Perinephritis,  chronic,  717. 
Perinuclear  basophilic  granules,  400. 
Periodical  paralysis,  1099. 
Periosteal  cachexia,  753. 


1184 


INDEX. 


Peripheral  neuritis,  998. 

Perisigmoiditis,  533. 

Peristaltic  unrest,  490,  1082. 

Peritoneum,  diseases  of,  580. 

Peritonaeum,  fluid,  in,  589,  592;  cancer  of,  588;  new 
growths  in,  588. 

Peritonaeum,  tuberculosis  of,  310;  tumor  forma- 
tions in  tuberculosis  of,  311. 

Peritonitis,  actinomj'cotic,  2C4;  acute  general,  516. 
580;  appendicular,  516,  580;  chronic.  586;  chronic 
hemorrhagic,  588;  diffuse  adhesive,  587;  hysteri- 
cal, 583;  idiopathic,  580;  in  infants,  584;  in 
typhoid  fever,  82;  leukiemic,  734;  local  adhesive, 
586;  localized,  584;  pelvic,  580;  perforative,  580; 
primary,  580;  proliferative.  .587;  pyaemic,  581; 
rheumatic,  580;  secondary.  580;  septic,  581;  sub- 
phrenic, 584;  tuberculous.  310,  588. 

Peritonitis,  tuberculous,  effects  of  operation  on,  591. 

PerityphUtis,  512. 

"Perles"  of  Laennec,  611. 

Pernicious  antemia,  724. 

Pernicious  malaria,  15,  21. 

Peroneal  type  of  muscular  atrophy,  905. 

Pertussis  (see  Whooping-cough),  148. 

Pesta  magna,  112. 

Pestis  minor,  240. 

Petechiae,  743;  in  epilepsy,  1062;  in  relapsing  fever, 
110;  in  scurvy,  752;  in  small-pox,  115;  in  typhoid 
fever,  74;  in  typhus  fever,  107. 

Petechial  fever,  157. 

Petit  mal,  10.58.  1062;  in  general  paresis.  898. 

Peyer'g  patches  in  typhoid  fever,  65;  in  tuberculosis, 
341. 

Phagocytosis  in  erysipelas,  211 ;  in  tuberculosis,  296. 

Pharyngitis,  442;  acute,  442;  chronic,  443;  sicca, 
443. 

Pharynx,  acute  infectious  phlegmon  of,  444; 
haemorrhage  into,  442;  hyperspmia  of,  442; 
cedenia  of,  442;  paralysis  of.  1027;  spasm  of, 
1027;  tuberculosis  of,  339;  ulceration  of,  443. 

Pharynx,  diseases  of,  442. 

Philadelphia  Hospital,  relapsing  fever  at,  in  1844, 
109;  statistics  of  cerebro-spinal  fever,  161;  of 
delirium  tremens  in.  372. 

Philadelphia  Infirmary  for  Nervous  Diseases, 
statistics  of  chorea,  1045;  of  epilepsy,  1059. 

Philadelphia,  tuberculosis  in  city  wards,  291; 
yellow-fever  epidemic  in  1793,  233;  typhus 
epidemic  in  1883.  100. 

Philippine  itch,  113. 

Phlebitis  of  portal  vein,  564. 

Phlebo-sclerosis.  851. 

Phlegmon,  acute  infectious,  of  pharynx,  444. 

Phobias  in  neurasthenia,  1089. 

Phosphates,  alkaline,  679;  earthy,  679. 

Phosphatic  calculi,  710. 

Phosphaturia,  679. 

Phosphorus  poisoning,  similarity  of  acute  yellow 
atrophy  to,  540. 

Phrenic   nerve,    affections   of,    1034;    neuralgia  of, 

1070. 
Phthiriasis,  53. 
Phthirius  pubis,  54. 

Phthisical  frame,  Hippocrates'  description  of,  293. 
Phthisis,     312;     chronic     ulcerative,     317;     acute 
pneumonic,  313;  arterio-sclerosis  in,  337;  basic 
form  of,  318;  Bright's  disease  in,  334;  of  coal- 


miners,  631;  chronic  arthritis  in,  337;  cough  in 
323;  endocarditis  in,  321,  333;  diagnosis  of,  33.5; 
distribution  of  lesions  in.  317:  ery.sipela.'i  in.  337; 
fatal  haemorrhage  in,  338;  fever  in,  327;  forms  of 
cavities  in,  319;  gastric  symptoms  of,  333; 
haemoptysis  in,  325;  modes  of  death  in,  338;  modes 
of  onset  in.  321;  physical  signs  of,  329;  pneumonia 
in,  337;  relation  of  fistula  in  ano  to,  341;  sputum 
in,  323;  summary  of  lesions  in,  318;  typhoid  fever 
in,  337;  vomiting  in.  333. 

Phthisis,  fibroid,  335,  628;  florida,  315;  renum,  345; 
sj-philitic,  274;  of  stone-cutters,  631;  unity  of, 
297;  ventriculi,  401. 

Physiological  albuminuria,  672. 

Pia  mater,  diseases  of,  925. 

Pick's  disease,  783. 

Picric-acid  test  for  albumin,  674. 

Pigeon-breast,  in  rickets,  428;  in  mouth-breathers, 
449. 

Pigmentation  of  skin,  from  arsenic,  380;  in  Base- 
dow's disease,  767;  from  phthiriasis,  54;  in 
Addison's  disease,  757 ;  in  chronic  pulmonary 
tuberculosis,  335;  in  melanosis,  758;  in  peritoneal 
tuberculosis,  311;  in  scleroderma,   1109. 

Pigmentation  of  viscera  in  pellagra,  384. 

Pigs,  tuberculosis  in,  284. 

Pin-worms,  39. 

Piroplasmosis,  9. 

Pitting  in  small-p>ox,  117;  measures  to  prevent,  122. 

Pituitary  body  in  acromegaly,  1106;  in  gigantism, 
1106;  tumors  of,  991. 

Pityriasis  versicolor,  335. 

Placenta,  tuberculosis  of,  348. 

Plague,  239;  bubonic,  240;  septicsemic,  241;  pneu- 
monic, 241;  spots,  241. 

Plantar  neuralgia,  1071. 

Plaques  jaunes,  978. 

Plasmodium  malarix,  12;  pra?cox,  13;  vivax,  12. 

Plastic  bronchitis,  013. 

Pleura,  diseases  of,  643. 

Pleura,  echinococcus  of,  36;  tuberculosis  of,  308. 

Pleural  effusion,  Baccelli's  sign  in,  647,  649;  com- 
pression of  lung  in,  04.5;  haemorrhagic,  650; 
position  of  heart  in,  04C;  pseudo-cavernous  signs 
in,  647;  purulent,  648;  serous  effusion,  constitu- 
ents of,  645;  sudden  death  in,  648. 

Pleural  membranes,  calcification  of,  655. 

Pleurisy,  acute,  643;  chronic.  655;  diaphragmatic, 
651;  dry,  655;  with  effusion,  643,  655;  encysted, 
651;  fibrinous,  643;  haemorrhagic,  650;  interlobar, 
651;  in  typhoid  fever,  85;  pain  in  side  in,  645; 
plastic,  643;  pleural  friction  in,  647;  primitive 
dry,  656;  pulsating,  649;  purulent,  648;  sero- 
fibrinous, 643;  tuberculous,  308,  644,  650;  vaso- 
motor phenomena  in,  650. 

Pleurodynia.  396. 

Pleuro-pericardial  friction,  330,  777. 

Pleuro-peritoneal  tuberculosis,  308. 

Pleurothotonos  in  tetanus,  260. 

Plexiform  neuroma,  1004. 

Plica  polonica,  53. 

Plumbism,  375;  and  gout,  398;  as  a  cause  of  renal 
cirrhosis,  695;  paralysis  in,  .377. 

Plymouth,  epidemic  of  typhoid  fever  at,  62. 

Pneumatosis,  491. 

Pneumaturia,  416,  681. 

Pneumococcus,  167,  644. 


INDEX. 


1135 


Pneumogastric  aurie   1060. 

Pneumogastnc  nerve    affections  of    1027;  cardiac 
branches     of,     1029;     gastric     and     oesophageal 
branches  of,  1029;   laryngeal  branches  ot     U)27, 
pharyngeal      branches      of,      1027;      pulmonary 
branches  of,   1029. 
Pneumonia,  acute  croupous,   104;   abscess  in.   186; 
acute   deUrium   in,    179;    anaesthesia,    185;    anti- 
pneumococcic  serum  in,   191;   bleeding  in,   190; 
caseous,   323;    clinical   varieties   of,    182;    cohtis, 
croupous,  in,  172,  281 ;  com£lications  of,  180;  crisis 
in  174;  delayed  resolution  in,  185; "  diagnosis  from 
acute     pneumonic     phthisis,     315;     diplococcus 
pneumoniae,  167;   endocarditis  in    171,  180:  en- 
gorgement of  lung  in,   170;   epidemics   of,   169; 
fever  of,  172;  gangrene  in,  187;  gray  hepatiza- 
tion in,  170;  herpes  in,  179;  immunity  from,  169; 
in  diabetes,   183;   in  infants,    183;   in  influenza, 
185;   in   old   age,    183;   meningitis  in,    172,    181; 
mortality  of,  187;  pericarditis  in,  171, 180;  pseudo- 
crisis  in,   174;   purulent  infiltration  in,   170;   re- 
currence of,   182;   red   hepatization  in,   170;   re- 
lapse in,  182;  resolution  of,  170;  serum  therapy 
in,   169;    thrombosis  in,   181;    toxamia  in,    188; 
trauma  in,  166. 
Pneumonia,    apex    pneumonia,    182;    aspiration    or 
deglutition,     621;     asthenic,     184;     central,   183; 
"cerebral,"  179;  cheesy,  297;  chronic  interstitial, 
628;  contusion,  166;  creeping,  182;  double,  182; 
ether,  185;  epidemic,  184;  fibrinous,  164;  hypo- 
static, 015;  in  malaria,  16;  interstitial,  of  the  root, 
in  syphihs,  274;  in  typhoid  fever,  84;  larval,  184; 
lobar,  164;   massive,  182;   migratory,  182;  pleur- 
ogenous    interstitial,    628;     post-operative,    185; 
scrofulous.   297;   secondary,   183;   terminal,   183; 
toxic,  184;  typhoid  pneumonia,  184;  white,  of  the 
fcBtus,  273. 
Pneumonitis,  164. 
Piieumonokoniosis,  631. 
Pneumo-pericardium,  785. 
Pneumo-peritonwum,  583. 
Pneumorrhagia,  017. 

Pneumothorax,    057;    accutissimus   of    Unverricht, 
658;     after     tracheotomy,     063;     chronic,     660; 
Hippocratic  succussion  in,  659;  in  phthi.sis,  320;    ' 
from  muscular  effort,  658;  recurrent,  658. 
Pneumo-typhus,  69,  84. 
Podagra,  397. 
Pododynia,  1071. 
Poikilocytosis,  722,  728. 

Poisoning,  by  arsenic   379;    by  food,  380;  by  grain, 
383;  by  lead,  375;  by  meat,  381 ;  by  milk-products, 
382;    ptomaine,    381;    by    sewer-gas,    363;    by 
vegetables,  383;  shell-fish  and  fish,  383. 
"Poker-back."  392. 
Polariscope  test  in  diabetes,  415. 
Poliencephalitis,  986;  superior,  1017. 
Polio-myelitis,  acute  and  subacute,  in  adults,  918; 
anterior  acute,  914;  epidemics  of,  915;  etiology 
of,  915;  anterior  chronica,  901,  914. 
Polyadenomata,  486. 
Polysemia,  732. 

Polyarteritis  acuta  nodosa,  866. 
Polycythemia,  in  diabetes,  416;  in   gastric  ulcer, 

475;  with  enlarged  spleen  and  cyanosis,  762. 
Polymyositis  hajmorrhagica,  1112. 
Polyneuritis,  acute  febrile,  1000;  recurreiis,  1001. 


Polyorrhomenitis,  308,  587. 

Polyphagia,  414. 

PolypncEa,  1116. 

Polyserositis,  308,  587,  784. 

Polyuria  (see  Diabktes  Insipidus). 

Polyuria,   in  abdominal   tumors,  424;  in  hysteria, 

424,  1078;  in  typhoid  fever,  87. 
Pons,  lesions  of,  952;  tumors  of.  991. 
Popliteal  nerve  paralysis  of.  1038. 
Porencephalus,  986. 
Porocephalus  constrictus.  52. 
Portal  vein,  diseases  of,  542;   thrombosis  of,  542; 

suppuration  in,  564. 
Post-epileptic  symptoms.  1062. 
Posterior  cerebral,  artery  blocking  of,  979. 
Post-hemiplegic   chorea,  987;    epilepsy,  987,  1063; 

movements,  987. 
Post-mortem  movements  in  cholera  bodies,  230. 
Post-pharyngeal  abscess,  444. 
Post-typhoid,  anaemia,  76;  temperature,  72. 
Potato  poisoning,  384. 
Pott's  disease,  938. 

Pregnancy,   and  acute  yellow  atrophy,   538;   and 
chorea,  1046;  and  heart-disease,  814;  and  phthisis, 
351;  and  typhoid  fever,  92. 
Presystolic  murmur,  810. 
Priapism  in  leukaemia,  734. 
Prickly  heat  (see  Urticaria). 
Procession  caterpillar,  effects  of,  56. 
Professional  spasms,  1072. 
Prof  eta's  law,  266. 
Progeria,  774. 
Proglottis  of  t.-cnia,  28. 

Progressive  muscular  atrophy,  901;  neural,  905. 
Progressive  pernicious  anaemia,  724;  blood  in,  727. 
Prophylaxis,  against  cholera,  232;  against  scurvy', 
752;  against  tuberculosis,  .351;  against  ta?nia,  30; 
against  trichina,  44;  against  typhoid  fever,  90; 
against  yellow  fever,  238. 
Prostate,  tuberculosis  of,  347. 
Proteus  vulgaris,  in  appendicitis,  512;   in  epidemic 

jaundice,  364;  in  meat  poisoning,  381. 
Protozoa,  disea.ses  caused  by,  1;  parasitic,  1. 
Prune-juice  expectoration,  642. 
Pruritus  in  diabetes,  414,  417;  in  llod^kin's  disease, 
741;   in   ura;mia,  684;   in    obstructive    jaundice, 
535;  in  gout,  405;  in  Graves'  diseafse,  707. 
Psammoma  of  spinal  cord,  941. 
Pseudo-anamia,  718. 
Pseudo-apoplectic  seizures  in  fatty  heart,  828;  with 

slow  pulse,  8.38. 
Pseudo-biliary  colic,  551. 
Pseudo-bulbar  paralysis,  905,  956. 
Pseudo-cavernous  .signs,  331 ,  647,  652. 
Pseudo-cyesis,  1079. 
Pseudo-diphtheria,  196. 
Pseudo-hydrophobia,  258. 
Pseudo-hypertrophic  muscular  paralysis,  906. 
Pseudo-leuka;mia,  738. 
Pseudo-lipoma,  supraclavicular.  770. 
Pseudo-paralyisis,  syphilitic,  754. 
Pseudo-ptosis,  1014. 
Pseudo-scl^rose  en  plaques,  931. 
Pseudo-tabes,  120. 

Pseudo-tuberculosis  hominis  streptothrica,   287. 
Psilosis,  500. 
Psittacosis,  368. 


1136 


INDEX. 


Psoriasis,  buccal,  439. 

Psorospermiasis,  1 ;  internal,!;  cutaneous,  2. 

Psychasthenia,  1091. 

Psychoses,  tj-phoid,  86. 

Psychosis  pol>"neuritica,  370. 

Ptomaine  poisoning,  381. 

Ptosis,  forms  of,  1013;  hysterical,  1013;  in  ataxia, 

889;  pseudo,  1014. 
Ptyalism,  437,  440. 
Puberty,  barking  cough  of,  1081. 
Pulex,  irritans,  54;  penetrans,  55. 
Pulmonal-cerebral  abscesses,  994. 
Pulmonary  (see  Lungs);  apoplexy,  618. 
Pulmonarj-  artery,  sclerosis  of,  851;  perforation  of, 

860. 
Pulmonary  hiemorrhage.  325,  617. 
Pulmonary    orifice,    congenital     lesions     of,    845; 
atresia  of,  845;  stenosb  of,  845;  tuberculosis  in, 
337,  845. 
Pulmonary  osteo-arfhropathy,  hypertrophic,  1107. 
Pulmonary  valve,  insufficiency  of,  813;  stenosis  of, 

813. 
Pulsating  pleurisy,  649. 
Pulsation,  dynamic,  of  aorta,  860. 
Pulse,  alternating,  834;  dicrotic,  70,  76;  under  in- 
fluence  of   digitalis.   817;   intermittent,   834;   ir- 
regular, 834;  bigeminal.  834;  trigeminal,  834. 
Pulse,    capillary    (see   Capillary);    Corrigan,   801; 

water-hammer,  801. 
Pulse,    slow,    in    tuberculous    meningitis,    302;    in 

jaundice,  536  (see  Bradyc.vrdi.\.  836). 
Pulsus  paradoxus,  779,  784.  834. 
Pupil.  Argyll  Robertson.  889,  897,  1014. 
Pupillary  inaction,  hemiopic,  1012. 
Pupils,  unequal,  1014;  in  general  paresis,  897. 
Purpura.    742;    arthritic.    744;    cachetic.    743;    ful- 
minans.    745;     Henoch's,    745;    infectious.    743; 
mechanical.  744;  neurotic.  743;  peliosis  rheuma- 
tica   in,   744;    haemorrhagica.   745;    myelopathic, 
743;    pemphigoid.    744;    .simplex.    744;    .sympto- 
matic, 743;  toxic.  743;  urticans,  744;  variolosa, 
118. 
Purpuric  oedema,  febrile.  744. 
Pus  in  the  urine.  676. 
Pustule,  malignant.  253. 
Putrid  sore  mouth.  435 

Pyaemia.  213;  arterial.  791;    idiopathic.  216;  post- 
typhoid. 89 
Pyoemic  abscess  of  liver.  563,  566. 
Pyelitis,  703;  intermittent  fever  in.  705;  pyuria  in, 

676,  705;  in  typhoid  fever,  88. 
Pyelonephritis.  703. 
Pylephlebitis  adhesiva.  542. 
Pylephlebitis,  in  dysentery.  245;  in  pyaemia.  217; 

suppurative,  542.  564 
Pylorus,  hypertrophic  stenosis  of.  486;  congenital 
hMsertrophy  of,  487;  insufficiency  of.  492;  spasm 
of,  492. 
Pyonephrosis.  703. 
Pyo-pneumothorax.  309.  657. 
Pyo-pneumothorax  subphrenicus,  472,  585,  660. 
Pyorrhcea  alveolaris.  439. 
Pyramidal  tract.  870. 
Pyuria,  676;  in  tjiihoid  fever,  88. 

Quarantine  against  cholera,  232 
Quartan  ague,  17. 


Quincke's  disease,  1103;  lumbar  puncture,  1G3,  928. 

998. 
Quinine  rash,  137,  743. 
Quinsy  (see  Tonsillitis,  Suppurative). 
Quotidian  ague,  17. 

Rabies,  255. 

Radial  paralysis,  1036. 

Rag-picker's  disease.  254. 

Railway  brain,  109(3;  spine,  1096. 

Rainey's  tubes,  1. 

Rapid  heart,  835. 

Rashes,  from  drugs.  137,  743:  in  glanders.  262;  in 

measles,  142;  in  relapsing  fever.  110;  in  rubella, 

145;  in  scarlet  fever,  132;  in  small-pox,  115, 116; 

in  s>T3hilis,   268.   270;   in   typhoid   fever,   74;   in 

typhus  fever,  107;  in  pyjemia.  217;  in  vaccination, 

126;  in  varicella.  129. 
Raspberry  tongue  in  scarlet  fever,  133. 
Ray-fungus  (actinomyces).  263. 
Raynaud's   disease.    1100;    aphasia   in.    1101;    and 

scleroderma.    1110;    epilepsy   in,     1101;     hsemo- 

globinuria  in.  1101. 
Reaction  of  degeneration.  881.  1003.  1021. 
von  Recklinghausen's  disease.  1005 
Recrudescence  of  fever  in  typhoid  fever,  72. 
Rectal  crises  in  tabes.  891. 
Rectum,  irritable.  1082;  stricture  of.  276;  syphilis 

of.  276;  tuberculosis  of.  341. 
Recurrent  laryngeal  nerve,  paralysis  of,  1027. 
Recurring  multiple  neuritis,  1001. 
Red  softening  of  brain,  978. 
Redux  crepitus,  177. 
Reflex  epilepsy.  1060. 
Reflexes,  absence  of,  in  transverse  lesion  of  the  cord, 

9.39. 
Reflexes   in   ascending  paraly.sis,   910;    in   cerebral 

hipmorrhage.  974;  in  locomotor  ataxia.  889.  891; 

in  polio-myelitis  acuta.  916;  in  .spo-stic  paraplegia. 

910;    in    hysterical    paraplegia,    914.     1079;    in 

progressive  muscular  atrophy.  903. 
Regurgitation,  tricuspid,  811. 
Reichrniinn's  disease.  492. 

Relapse  in  typhoid  fever,  92;  in  scarlet  fever,  136. 
Relapsing  fever.  109;  spirillum  of.  110. 
Remittent  fever.  20. 
Renal  calculus.  709. 
Renal,  colic.  711;  epistaxis,  669;  sand,  709;  syphilis, 

277;  sclero.sis.  694. 
Rendu's  type  of  tremor,  1080. 
Ren  mobilis,  664. 

Resolution  in  pneumonia.  170;  delayed.  185. 
Resonance,  amphoric,  331,   658;   tympanitic,  331 

646.  658. 
Respiratory  .system,  diseases  of,  593. 
Rest  treatment.  1080;  in  aneurism.  861. 
Retina,  lesions  of.  1006. 
Retinal  hyperaesthesia.  1008. 
Retinitis.    1007;    albuminuric.    1007;    in    anaemia, 

1007;    in    malaria,    1007;    leukiemic,    1007;    pig- 
mentosa. 1007;  syphilitic.  268.  1007. 
Retraction  of  head  in  meningitis.  303.  927;  in  otitis 

media.  926;  in  typhoid  fever.  85. 
Retro-colUc  spasm.  1031. 
Retroperitonteum.  hsemorrhage  into,  114. 
Retro-pharyngeal  abscess,  444. 
Retropulsion  in  paralysis  agitans,  1044. 


INDEX. 


1137 


Revaccination,  125. 
Rhabditis  Niellyi.  47. 
Rhabdo-myoma  of  kidney,  714. 
Rhabdonema  intestinale,  51. 
Rhachitic  bones,  426. 
Rhachitis,  426. 
Rhagades,  270. 

Rheumatic  fever,  219;  cerebral  complications  of, 
224;  endocarditis  in,  223;  fibrous  nodules  in,  224; 
germ  theory  of,  221;  heredity  in,  220;  hyper- 
pyrexia in,  22.3;  metabolic  theory  of,  221; 
nervous  theory  of,  221;  pericarditis  in,  223; 
purpura  in,  224;  sudden  death  in,  225. 
Rheumatic  gout  (.see  Arthritis  Deform.'VNs). 
Rheumatic  nodules,  224. 

Rheumatism,    chronic,    394;    muscular,    396;    sub- 
acute, 223;  and  tonsillitis,  445. 
Rheumatoid  arthritis  (.see  .\rthritis  Df.form.\ns). 
Rhinitis,  fibrinous,  201;   membranous,  201;  syphi- 
litic. 269. 
Ribs,  resection  of,  in  empyema,  655. 
Rice-water  stools.  231. 
Rickets,  420;  acute,  430,  7.'')3;  fiptal,    769. 
Riga's  disease,  150,  435. 

Rigidity,  early,  in  hemiplegia,  970;  late,  974. 
Rigors,  in  abscess  of  brain,  994;  in  abscess  of  liver, 
505;  in  ague,  16;  in  pneumonia,  172;  in  pj'aemia, 
217;  in    pyelitis,    705;  in    tuberculosis,    322;  in 
typhoid  fever,  74. 
Risus  sardoniuus,  260. 
Rock-fever,    248. 
Rocky-mountain  fever,  368. 

Romberg's  maaUcatory  spasm,  1018;  symptom,  890. 
Root-nerve  .symptoms  in  compression  paraplegia, 

938. 
Roaary,  rickety,  428. 
Roseola  (see  Rosi-;  Rash  ofTyhhoiu),  74;  epidemic, 

145;  syphilitic,  268. 
"  Ro.se  cold,"  594. 
Ro.se  rash  in  typhoid  fever,  74. 
Rotation  in  epilepsy,  1001. 
Rotatory  spasm  in  hysteria,  1080. 
Rotheln,  145. 

"  Rough-on-rats,"  poisoning  by,  379. 
Round-W(»rms,  38. 
Rub  (see  I'larrioN). 
Rubella,  145. 
Rubeola,  140;  not  ha,  145. 
Rumination,  491. 
Running  pul.se  in  typhoid  fever,  76. 

Sable  intestinal,  532. 

Saccharomyces  albicans,  436. 

Sack's  disease,  912. 

Sacral  plexus,  lesions  of,  1038. 

St.  Vitus's  dance,  1045. 

Salaam  convulsions,  1056,  1080. 

Saline   injections,   intravenous,   in   diabetic   coma, 

423;  subcutaneous,  in  cholera,  233. 
Saliva,  arrest  of,  441 ;  .supersecretion  of,  440. 
Salivary  glands,  diseases  of,  440;  inflammation  of, 

441. 
Salivation  (see  Pty.\lism),  437,  440;  in  small-pox, 

117;  in  bulbar  paralysis,  904. 
Salpingitis,  tuberculous,  348. 
Saltatory  spasm,  1055. 

Sanatoria,  treatment  of  tuberculosis  in,  354. 
73 


Sand-flea,  55. 

Sand,  intestinal.  532;  renal,  709. 
Sapraemia,  213. 
Saranac  Sanitarium,  354 

Sarcina,  ventriculi,  468;  in  lung  cavities,  324. 
Sarcocystis  Miescheri.  1;  S.  hominis,  1, 
Sarcoma,  of  brain.  988;   of  kidney,  714;   of  liver. 
568;  of  lung    641;  mediastinal,  661;  melanotic, 
of  liver  568. 
Sarcoptes  scabiei,  52. 
Saturnine  neuritis.  1002. 
Saturnism-,  375. 
Sausage  poisoning,  381. 
Scapulodynia.  397. 
Scarlatina  miliaris,  132. 
Scarlatini^  sine  eruptione,  134, 
Scarlatinal  nephritis,  134. 

Scarlet  fever,  130;  anginose  form,  134;  atypical 
form,  134;  complications  and  sequelae,  134; 
desquamation  in,  134;  eruption  in,  132;  fulminant 
toxic  variety,  134;  haemorrhagic  form,  134;  in- 
cubation of,  132;  infectivity  of,  130,  138;  in- 
vasion in, 132;  malignant,  134;  puerperal  (seeSuR- 
gic-vl);  surgical,  131  ;  and  typhoid  fever,  89,  138. 
Schistosomum    hamatobium,    27;  Japonicum    vel 

Cattoi,  28. 
Schiinlein's  disease,  744. 
School-made  chorea,  1040. 
Schott  treatment  in  mycjcardial  disease,  829, 
Schultze's  granule  mas.ses,  333. 
Schweninger  cure  in  obesity,  432. 
Sciatica,  1039. 

Sciatic  nerve,  affections  of,  1038. 
Scirrhous  cancer  of  lung,  641;  of  stomach,  480. 
Sclerema  in  cholera  infantum,  507. 
Sclerema  neonatorum,  1109. 
Sclerodactylie,  1110. 
Scleroderma,  1109. 
Scli^ro.se  en  [)laques,  930. 

Scleroses  of  the  brain,  928;  diffuse,  929;  dissemin- 
ated, 930;   insular,  930;   multiple,  929;   miliary, 
929;  tuberous,  930. 
Sclero.sis,    cerebro-sriinal,    929;    degenerative,    929; 
developmental,  929;  inflammatory,  929;  of  scurvy 
752. 
Sclerosis,  primary,  lateral,  909;  posterior  spinal  (see 
LoroMOTOR  At.\xia),  88G;   in  chronic  ergotism, 
.383;   primary  combined,  920;   in  tubercles,  296; 
renal,  694;  to.xic  combined,  922. 
Sclerostoma,  4.5. 
Sclerotic  gastritis,  460. 
Scolices  of  echinococcus,  34. 
Scorbutus,  7.50. 
Screw-worm,  .55.  . 
Scrivener's  palsy,  1072. 

Scrofula,  .304;  alleged  protective  inoculation  by,  306. 
Scrofulous  pneumonia,  297. 
Scurvy,   750;   infantile,   753;   prophylaxis   of,   752; 

sclerosis,  752. 
Scybala,  526. 

Seasonal    relations,    of   chorea,    1045;    of   malaria, 
10;  of  pneumonia,  167;  of  rheumatism,  219;  of 
typhoid  fever,  59. 
Seborrhoea  nigricans,  1083. 
Secondary  contracture  in  hemiplegia,  974. 
Secondary  deviation  in  eye  muscle  paralysis,  1015. 
Secondary  fever  of  small-pox,  116, 


1138 


INDEX. 


Self-limitation  in  tuberculosis,  350. 
Bemiluuar  space  of  Traube,  647. 
Semilunar  valves,  aortic,  incompetencj-  of,  796. 
Senile  emphysema,  638. 

Sensation,  painful,  loss  of,  in  syringomyelia,  943. 
Sensation,  retardation  of,  in  ataxia,  891. 
Sensory  system,  diseases  of,  886. 
Septicaemia,  213;  cryTstogenetic,  215;  general,  215; 
gonorrhQeal,282;progressive,214;post-t>-phoid,89. 
Septieo-pyiEmia,  216. 
Serratus  paralysis,  1036. 
Serum  disease,  205. 
Seven-day  fever,  109. 
Sewer-gas,  and  tonsillitis,  445;  poisoning,  effects  of, 

363. 
Sex,  influence  of,  in  heart-disease,  814. 
Sexes,   proportion   of,   affected  with  acute  yellow 

atrophy,  538;  in  chlorosis.  721;  in  chorea,  1045; 

in  exophthalmic  goitre,  765;  in  general  paresL*, 

896;  in  haemophilia,  748. 
Shaking  palsy,  1042. 
SheU-fish,  poisoning  by,  383. 
Shingles,  900. 
Ship-ffever,  105. 

Shock  as  a  cause  of  traumatic  neuroses,  1096. 
Shock,  death  from,  in  acute  obstruction,  522. 
Shoemaker's  cramp,  1074. 
Sick  headache,  1066. 
Sickness,  sleeping.  7,  8. 
Siderodromophobia,  1089. 
Siderophobia,  1089. 
Siderosis,  631 ,  632. 

Signal  symptom  (in  cortical  Ict^ions),  948,  990. 
Singultus  (see  Hiccough). 
Sinu.s    thrombosis,    983;    anil    anaemia,    983;    and 

chlorosis,  724,  983;  autochthonous,  9S3;  second- 
ary, in  ear-disease,  983. 
Siriasis,  385. 

Sixth  nerve,  paralysis  of,  1015. 
Skin,  itching  of,  417,  .535,  084,  699,  767. 
Skoda's    resonance    in    pleural    effusion,    046;    in 

pneumonia,  176. 
Skull,  of  congenital  sypliilis,  270;  of  hydrocephalus, 

997;  of  rickets,  429;  percussion  of,  995. 
Sleeping  sickness  and  trypanosomiasis,  7,  8. 
Sleep-start  in  mitral  incompetency,  806. 
Slow  heart,  836. 
Small-pox,    112;    complications   of,    119;   confluent 

form,  117;  contagiousness  of,  112;  discrete  form, 

116;  eruption  in,  116;  ha-morrhagiC;  117;  'noculu- 

tion  in,  112;  recurrent,  120;  vaccination  in,  112. 
Small  sciatic  nerve,  affections  of,  1038. 
Smell,    affections    of    sense    of    (see    Olfactory 

Nerve),  1006. 
Snake-virus,  purpura  caused  by,  743. 
SnuflSes,  270, 
Softening  of  brain,  977. 
Soil,  influence  of,  in  cholera,  230;  in  typhoid  fever, 

61. 
Solanin  poisoning,  384. 
Solvent  treatment  of  renal  calculi,  713 
Soor,  436. 
Sordes,  79. 
Sore  throat,  442. 
Soya  bread,  422. 

Spasm,  congenital  gastric,  487;  pyloric,  492. 
Spasm,  lock,  in  writer's  cramp,  1073. 


Spasmodic  wrjiieck,  1031. 

Spasms,  in  ergotism,  383;  in  hydrophobia,  256;  in 
hysteria,  1077;  of  face,  1022;  of  muscles,  after 
facial  paralysis,  1022;  professional,  1072;  salta- 
tory, 1055. 

Spastic  paraplegia  of  adults,  909;  hereditary,  912; 
hysterical,  914;  Erb's  sj'philitic,  913;  in  children, 
910;  seeondarj',  913. 

Specific  infectious  diseases,  57. 

Specific  treatment  of  typhoid  fever,  102. 

Spectra,  fortification,  1067. 

Speech  (see  Aphasia),  955. 

Speech,  in  adenoid  vegetations,  449;  in  bulbar 
paralysis,  904;  in  insular  sclerosis,  930;  in  general 
paralysis,  898;  in  hereditary  ataxia,  922;  in 
paralysis  agitans,  1043;  scanning,  in  insular 
sclerosis,  930. 

Spes  phthisica,  334. 

Spina  bifida,  involvement  of  cauda  equina  in,  940. 

Spinal  accessory  nerve,  paralysis  of,  1030. 

Spinal  apoplexy,  936. 

Spinal  concussion,  effects  of,  1097. 

Spinal  cord,  diffuse  and  focal  diseases  of,  931. 

Spinal  cord,  affections  of  blood-vessels  of,  934; 
ana'Hiia  of,  934;  chronic  lepto-meningitis  of, 
928;  complete  transverse  lesions  of,  932;  com- 
pression of,  938;  congestion  of,  934;  embolism 
and  thrombosis  of  ves.sels  of,  935;  entiarteritis 
of  vessels  of,  935;  fissures  in,  937;  focal  lesions 
of,  932;  haemorrhage  into,  936;  lepto-meningitis 
of,  925;  localization  of  functions  of,  871;  pachy- 
meningitis of,  924;  sclerosis,  primary  combined, 
of,  920;  syphilis  of,  271;  tuberculosis  of,  342; 
tumors  of,  941 ;  imilateral  lesions  of,  933. 

Spinal  epilep.sy,  910. 

Spinal  irritation,  1089. 

Spinal  membranes,  huMnorrhage  into  935;  tumors 
of,  941. 

Spinal  nerves,  diseases  of,  1033. 

Spinal  neurasthenia,  1089. 

Spinal  p..ralysis,  atrophic,  914. 

Spirals,  Curschmn tin's.  611,  613. 

Spirillum  of  relapsing  fever,  1 10. 

Spirochrete  of  Obermeier,  109;  of  sj'philis,  265. 

Splanchnoptosis,  528. 

Spleen,  amyloid  degeneration  of,  in  syphilis,  276; 
in  tuberculosis,  321. 

Spleen,  diseases  of,  7(50;  abscess  of,  7Cl ;  cysts  of, 
701;  endothelioma  of  702;  gummata  of,  761; 
infarct  of,  761;  tumors  of,  701. 

Spleen,  enlargement  of,  in  congenital  syphilis, 
209,  271;  in  malaria,  15,  17. 

Spleen,  e.xcision  of,  in  leuka-mia,  738. 
Spleen   floating,  529,  760;  pulsating,  734. 

Spleen,  in  ague  15,23;  in  anthrax.  254;  in  cirrhosis 
of  liver,  559,  561 ;  in  I/odgkin's  disease,  740;  in 
leukff-mia,  732,  734;  in  rickets,  428,  4.30;  in  acute 
miliary  tuberculosis.  299;  in  typhoid  fever,  68, 
83;  in  typhus,  107. 
Spleen,  rupture  of   761;  in  malaria,  15;  in  typhoid 

fever,  G8. 
Splenectomy,  statistics  of,  738,  762. 
Splenic  anaemia,  762. 
Splenic  fever,  252. 
Splenization  of  lung,  310,  615,  622. 
Splenomegaly,  family  or  infantile  forms  of,  7S2; 
primitive,  762;  tropical,  9. 


INDEX. 


1139 


Spondylitis  deformans,  392. 

Spondylose  rhizovielique,  393. 

Sporozoa,  1;  parasitic,  1. 

Spotted  fever,  105,  157. 

Sprue,  500. 

Sputa,  albuminoid,  after  aspiration  of  chest,  654: 
alveolar  cells  in,  603;  amcsba  coli  in,  6;  anchovy 
sauce,  6;  in  cancer  of  lung,  642;  in  influenza, 
154;  hsematoidin  crystals  in,  566;  in  anthracosis, 
633;  in  asthma,  611;  in  bronchiectasis,  608; 
in  acute  bronchitis,  602;  in  chronic  bronchitis, 
604;  in  putrid  bronchitis,  605;  in  gangrene  of 
lung,  639. 

Sputa,  in  phthisis,  323;  in  pneumonia,  175;  in 
acute  pulmonary  tuberculosis,  314;  prune-juice, 
642;  uric-acid  crystals  in,  401. 

Staphylococci,  in  broncho-pneumonia,  623;  in 
diphtheria,  196;  in  endocarditis,  789;  in  peritoni- 
tis, 581;  in  pneumonia,  168;  in  pyaemia,  216;  in 
septicEcmia,  215;  in  tonsillitis,  445. 

Status,  epilepticus,  1061;  hystericus,  1084. 

Status  lymphaticus,  755;  sudden  death  in,  755. 

Stellwag's  sign,  766. 

Stenocardia,  839. 

Steno's  duct,  gaseous  tumors  of,  442. 

Stenosis,  of  aortic  orifice,  802;  of  mitral  orifice. 
808;  of  pulmonary  orifice,  813,  845;  of  tricuspid 
orifice,  812. 

Steppage  gait,  378,  380,  1002. 

Stercoraceous  vomiting,  522. 

Stercoral  ulcers  in  colitis,  501. 

Stertor,  in  apoplexy,  970. 

Stiff  neck,  396. 

Stigmata,  in  hysteria,  1083 ;  in  purpura,  744. 

S nil's  disease,  393. 

Stitch  in  side  in  pneumonia,  1 74 ;  in  pleurisy,  645. 

Stokes-Adams  disease,  834,  837,  852. 

Stolidity  of  face  in  general  paresis,  898. 

Stomach,  atrophy  of,  460;  atony  of,  492;  chronic, 
catarrh  of,  4.59;  erosions  of,  470;  foreign  bodies  in, 
486;  ha;morrhage  from,  474,  487;  hair  tumors  in, 
486;  hour-glass,  475;  neuroses  of,  490;  non-cancer- 
ous tumors  in,486;8jq5hilis  of,  276;  tuberculosis  of, 
340;  ulcer  of,  470;  washing  out  of  (lavage),  465. 

Stomach,  cancer  of,  479;  acute,  485;  absence  of  free 
HCl  in,  484;  diagnosis  from  gastric  ulcer  and 
chronic  gastritis,  485;  haemorrhage  in,  483; 
secondary,  480;  vomiting  in,  482. 

Stomach  contents,  examination  of,  483. 

Stomach,  dilatation  of,  467;  tetany  in,  468. 

Stomach,  diseases  of,  456. 

Stomatitis,  434;  acute,  434;  aphthous,  434;  epidemic, 
367;  fetid,  435;  follicular,  434;  gangrenous,  437; 
herpetic,  436;  mercurial,  437;  neurotica  chronica, 
436;  parasitic,  436;  pemphigoid,  436;  vesicular, 
434;  uraemic,  685. 

Stone-cutter's  phthisis,  631. 

Stools,  of  acute  yellow  atrophy,  540;  of  cholera; 
231 ;  of  dysentery,  5,  244;  of  typhoid  fever,  80;  in 
hjematemesis,  489;  of  obstructive  jaundice,  535. 

Strabismus,  1015. 

Strangulation  of  bowel,  519,  524. 

"Strawberry"  tongue  in. scarlet  fever,  133. 

Streptococci  in  diphtheria,  196;  in  endocarditis, 
788;  in  pneumonia,  168;  in  peritonitis,  581;  in 
pleurisy,  644;  in  pyaemia,  216;  in  scarlet  fever, 
131;  in  septicaemia,  215;  in  tonsillitis,  445. 


Streptococcus  diphtheritis,  196. 

Streptococcus  erysipelatos,  211. 

Streptococcus  pyogenes,  in  broncho-pneumonia, 
623;  in  erysipelas,  211. 

Streptothrix  actinomyces,  263. 

Stricture  of  bile-duct,  547. 

Stricture  of  colon,  cancerous,  521. 

Stricture  of  intestine,  621;  after  dysentery,  245, 
521;  after  tuberculous  ulcer,  341; 

Stricture  of  oesophagus,  453. 

Stricture  of  pylorus,  486. 

Strictures  and  tumors  of  the  bowel,  521. 

Stroke,  apoplectic,  969. 

Strongyloides  intestinalis,  51. 

Stuttering  in  mouth-breathers,  449. 

Styrian  peasants,  arsenical  habit  in,  380. 

Subclavian  artery,  murmur  in  and  throbbing  of,  in 
phthisis,  331. 

Subphrenic  peritonitis,  584. 

Subsultus  tendinum  in  typhoid  fever,  85. 

Succussion,  Hippocratic,  659. 

Succussion  splash  in  dilated  stomach,  469. 

Sudamina,  in  rheumatic  fever,  222;  in  typhoid  fever, 
74. 

Sudoral  form  of  typhoid  fever,  75. 

Sugar  in  the  urine,  408. 

Sulphocyanides  in  excess  in  saliva  in  rheumatism, 
222. 

wSun-stroke,  385;  after-effects  of,  386. 

Supermotility  of  stomach,  490. 

Suppression  of  urine,  668;  obstructive,  711. 

Suppurative  nephritis,  704. 

Suppurative  pylephlebitis,  542,  564. 

Suppurative  tonsillitis,  446. 

Suprarenal  bodies,  diseases  of,  756;  haemorrhage 
into,  760;  tuberculosis  of,  760;  tumors  of,  760. 

vSuprarenal  extract,  treatment  by,  759. 

Surgical  kidney,  704. 

Suspension  in  compression  paraplegia,  940. 

Sweating,  in  acute  rheumatism,  222;  in  ague,  17; 
in  diabetes,  414;  in  phthisis,  328;  in  pyaemia, 
217;  in  typhoid  fever,  75;  in  malignant  endo- 
carditis, 790;  profuse,  in  rickets,  428;  unilateral; 
in  cervical  caries,  939;  unilateral,  in  aneurism, 
860. 

Sweating  sickness,  367. 

Swine  fever,  368. 

Si/denham's  chorea,  1045. 

Symmetrical  gangrene,  1101. 

Sympathetic  ganglia,  in  Addison's  disease,  757. 

Sympathetic  nerve  fibres  (see  Vaso-motor). 

Symptomatic  parotitis,  441. 

Syncope,  fatal,  in  cardiac  disease,  800,  827;  in 
phthisis,  338;  in  pleural  effusion,  648;  local,  1100. 

Synovial  rheumatism  (see  Gonorrhceal  Rheu- 
matism), 282. 

Synovitis,  gonorrhceal,  282. 

Synovitis,  symm'-Li'ical,  in  congenital  syphilis,  271. 

Syphilides,  macular,  268;  papular,  268;  pustular, 
268;  squamous,  268;  the  late,  269. 

Syphilis,  265;  accidental  infection,  266;  acquired, 
267;  amyloid  degeneration  in,  269;  bone  lesions, 
271 ;  congenital, 269 ;  and  dementia  paralytica, 269, 
272;  diagnosis,  278;  early  nerve  lesions,  272;  gum- 
mata  in,  267,  269;  hereditary  transmission,  266; 
modes  of  infection,  266;  of  brain  and  cord,  271, 
988 :  of  circulatory  system,  276;  of  digestive  tract. 


1140 


INDEX. 


276;  and  life  insurance,  2S1;  of  liver,  274;  and 
locomotor  ataxia.  269,  SS6;  of  lung.  273;  and 
marriage,  281;  orchitis  in,  277;  primary  stage  of, 
267;  prophylaxis  of,  278;  quaternary  stage  of, 
269;  renal,  277;  secondary  stage  of.  267;  tertiary 
stage  of,  269;  third  generation,  271;  of  trachea 
and  bronchi,  273;  and  vaccinia,  126;  visceral, 
271. 

Syphilis  hsemorrhagica  neonatorum,  270,  747. 

Syphihtic  arteritis.  277. 

Syphilitic  fever.  267. 

SjT>hilitio  nephritis,  277. 

Syringomyeha,  943. 

Tabes,  diabetic,  418. 

Tabes  dorsalis  (see  Locomotor  Ataxia),  886;  iu 
chronic  ergotism,  383. 

Tabes  dorsalis  spasmodique,  909. 

Tabes  mesenterica,  308. 

Tabo-paralysis,  895. 

Tache  cergbrale,  75,  303. 

Taches  bleuatres,  54,  75. 

Tachycardia,  766,835;  neurasthenic,  1090;  paroxys- 
mal, 836. 

Tactile  fremitus,  in  pneumonia,  176;  in  pleural 
effusion.  646;  in  pneumothorax,  658;  in  pulmo- 
nary tuberciilosis,  329;  at  right  apex,  329. 

TEeniffi,  varieties  of,  28,  29,  31,  32. 

Tseniasis,  intestinal,  28;  somatic,  31. 

Tapping,  in  ascites,  592;  in  cirrhosis  of  the  liver, 
563;  in  pericarditis,  782. 

Taste,  disturbances  of,  1026;  tests  for  sense  of,  1026. 

Tea,  neuritis  caused  by,  1002. 

Techomyza  fusca,  55. 

Teeth,  actinomyces  in,  264;  looseness  of,  in  scurvy, 
751;  effects  of  stomatitis  on.  438;  erosion  of,  438; 
Hutchinson's.  271, 438;  of  infantile  stomatitis,  438. 

Teichopsia,  1067. 

Telangiectasis,  multiple,  in  recurring  epistaxis,  595, 
749. 

Telegrapher's  cramp.  1072. 

Temperature  .sense,  loss  of,  in  syringomyelia,  943; 
in  Morva7i's  disease,  944. 

Temperature,  subnormal,  in  acute  alcoholism,  369; 
in  acute  tuberculosis,  299;  in  apoplexy,  970,  in 
heat  exhaustion,  385;  in  malaria,  22;  in  pulmonary 
tuberculosis,  327;  in  tuberculous  meningitis,  303; 
in  urEemia,  684. 

Temporal  lobe,  tumors  of,  990. 

Temporo-sphenoidal  lobe,  centre  for  hearing  in, 
1023. 

Tender  points  in  neuralgia,  1069;  in  neurasthenia, 
1088. 

Tender  toes,  in  typhoid  fever,  86. 

Tendon-reflexes  (see  Reflexes). 

Tendon  transplantation  in  infantile  paralysis,  912, 
918;  in  hemiplegia   981. 

Tenth  nerve,  lesions  of,  1027. 
Terminal  infections,  218. 
Tertian  ague,  17. 

Testes,  tuberculosis  of,  348;  sj-pbilis  of,  277;  and 
tonsils,  relations  between,  445;  (see  also  Orchi- 
tis). 
Tetanus,  258;  bacillus  of,  259;  cephalic,  260; 
neonatorum,  258;  pseudo,  260;  and  vaccinia,  127. 
Tetany,  1074;  after  thyroidectomy,  1074;  epidemic 
or  rheumatic,  1074;  in  dilatation  of  the  stomach. 


463,     1074;     idiopathic     workman's.     1074;     in 
myxoedema.  1074;  in  typhoid  fever,  SC. 
Tetrodon,  poisoning  by,  383. 
Therapeutic  test  in  syphilis,  278. 
Therapy,    serum,   in   diarrhoeas   of   children,   510; 
in  exophthalmic  goitre,  768;  in  plague.  242;  in 
pneumonia,  169;  in  scarlet  fever,  140;  in  typhoid 
fever,  102. 
Thermic  fever,  385;  continued,  387. 
Thermic  sense,  loss  of.  in  syringomyelia,  943. 
Third  nerve,  diseases  of,  1013. 
Third  nerve,  recurring  paralysis  of,  1013;  signs  of 

paralysis  of,  1013. 
Thirst  in  diabetes,  414. 
Thomsen's  disease,  1112. 
Thoracic  duct,  tuberculosis  of,  298. 
Thorax,  deformity  of,  in  mouth-breathers.  449;  in 

rickets,  428. 
Thorax  in  emphysema,  636;  in  phthisis,  293   329. 
Thorn-headed  worms,  51. 
Thornwaldfs  disease,  450. 
Thread-worm,  39. 
Throbbing  aorta,  864,  1090. 
Thrombi  in  heart.  809;  in  pneumonia.  171. 
Thrombi  in  veins  ii^  typhoid  fever,  78. 
Thrombi,  marantic,  983. 

Thrombosis,  in  pneumonia,  181 ;  of  cerebral  arteries, 
977;   of  cerebral  sinuses,  983;  of  cerebral  veins, 
983;  of  mesenteric  vessels,  533;  of  portal  vein,  542. 
Thrush,  436. 

Thymic  asthma,  599,  772. 

Thymus  gland,  diseases  of,  771;  abscess  of,  773; 
in  acromegaly,  1106;  atrophy  of,  773;  and 
exophthalmic  goitre,  773;  tumors  of.  773;  per- 
sistence of,  7.72;  enlargement  of,  772;  sudden 
death  in,  772. 
Thymus  Tod,  756. 

Thyroid  extract,  administration  of,  771,  1076. 
Thyroid  gland,  aberrant  or  accessory   tumors  of, 
764;  absence  of.  in  cretins,  768;  adenomata  of, 
764;  cancer  of,  764;  congestion  of,  763;  in  ex- 
ophthalmic goitre,  767;  in  goitre,   764;   lingual, 
764;    in    myxoedema,    770;    sarcoma    of,    764; 
tumors  of,  764. 
1    Thyroid  gland,  diseases  of,  763. 
I    Thyroidism,  771. 
I    Thyroiditis,  acute,  763. 
I    Tic  convulsif.  1053. 

j    Tic    douloureux,    i069;    extirpation    of    Gasserian 
ganglion  in,  1070. 
Tick  fever,  53,  368. 
I   Ticks,  52. 

Tinnitus  aurium,  1023. 
I    Tobacco,  influence  of,  on  the  heart.  842. 
Tongue,  atrophy  of.  1033;  eczema  of.  438;  geograph- 
ical, 438;  in  bulbar  paralysis,  904;  smoker's,  439; 
spasm  of,  1033;   tuberculosis  of,  339;   unilateral 
j    .   hemiatrophy    of,    1033;    tremor    of,    in    general 
paresis,  897;  ulcer  of  frsenum  in  whooping-cough, 
150. 
Tonsillitis,  445;   acute,  445;   albuminuria  in,  446; 
endocarditis  in,  446;  in  the  newly  married,  445. 
Tonsillitis,  chronic,  447;  follicular,  445;  lacunar,  445; 

suppurative,  446;  ami  rheumatism,  445. 
Tonsils,    abscess    of,    446;    calculi   of,    450;    cheesy 
masses  in,  450;  enlarged,  447;   and   testes,  rela- 
tions between,  445;  tuberculosis  of,  339. 


INDEX. 


1141 


Tonsils,  diseases  of,  44.5. 

Tophi,  401. 

Topical  diagnosis,  spinal,  931;  cerebral,  947. 

Torticollis,  396,  1030;  congenital,  1030;  facial 
asymmetry  in,  1030;  mental,  1031;  spasmodic, 
1031. 

Toxaemia,  214;  in  pneumonia,  188. 

Toxic  gastritis,  458. 

Toxines,  in  septicaemia,  213. 

Tracheal  tugging,  858. 

Traction  aneurism,  855. 

Trance  in  hysteria,  1078,  1084. 

Traube's  semilunar  space,  647. 

Trauma  as  a  factor  in  abscess  of  the  liver,  563;  can- 
cer of  the  stomach,  479;  in  delirium  tremens,  371; 
in  hsematuria,  669;  in  neurasthenia,  1096;  in 
cysts  of  pancreas,  577;  in  pneumonia,  166;  in 
tuberculosis,  295. 

Trembles  in  cattle,  365. 

Tremor,  alcoholic,  370,  1045;  in  Graves'  disease, 
767;  hereditary,  1045;  hysterical,  1045,  1080;  in 
exophthalmic  goitre,  767;  intention,  930;  lead, 
378;  in  paralysis  agitans,  1043;  Rend,u's  type  of, 
1080;  senile,  1045;  simple,  1044;  toxic,  1045; 
volitional,  in  insular  sclerosis,  930. 

Trichina  spiralis,  39;  distribution  of,  41;  statistics 
of,  in  American  hogs,  41;  in  Germany,  41;  modes 
of  infection,  41. 

Trichiniasis,  39;  epidemics  of,  42;  prophylaxis  of,  44. 

Trichocephalus  dispar,  51. 

Trichomonas  vaginalis,  25;  T.  hominis,  25. 

Trichter  brust,  329,  449. 

Tricuspid  regurgitation,  811. 

Tricuspid  valve,  disease  of,  811;  insufficiency  of, 
811;  stenosis  of,  812. 

Trigeminal  neuralgia,  1069. 

Trigeminus  (see  Fifth  Nerve). 

Trilocular  heart,  844. 

Trismus,  neonatorum,  258;  hysterical,  1079. 

Troinmer's  test,  415. 

Trophic  disorders,  1100. 

Tropical  dysentery,  2. 

Trousseau's  symptom,  in  tetany,  1075. 

Trypanosomes,  varieties  of,  7.  8. 

Trypanosomiasis,  7;  and  sleeping  sickness,  8. 

Tsetze  fly  disease,  7. 

Tubal  pregnancy,  ruptured,  simulating  peritonitis, 
584. 

Tubercle  bacilli,  285,  323. 

Tubercle,  diffuse  infiltrated,  297;  miliary,  295,  318; 
changes  in,  295;  structure  of,  295;  nodular,  295. 

Tubercles,  miliary,  in  chronic  phthisis,  318. 

Tubercula  dolorosa,  1005. 

Tuberculin,  286;  test,  350;  treatment,  356. 

Tuberculosis,  acute  miliary,  298;  general  or  typhoid 
form,  299;  meningeal  form,  301;  pulmonary  form, 
300. 

Tuberculosis,  284;  bacillus  of,  285,  323;  changes 
produced  by  bacillus,  295;  chronic  miliary,  318 
of  circulatory  system,  349;  cirrhotic,  of  liver,  342 
conditions  influencing  infection,  292;  congenital 
287;  dietetic  treatment  of,  356;  distribution  of 
the  tubercles  in,  295;  duration  of  pulmonary  form 
of,  350;  hereditary  transmission  of,  287;  in- 
dividual prophylaxis  in,  352;  infection  by  meat, 
292;  infection  by  milk,  292;  infection  by  inhala- 
tion, 290;  inoculation  of,  289;  in  infants,  338;  in 


old  age,  337;  mastitis,  334;  treatment,  352; 
modes  of  death  in  pulmonary,  3.38;  modes  of  in- 
fection in,  287;  natural  or  spontaneous,  cure  of, 
352;  of  alimentary  canal,  339;  of  brain  and  cord, 
342;  of  Fallopian  tubes,  348;  of  genito-urinary 
system,  343;  of  kidneys,  345;  of  Hver,  341;  of 
lymphatic  system,  304;  of  mammary  gland,  349; 
of  ovaries,  348;  of  pericardium,  309;  of  peri- 
tonaeum, 310;  of  placenta,  348;  of  pleura,  308; 
of  prostate,  347;  of  serous  membranes,  308;  of 
testes,  348;  of  ureters  and  bladder,  347;  of  uterus. 
348;  of  vesiculse  seminales,  347;  pregnancy,  in- 
fluence of,  in,  351;  prophylaxis  in,  351;  pseudo- 
287;  pulmonary,  312;  and  typhoid  fever,  90;  and 
vaccinia,  126  ;  and  valvular  disease  of  heart,  337. 

TufnelVs  treatment  of  aneurism,  861. 

Tumors  of  brain,  988. 

Tunnel  anaemia,  44. 

Twists  and  knots  in  the  bowel,  520. 

Tympanites,  in  intestinal  obstruction,  522;  hysteri- 
cal, 1082;  in  peritonitis,  582;  in  tuberculous  peri- 
tonitis, 311;  in  typhoid  fever,  80;  as  a  cause  of 
sudden  heart  failure,  531. 

Typhlitis,  512. 

Typhoid  fever,  57;  abortive  form,  90;  afebrile,  74, 
91;  ambulatory  form,  71,  91;  anaemia  in,  76;  and 
tuberculosis,  90;  bacillus  of,  59;  carriers,  62;  chills 
in,  74;  circulatory  system  in,  76;  diabetes  in,  90; 
diarrhoea  in,  79;  digestive  system  in,  78;  Ehrlich's 
reaction  in,  87;  erysipelas  in,  89;  grave  form  of, 
91;  haemorrhage  in,  80;  haemorrhagic,  91;  his- 
torical note  on,  57;  immunity  from,  59;  and 
influenza,  90;  in  the  aged,  91;  in  children,  91; 
in  the  foetus,  92;  in  pregnancy,  92;  laparotomy 
in,  103;  liver  in,  68,  S3;  Maidstone  epidemic  of, 
62;  meteorism  in,  80;  mild  form,  90;  modes  of 
conveyance  of,  61;  nervous  system  in,  69,  85; 
noma  in,  89,  91;  osseous  system  in,  88;  oysters 
and,  63;  parotitis  in,  79;  perforation  of  bowel  in, 
67,  81;  peritonitis  in,  82,  103;  polyuria  in,  87; 
post- typhoid  variations  of  temperature  in,  72; 
prognosis  of,  96;  prophylaxis  of,  96;  pyuria  in, 
88;  relapses  in,  92;  renal  system  in,  87;  respiratory 
system  in,  84;  and  scarlet  fever,  89,  138;  serum 
therapy  in,  102;  skin  rashes  in,  74;  spleen  in,  83; 
tender  toes  in,  88;  tetany  in,  86;  and  tuberculosis, 
90;  varieties  of,  90;  Widal's  reaction  in  typhoid 
fever,  94;  Durham's  theory  of  relapse  in,  93. 

Typhoid  gangrene,  78;  sspticaemia,  89. 

Typhoid  psychoses,  86. 

Typhoid  spine,  89. 

Typhoid  state  in  obstructive  jaundice,  536;  in  acute 
yellow  atrophy,  539. 

Typho-lumbricosis,  39. 

Typho-malarial  fever,  so-called,  95,  20. 

Typho toxin,  65. 

Typhus  fever,  105;  complications  and  sequelae  of, 
108. 

Typhus  siderans,  108. 

Tyrosin,  539. 

Tyrotoxicon,  382. 

Ulcer,  cancerous,  of  intestine,  502;  gastric,  470;  of 
duodenum,  470;  of  bowel  in  dysentery,  3;  in 
typhoid  fever,  66. 

Ulcer  of  mouth,  435 ;  in  the  new-born,  436 ;  in 
nursing  women,  435  ;  of  palate  in  infants,  436. 


1142 


INDEX. 


Ulcer,  perforating,  of  foot,  in  tabes,  892;  in  diabetes, 
417. 

Ulcerative  endocarditis,  787. 

Ulcers,  Parrot's,  436. 

Ulnar  ner\-e.  affections  of,  1037. 

Uncinaria  Americana,  45. 

Uncinariasis.  44. 

Unconsciousness  (see  Coma). 

Undulant  fever,  247. 

Urffimia.  683;  cerebral  manifestations  of,  683; 
coma  in,  684;  con^iilsions  in,  684;  diagnosis  from 
apoplexy,  685;  dyspnoea  in,  684;  headache  in, 
684;  in  nephritis,  688,  702;  latent.  668;  local 
palsifcs  in,  684;  mania  in,  683;  cedema  of  brain 
in,  965  ;  stomatitis  in,  685  ;  theories  of,  683. 

Urate  (Uthate)  of  soda  in  gout,  399. 

Urates  in  the  urine,  677. 

Urates  (Uthates),  amorphous,  677. 

Ureter,  blocking  of.  668;  mucous  cysts  of,  2;  ob- 
structed by  calculi,  711;  psorospermiasis  of,  2; 
tuberculosis  of,  347. 

Urethritis,  gouty.  405. 

Uric  acid,  calculus.  709;  deposition  of,  677;  in  gout, 
398:  in  urine.  677;  "  showers,"  405. 

Uric-acid  diathesis  (see  Lith.emia),  677. 

Uric-acid  headache,  405. 

Uric-acid  theory  of  gout,  398. 

Urinary  calculi,  709. 

Urine,  anomalies  of  the  secretion  of,  668. 

Urine,  density  of,  in  acute  nephritis,  688;  in  chronic 
nephritis,  698;  in  diabetes,  415;  in  diabetes  in- 
sipidus, 425. 

Urine,  hsemoglobin  in,  670. 

Urine,  in  acute  yellow  atrophy  of  liver,  540;  in 
grave  anEemia,  729;  in  diabetes  insipidus,  425;  in 
diabetes  mellitus,  415;  in  diphtheria,  204;  in 
erj'sipelas,  212;  in  gout,  402,  404.  405;  in  jaundice, 
535;  in  melaniiria,  680;  in  pneumonia,  179;  in 
pulmonary  tuberculosis,  334;  in  typhoid  fever, 
87;  oxalates  in,  678;  pus  in,  676. 

Urine,  quantity  of,  in  chronic  Bright's  disease, 
698;  in  diabetes  insipidus,  425;  in  diabetes 
mellitus,  415;  in  intestinal  obstruction,  522. 

Urine,  retention  of,  in  typhoid  fever,  87. 

Urine,  suppression  of.  668;  treatment  of,  669;  in 
cholera.  231;  in  acute  nephritis,  689;  in  scarlet 
fever,  135;  in  acute  intestinal  obstruction,  522; 
obstructive  suppression,  711. 

Urine,  tests  for  albumin  in.  673;  biliary  pigment  in. 
535;  blood  in,  669;  albumose  in,  674;  peptones  in, 
674. 

Urobilin,  increase  of,  in  pernicious  ansemia,  729. 

Uro-genital  tuberculosis,  343. 

Urticaria,  after  tapping  of  hydatid  cysts,  35;  in 
bronchial  asthma,  610;  epidemica,  56;  giant  form 
(see  Neurotic  (Edema),  1104;  -with  purpura,  744; 
in  small-pox,  116;  in  tjTDhoid  fever,  75. 

Uterus,  tuberculosis  of,  348. 

U-^-ula,  oedema  of,  442;  infarction  of,  442;  necrosis 
and  sloughing  of,  442,  745. 

Vaccination,  123;  law,  124;  mark,  125;  technique  of, 
127;  rashes.  126;  ulcers,  126;  value  of,  127; 
against  typhoid  fever,  98. 

Vaccine,  antityphoid,  98. 

Vaccine  lymph,  choice  of,  127. 

Vaccinia,  123;  bacteriology  of ,  125;  generalized,  126. 


Vaccino-sj-pliilis,  126. 

Vagabond's  discoloration,  54,  7.58. 

Valleix's  points,  1088. 

Valvular  disease  of  heart,  793 ;  and  tuberculosis,  337. 

Vaquez's  disease,  762. 

Varicella,  128;   hemorrhagic,  129. 

Varicella  bullosa,  129;  escharotica,  129. 

VariceUae  variolaformes,  129. 

Varices,  oesophageal,  in  cirrhosis  of  Uver,  452,  559. 

Variola,  112;  hemorrhagica,  115,  117,  118;  vera, 
115. 

Variola  haemorrhagica  pustulosa,  118. 

Variola  sine  eruptione,  119. 

Varioloid.  115,  119. 

Vaso-motor  disorders,  1100. 

Vaso-motor  disturbances  in  caries,  939;  in  chronic 
pleurisy.  656;  in  exophthalmic  goitre,  767;  in 
hemicrania,  1067;  in  myelitis,  945;  in  neuralgia, 
1069. 

Veins,  cerebral,  thrombosis  in,  983;  cer^^cal  dias- 
tolic collapse  of,  783;  pulsation  in,  333,  1049, 
1090;  sclerosis  of,  851. 

Vena  cava,  twist  in,  645. 

Vena  cava,  superior,  perforation  of,  by  aneurism, 
856,  865. 

Venereal  disease,  265. 

Venesection  (see  Bloodletting) 

Venous  pulse,  333,  1049,  1090. 

Ventricles  of  brain,  dilatation  of  (hydrocephalus), 
996;  puncture  of,  998. 

^'entricula^  hemorrhage,  968. 

Verruca  necrogenica,  289 

Vertebre,  caries  of,  938;  cervical,  caries  of.  939. 

Vertebral  artery,  obstruction  of,  979. 

^'ertigo.  auditory,  1024;  cerebellar,  954;  in  arterio- 
sclerosis, 852;  in  brain  tumor,  989;  gastric,  462; 
labyrinthine,  1024;  endemic  paralytic,  1025. 

Vesiculse  seminales,  tuberculosis  of,  347. 

Vestibular  nerve,  lesions  of,  1024. 

Vicarious,  epistaxis,  596;  hgemoptysis,  617. 

Vincent's  angina,  201. 

Virus  fixe,  257. 

Visceroptosis,  528. 

Vision,  double,  1016. 

Vitiligoidea,  535. 

Vocal  fremitus,  176,  637,  646;  resonance,  177,  647. 

Voice  (see  Speech). 

Voice,  alteration  of,  in  mouth-breathers,  449. 

Volitional  tremor,  930. 

Volvulus.  520,  524. 

Vomica,  319;  signs  of,  in  phthisis,  331. 

Vomit,  black,  237;  coffee-ground,  483. 

Vomiting,  in  Addison's  disease,  758;  in  Bright's 
disease,  699;  in  cerebral  abscess,  994;  in  cerebral 
tumor,  989;  in  acute  obstruction  of  intestines, 
522;  in  chronic  ulcerative  phthisis,  333;  in  gall- 
stone coUc,  711;  in  gastric  cancer,  482;  in  gas- 
tric ulcer,  474;  hysterical  fecal,  1082;  inter- 
mittent, of  Lei/rfen,  1103;  in  chronic  obstruction 
of  intestines,  523;  in  tuberculous  meningitis,  302; 
in  migraine,  1067;  in  peritonitis,  582;  in  small- 
pox, 115;  nervous,  491;  primary  periodic,  491; 
stercoraceous,  522;  uremic,  685. 

von  Noorden's  dietary  in  obesity,  432. 

WaU-paper,  poisoning  by  arsenic  in,  379. 
Warnings  in  apoplexy,  969 


INDEX. 


1143 


Wart-pox,  119. 

Warts,  post-mortem,  289. 

Washing  out  stomach,  465,  470. 

Wassermanns  reaction,  278. 

Water-hammer  pulse,  801. 

Water,  infection  by,  in  diphtheria,  193;  in  cholera, 
229;  in  typhoid  fever,  61. 

"Water  on  the  brain,"  301. 

Weber,  syndrome  of,  303,  973,  991. 

Weber's  test  in  gastric  hsemorrhage,  474. 

Weil's  disease,  364. 

Werlhof's  disease,  745. 

Wernicke's  hemiopic  pupillary  inaction,  1012. 

Wet-pack,  139. 

Whip-worm,  51. 

White  infarct  of  coronary  arteries,  823. 

White  softening  of  the  brain,  978. 

White  thrombi  in  heart,  809. 

Whooping-cough,  148. 

Winckel's  disease  (see  Epidemic  Hemoglobi- 
nuria OF  THE  New-born),  270,  671,  747. 

"Winged  scapulae,"  329. 

Wintrich's  sign,  331. 

Wiring  and  electrolysis  in  aneurism,  862. 


Woillez,  maladie  de,  614. 

Wool-sorter's  disease,  252,  254. 

Word-blindness,  959. 

Word-deafness,  959. 

Wormian  bones  in  hydrocephalus,  997. 

Worms  (see  Parasites). 

Wounds  of  the  heart,  831. 

Wrist-drop,  1037;  in  lead-poisoning,  377. 

Writer's,  cramp,  1072. 

Wryneck,  1030;  spasmodic,  1031. 

Xanthelasma,   535. 
Xanthine  calculi,  710. 
Xanthomata,  417,  535,  551. 
Xanthopsia,  39 ;  in  jaundice,  536. 
Xerostomia,  441. 

Yellow  fever,  233 ;  epidemics  of,  233. 
Yellow  softening  of  brain,  978. 
Yellow  vision,  39. 

Zinc,  peripheral  neuritis  from,  1002. 
Zoomotherapy,  356. 
Zona,  900. 


(31) 


THE    END, 


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